Health inspection·September 13, 2023

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some on the floor and not stored inside a bag increased the risk for cross contamination which could cause respiratory infection. LVN 2 stated, Resident 2's used of nasal cannula should have been care planned to ensure license nurse had directions to follow for proper care of oxygen therapy equipment. During an interview on 9/12/23 at 11:40 a.m. with the Infection Preventionist (IP), the IP stated, Resident 2 used of the nasal cannula should have been care planned to ensure Resident 2 received appropriate respiratory care. 2. During a concurrent observation and interview on 9/12/23 at 9:25 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 3's room, Resident 3's nebulizer mask was connected to the nebulizer machine, and the nebulizer mask was on top of the nightstand. The nebulizer mask was not dated and not stored in a bag. CNA 1 stated, the nebulizer mask should have not been placed on top of the nightstand. CNA 1 stated, the nebulizer mask should have been dated, placed in a bag, and stored inside the nightstand drawer when not in used. The nebulizer mask placed on top of the nightstand and not stored inside a bag could collect bacteria and make the resident sick. During a review of Resident 3's Facesheet, dated 8/17/23, the Facesheet indicated, Resident 3 had a diagnosis of asthma (a chronic [long term] condition that affects the airway. The airway becomes narrow and inflamed). During a concurrent observation and interview on 9/12/23 at 9:40 a.m. with the IP in Resident 1's room, Resident 1's nebulizer mask was connected to the nebulizer machine and the nebulizer mask was on top of the nightstand. The nebulizer mask was not dated and not stored inside a bag. The IP stated, Resident 1's nebulizer mask should have not been placed on top of the nightstand. The IP stated, Resident 1's nebulizer mask should have been labeled with the date and time when it should be replaced and placed inside a bag and stored inside the nightstand drawer when not in used. During a review of Resident 1's Facesheet, dated 8/28/23, the Facesheet indicated, Resident 2 had a diagnosis of COPD. During a concurrent interview and record review on 9/12/23 at 10:45 a.m. with LVN 2, Resident 1's Care Plan dated 8/28/23 and Resident 3's Care plan dated 8/17/23 were reviewed. Resident 1 and Resident 3 did not have care plan interventions for the used of the nebulizer mask. LVN 2 stated, Resident 1 and Resident 3's nebulizer mask was scheduled to be replaced every Friday and should have been labeled with the date and time when it should be replaced. LVN 2 stated, Resident 1 and Resident 3's nebulizer mask should have been stored inside a bag when not in use. LVN 2 stated, Resident 1 and Resident 3's nebulizer mask placed on top of the nightstand and not stored inside a bag increased the risk for cross contamination (a process by which bacteria are unintentionally transfer from one person or object) which could cause respiratory infection. LVN 2 stated, Resident 1 and Resident 3's used of nebulizer mask should have been care planned to ensure license nurse had directions to follow for proper care of oxygen therapy equipment. During an interview on 9/12/23 at 11:40 a.m. with the IP, the IP stated, Resident 1 and Resident 3's used of the nebulizer mask should have been care planned to ensure Resident 1 and Resident 3 received appropriate respiratory care. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated 3/2022, the P&P indicated, A comprehensive, person- centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 2 of 6 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 056338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete functional needs is developed and implemented for each resident . The care plan interventions are derived from a thorough analysis of the information gathered as part of he comprehensive assessment .The comprehensive, person-centered care plan . describes the services that are furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including . any specialized services to be provided . which professional services are responsible for each element of care . reflects currently recognized standards of practice for problem areas and conditions . Event ID: Facility ID: 056338 If continuation sheet Page 3 of 6 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 056338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612 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 maintain an effective infection prevention and control program for three of five sampled resident (Resident 1, Resident 2, and Resident 3) when: Residents Affected - Some 1. Resident 2' nasal cannula (a lightweight tube placed in the nostrils used to deliver supplemental oxygen to patients) was on the floor without a date per physician order and not stored inside a bag. 2. Residents 1 and Resident 3's nebulizer mask (a face mask used to deliver aerosol medications for breathing treatments) was placed on top of the nightstand without a date and not stored inside a bag. These failures placed Resident 1, Resident 2, and Resident 3 at increased risk for healthcare associated infections (infections patients get while they are receiving health care for another condition) from cross contamination (a process by which bacteria are unintentionally transfer from one person or object). Findings: 1. During a concurrent observation and interview on 9/12/23 at 9:17 a.m. with Licensed Vocational Nurse (LVN) 1 in Resident 2's room, Resident 2's nasal cannula was on the floor with no date when it should be replaced and not stored inside a bag. LVN 1 stated, the nasal cannula should have not been on the floor and should have been labeled with the date and time when it should be replaced and stored inside a bag. LVN 1 stated, the nasal cannula was considered contaminated and increased the resident's risk for infection. During a review of Resident 2's Face sheet (a one-page summary of important information of a patient, which includes patient identification, past medical history, medications, and allergies, and insurance information), dated 6/6/21, the Facesheet indicated, Resident 2 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD- a disease that cause airflow blockage and breathing problems). During a concurrent interview and record review on 9/12/23 at 10:45 a.m. with LVN 2, Resident 2's Care Plan dated 8/9/23 was reviewed. Resident 2 did not have a care plan for the use of the nasal cannula. LVN 2 stated, Resident 2's nasal cannula was scheduled to be replaced every Friday and should have been labeled with the date and time when it should be replaced. LVN 2 stated, Resident 2's nasal cannula should have been stored in a bag when not in use. LVN 2 stated, Resident 2's nasal cannula on the floor and not stored inside a bag increased the risk for cross contamination (a process by which bacteria are unintentionally transfer from one person or object) which could cause a respiratory infection. During a concurrent interview and record review on 9/12/23 at 11:40 a.m. with the Infection Preventionist (IP), Resident 2's Physician Order dated 8/8/23 was reviewed. The Physician Orders indicated, .Change Oxygen Mask and/or Tubing [nasal cannula] Weekly & PRN Label with Date every day shift every Fri . The IP stated, Resident 2's nasal cannula should have been placed inside the storage bag when not in used and should have been dated and replaced every Friday or as needed. The IP stated, Resident 2's nasal cannula on the floor and not placed inside the bag was unsanitary and increased the risk for cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 4 of 6 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 056338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a concurrent observation and interview on 9/12/23 at 9:25 a.m. with Certified Nursing Assistant (CNA) 1 in Resident 3's room, Resident 3's nebulizer mask was connected to the nebulizer machine (a device used to turn liquid medication into a mist so it can be breathed directly into the lungs through a face mask), and the nebulizer mask was on top of the nightstand. The nebulizer mask was not dated and not stored in a bag. CNA 1 stated, the nebulizer mask should have not been placed on top of the nightstand. CNA 1 stated, the nebulizer mask should have been dated, placed in a bag, and stored inside the nightstand drawer when not in used. The nebulizer mask placed on top of the nightstand and not stored inside a bag could collect bacteria and make the resident sick. During a review of Resident 3's Face sheet, dated 8/17/23, the Facesheet indicated, Resident 3 had a diagnosis of Asthma (a chronic [long term] condition that affects the airway. The airway becomes narrow and inflamed). During a concurrent observation and interview on 9/12/23 at 9:40 a.m. with the IP in Resident 1's room, Resident 1's nebulizer mask was connected to the nebulizer machine and the nebulizer mask was on top of the nightstand. The nebulizer mask was not dated and not stored inside a bag. The IP stated, Resident 1's nebulizer mask should have not been placed on top of the nightstand. The IP stated, Resident 1's nebulizer mask should have been labeled with the date and time when it should be replaced and placed inside a bag and stored inside the nightstand drawer when not in used. During a review of Resident 1's Face sheet, dated 8/28/23, the Facesheet indicated, Resident 2 had a diagnosis of COPD. During a concurrent interview and record review on 9/12/23 at 10:45 a.m. with LVN 2, Resident 1's Care Plan dated 8/28/23 and Resident 3's Care plan dated 8/17/23 were reviewed. Resident 1 and Resident 3 did not have care plan interventions for the used of the nebulizer mask. LVN 2 stated, Resident 1 and Resident 3's nebulizer mask was scheduled to be replaced every Friday and should have been labeled with the date and time when it should be replaced. LVN 2 stated, Resident 1 and Resident 3's nebulizer mask should have been stored inside a bag when not in use. LVN 2 stated, Resident 1 and Resident 3's nebulizer mask placed on top of the nightstand and not stored inside a bag increased the risk for cross contamination (a process by which bacteria are unintentionally transfer from one person or object) which could cause respiratory infection. During a concurrent interview and record review on 9/12/23 at 11:40 a.m. with the IP, Resident 1's Physician Order dated 8/28/23 and Resident 3's Physician Order dated 8/17/23 were reviewed. The Physician Orders indicated, .Change Oxygen Mask and/or Tubing Weekly & PRN Label with Date every day shift every Fri . The IP stated, Resident 1 and Resident 3's nebulizer mask should have been placed inside the storage bag when not in used and should be dated and replaced every Friday or as needed. The IP stated, Resident 1 and Resident 3's nebulizer mask placed on top of the nightstand and not placed inside the bag was unsanitary and increased the risk for cross contamination. During an interview on 9/12/23 at 12:50 p.m. with the Administrator (ADM), the ADM stated, the expectations was for license nurses to follow the facility policy and procedures for replacing, dating, and storing equipment's used for oxygen therapy. The facility policy and procedure did not indicate on when to replace the nasal cannula and oxygen mask and how to store when not in used. During a professional reference review titled Your Oxygen Equipment from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 5 of 6 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 056338 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Morning Star Post Acute 111 Barstow Ave. Clovis, CA 93612 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm https://www.ucsfhealth.org/education/your-oxygen-equipment undated, indicated .The nasal cannula should be changed every week . an oxygen face mask is used, it should be cleaned twice weekly with warm soapy water . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 6 of 6