Inspection·March 20, 2024

F 0625 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 the facility P&P titled, Bed Hold dated 7/2017, the P&P indicated, Transfer to an Acute Care Hospital/Therapeutic Leave A. The Facility notifies the resident and/or representative, in writing, of the bed hold, option, any time the resident is transferred to an acute care hospital or requests therapeutic leave. B. The Licensed Nurse will ask the Attending Physician to determine the resident ' s projected length of stay in the acute care hospital. C. When the resident or his/her representative provides notice within 24 hours of transfer that the resident elects his/her right to hold the bed, the Facility keeps that bed available for seven (7) days. Event ID: Facility ID: 056035 If continuation sheet Page 2 of 4 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to permit one of three sampled residents (Resident 1) to return to the facility after three days of hospitalization. This resulted in Resident 1 having an unnecessary stay in the hospital for additional seven days. Findings: During an interview on 2/7/24 at 3 p.m. with acute hospital Social Worker (SW), SW stated Resident 1 had discharge order to return to the facility on 2/6/24 (3 days after hospitalization). SW stated the facility was notified on 2/6/24 of Resident 1 ' s discharge orders and was told by the facility Business Developer and Marketer (BDM) Resident 1 ' s bed had been given to another resident and they did not have any long-term beds available. During a review of Resident 1 ' s admission Record (AR), dated 2/8/24, the AR indicated Resident 1 was a female originally admitted to the facility on [DATE]. The Progress Notes dated 2/3/24 at 1:22 a.m. indicated Resident 1 complained of severe chest pain and SOB [shortness of breath] and requested to be sent out to the acute hospital. During an interview on 2/8/24 at 10:07 a.m. with Interim Administrator (IA), IA stated the facility currently had 90 residents in house and two on a bed-hold (Resident 2 and Resident 3). IA reviewed the current facility census and stated there were a total of seven female beds available. During a concurrent interview and record review on 2/8/24, at 10:48 a.m. with Director of Nursing (DON), DON stated Resident 1 had abnormal vital signs and was transferred to the acute hospital on 2/4/24. DON stated she spoke to the acute hospital SW on 2/6/24. DON stated on 2/6/24 Resident 1 ' s bed was already filled, family had picked up Resident 1 ' s belongings and therefore was unable to re-admit the resident. During an interview on 2/13/24 at 10:49 a.m. with Resident 1 ' s Family Member (FM), FM stated the facility had refused to take Resident 1 back when they found out Resident 1 needed long-term care. FM stated Resident 1 verbalized wanting to return to the facility. FM stated Resident 1 was discharge from the acute hospital on 2/12/24 (7 days after discharge order) to a different long-term care facility (two hours away from where family lives). FM stated, We liked [facility name], we wanted her [Resident 1] to go back. During an interview on 2/22/24 at 1:11 p.m. with DON and IA, DON stated she did not see or review Resident 1 ' s clinical report provided by the acute hospital and therefore was not able to make the clinical decision whether the facility was able to meet Resident 1 ' s needs. During an interview on 2/22/24 at 1:29 p.m. with BDM, BDM stated Resident 1 was originally admitted for a short-term care. On 2/5/24, she received Resident 1 ' s clinical report from the acute hospital indicating Resident 1 needing a long-term care. BDM stated Resident 1 had a change in condition from needing short-term care to a long-term care and the facility was not able to meet her needs. BDM stated, Business wise we didn ' t want to take her because she was going to be long term. BDM stated the facility was only able to allocate [distribute] so many long-term beds with the insurance Resident 1 had. BDM stated, Well in the business aspects, that's what we need to do to make money. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 3 of 4 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 056035 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/20/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Shafter Nursing Care 140 East Tulare Avenue Shafter, CA 93263 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 0626 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1 ' s hospital Discharge Summary (DS) report dated 2/12/24, the DS indicated Resident 1 was admitted to the hospital on [DATE] at 12:59 a.m. was treated for sepsis (infection), chest pain and urinary infection. Resident 1 was ready for discharge on [DATE], back to the facility. During a review of Resident 1 ' s Clinical Note Social Services (CNSS), dated 2/6/24 at 2:19 p.m. the CNSS indicated, Pt [Resident 1] reports she resides at [facility name]. Reports her plan is to discharge back. The CNSS dated 2/6/24 at 4:20 p.m. indicated, [Facility name] is refusing to take pt [Resident 1] back. Permitting resident to return to facility P&P was requested from IT on 3/19/24 at 3:18 p.m. None was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056035 If continuation sheet Page 4 of 4