Health inspection·November 9, 2023

F 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 31's Census List (CL), dated 11/8/23, the CL indicated on 1/27/23, Resident 31 was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]A, on 5/1/23, Resident 31 was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]A, and on 7/19/23 Resident 31 was moved from room [ROOM NUMBER]A to room [ROOM NUMBER]H. During an interview on 11/8/23 at 11:17 a.m. with the Assistant Director of Nursing (ADON), the ADON stated the facility's practice for room changes was to notify residents or responsible representative by phone or in person. The ADON stated she was not aware of the requirement to provide written notification to the residents and responsible representative prior to room changed. During an interview on 11/8/23, at 11:19 a.m. with the Director of Nursing (DON), the DON stated the residents and responsible representative are notified in person or by phone for room changed. The DON stated it was not the facility's practice to provide written notification and the reason for the room change to the residents and the responsible representative. During a telephone interview on 11/9/23 at 2:36 p.m. with Resident 27's RR 2, RR 2 stated Resident 27 was in room [ROOM NUMBER]A and moved to room [ROOM NUMBER]A. RR 2 stated the facility did not provide written notification and reason for the move prior to room changed. During a review of Resident 27's AR, dated 11/9/23, the AR indicated Resident 27 was admitted to the facility on [DATE] with the diagnoses of Cognitive Communication Deficit and Major Depressive Disorder. During a review of Resident 27's Room Change (RC) report, dated 11/9/23, the RC report indicated Resident 27's room was moved from room [ROOM NUMBER]A to 16A on 10/12/23. During an interview on 11/09/23 at 8:28 a.m. with Resident 307, Resident 307 stated, he was moved from room [ROOM NUMBER]C to room [ROOM NUMBER]A. Resident 307 stated he did not recall receiving a written notice prior to the room change. During a review of Resident 307's Minimum Data Set (MDS), dated 10/13/23, the MDS Section C indicated resident 307 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During a review of Resident 307's AR, dated 11/9/23, the AR indicated Resident 307 was admitted to the facility on [DATE] with the diagnosis of Cognitive Communication Deficit. During a review of Resident 307's RC report, dated 11/9/23, the RC report indicated Resident 307's room was moved from room [ROOM NUMBER]C to 2A on 10/18/23. During an interview on 11/9/23 at 8:35 a.m. with Resident 307's spouse (SP) 1, SP 1 stated she was surprised with Resident 307's room changed. SP 1 stated, I did not get a written notification prior to the room change. During a concurrent interview and policy and procedure (P&P) review on 11/9/23, at 11:31 a.m. with the DON, the P&P Room Change/Roommate Assignment dated 3/21, was reviewed. The Room Change/Roommate Assignment indicated, . Prior to changing a room or roommate assignment all parties involved in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 2 of 47 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 11/09/2023 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 0559 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some change/assignment (e.g., residents and their representatives) are given at least a one hour advanced verbal notice of such change . The DON stated only verbal notification was given to residents and responsible representative prior to the room change. The DON stated he was not aware of the federal regulations which required the facility to provide written notice, including the reason for the room change to residents and the responsible representative. The DON stated the facility was ultimately responsible for the policies being up to date with the current federal regulations. The DON stated the ADM was responsible for reviewing and updating the policies and procedures of the facility. During an interview on 11/09/23 at 3:39 p.m. with the ADM, the ADM stated the facility's practice was to provide verbal notifications prior to room changes to residents and responsible representative. The ADM stated he was not aware of the federal regulations which required the facility to provide written notice, including the reason for the room change to residents and the responsible representative. The ADM stated the expectation was for the facility's policy and procedure for room change was up to date with the current federal regulations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 3 of 47 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 11/09/2023 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 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for three of 53 sampled residents (Resident 27, Resident 8, and Resident 6) when: 1. Resident 27 and Resident 8 did not have a comprehensive care plan for atrial fibrillation (a-fib- an abnormal heartbeat which reduces the heart's ability to pump properly and increases risk of blood clots) and the use of anticoagulation medication (medication that helps prevent blood clot formation). These failures placed Resident 27 and Resident 8 at risk for signs and symptoms of a-fib and bleeding complications from the used of anticoagulant to go unmonitored. 2. Resident 6's weight loss care plan intervention for weekly weights were not done. This failure placed Resident 6 at risk for delayed identification, reporting, and timely management for weight loss. Findings: During a concurrent interview and record review on 11/8/23 at 11:40 a.m., with Licensed Vocational Nurse (LVN) 1, Resident 27's electronic medical record (EMAR), was reviewed. The EMAR indicated, on 6/02/23 Resident 27 was prescribed apixaban oral tablet 2.5 mg (milligrams- unit of measurement) two times per day. LVN 1 stated Resident 27 was prescribed anticoagulant medication and residents taking anticoagulant medication has increased risk for bleeding. Resident 27 should have a comprehensive care plan with personalized interventions to monitor for signs of bleeding and to prevent injuries which could lead to bleeding. Resident 27 did not have a comprehensive care plan for the use anticoagulant medication. During a concurrent interview and record review on 11/8/23 at 11:48 a.m., with the Assistant Director of Nurses (ADON) and the Director of Nurses (DON), Resident 27's EMAR dated 6/2/23 was reviewed. The EMAR indicated, Resident 27 was prescribed apixaban oral tablet 2.5 mg two times per day for a-fib. The ADON stated Resident 27 was prescribed anticoagulant medication but did not have a care plan for anticoagulant used. The ADON stated residents prescribed with anticoagulant medication should have a comprehensive care plan to monitor for signs of bleeding and prevent accidents that could lead to injury. The DON stated Resident 27 should have an anticoagulant comprehensive care plan for the used of Apixaban but did not. During a concurrent interview and record review on 11/09/23 at 11:13 a.m., with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Anticoagulation - Clinical Protocol dated 11/2018 and Care Plans, Comprehensive Person-Centered dated 3/2022. The P&P Anticoagulation - Clinical Protocol indicated; .Monitoring and Follow-Up . 5. The staff and physician will monitor for possible complications in individuals who are anticoagulated and will manage problems . The P&P Care Plans, Comprehensive Person-Centered indicated, A comprehensive person-centered care plan that includes measurable objectives and timelines to meet the resident's physical. Psychosocial and functional needs is developed and implemented for each resident. The ADM stated a comprehensive care plan should have been initiated for residents with physician's order for anticoagulant medication. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 4 of 47 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 11/09/2023 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 During a review of Resident 8's admission Record (AR- document containing resident's brief medical history and contact information), undated, the AR indicated, Resident 8 was admitted to the facility on [DATE] with diagnoses which included fracture (broken) of one rib, chronic obstructive pulmonary disease (a group of diseases that cause airflow blockage and breathing-related problems), type 2 diabetes mellitus (high levels of sugar in the body), atrial fibrillation (a-fib- abnormal heartbeat which could lead to clot formation) and peripheral vascular disease (reduced circulation of the blood). During a concurrent interview and record review on 11/9/23 at 1:57 p.m. with LVN 4, Resident 8's Physician Orders (PO), and Care Plan undated, The PO indicated, Resident 8 was prescribed apixaban oral tablet 2.5 MG two times per day. LVN 4 stated she was unable to locate an anticoagulant care plan. LVN 4 stated an anticoagulant care plan was important for Resident 8 because the anticoagulant medication placed her at high risk for easy bruising, gastrointestinal (relating to the stomach and intestines) and urinary tract (the body's drainage system for removing urine) bleeding. LVN 4 stated Resident 8 was prescribed anticoagulant medication for a-fib diagnosis. LVN 4 stated Resident 8 did not have a care plan for a-fib. LVN 4 stated Resident 8 should have a care plan for a-fib to monitor Resident 8 for signs and symptoms of a-fib. LVN 4 stated the care plan was important to meet residents individualized care needs. During a concurrent interview and record review on 11/9/23 at 2:06 p.m. with the DON, Resident 8's Electronic Medical Record (EMR), undated was reviewed. The EMR indicated, Resident 8 had a physician's order of apixaban 5 milligrams (mg-unit of measurement) for a-fib. The DON reviewed Resident 8's care plans in the EMR and was unable to locate a care plan for a-fib and anticoagulant use. The DON stated Resident 8 should have a care plan for anticoagulant use which includes interventions to monitor for signs and symptoms of bleeding and a care plan for a-fib to monitor signs and symptoms a-fib such as chest pain. The DON stated care plans were important to provide personalized care and to keep residents safe. The DON reviewed 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 functional needs is developed and implemented for each resident . The comprehensive, person-centered care plan is developed within seven (7) days of the completion of the required MDS assessment . no more than 21 days after admission . The comprehensive, person-centered care plan . describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . The DON stated the P&P was not followed and should have been followed. During a review of the facility's P&P titled Anticoagulation - Clinical Protocol, dated 11/2018, the P&P indicated, .The staff and physician will monitor for possible complications in individuals who are be anticoagulated and will manage problems . 2. During a review of Resident 6's admission Face Sheet (a document containing resident profile information which includes patient identification, past medical history, insurance status, care providers, family contact information), indicated Resident 6 was admitted to the facility on [DATE] with diagnoses included Morbid Obesity (Body Mass Index (BMI- is a screening tool used to assess whether an individual's weight is within a healthy range based on their height) of 40 or higher due to excess calories, dementia (a progressive impairment of intellectual functioning, memory, and abstract thinking), and major depressive disorder (a mental health condition that causes persistent feeling of sadness and loss of interest in activities that once brought joy). (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 5 of 47 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 11/09/2023 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 During a concurrent interview and record review on 11/7/23 at 3:49 p.m. with the Registered Dietitian (RD), Resident 6's Weights and Vital Summary (WVS), dated was reviewed. The WVS indicated Resident 6's weight was not done on 7/17/23, 7/24/23, 8/7/23, 8/14/23, 8/21/23, 9/4/23, 9/11/23, 9/18/23, 9/25/23, 10/9/23, 10/16/23, and 10/23/23. The RD stated Resident 6's weight loss could have been prevented if weight loss interventions were implemented and monitored weekly as care planned. Residents Affected - Some During a concurrent interview and record review on 11/8/23 at 11:37 a.m. with the Family Nurse Practitioner (FNP), Resident 6's Weights and Vital Summary (WVS), dated was reviewed. The WVS indicated Resident 6's weight was not done on 7/17/23, 7/24/23, 8/7/23, 8/14/23, 8/21/23, 9/4/23, 9/11/23, 9/18/23, 9/25/23, 10/9/23, 10/16/23, and 10/23/23. The FNP stated she was not aware Resident 6 was not weighed weekly. The FNP stated it was important to monitor Resident 6's weight and recommend interventions for Resident 6's weight loss. During a concurrent interview and record review on 11/9/23 at 1:14 p.m. with Registered Nurse (RN) 1, Resident 6's Weight Loss Care Plan (WLCP), dated 4/12/23 was reviewed. The WLCP indicated, . Monitor weekly weight via weight variance . RN 1 stated the expectation was for the WLCP to be followed and Resident 6 weekly weight monitoring should have been done. During a concurrent interview and record review on 11/9/23 at 1:23 p.m. with the Director of Nurses (DON), Resident 6's Weight Loss Care Plan (WLCP), dated 4/12/23 was reviewed. The WLCP indicated, . Monitor weekly weight via weight variance . The DON stated the nursing staff should have followed Resident 6's WLCP for weekly weights to identify the weight loss, provide appropriate interventions, and evaluate if the interventions were effective. During a review of Resident 6's physician weight order, dated 6/8/23, the physician weight order indicated, .Monitor Weekly Weights . During a review of the Registered Nurse Job description, dated 8/31/23, the Job description indicated, . Observe residents and collect data pertinent to resident care. Communicate all relevant resident information with physicians and other healthcare professionals as needed . During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, . care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's and their causes . care plans are revised as information about the residents and the residents' conditions change .The interdisciplinary team reviews and updates the care plan . when desired outcome is not met . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 6 of 47 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 11/09/2023 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 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure services provided meet professional standards of practice for one of three sampled residents (Resident 6) when Resident 6's Physician order for weekly weights was not done on 7/17/23, 7/24/23, 8/7/23, 8/14/23, 8/21/23, 9/4/23, 9/11/23, 9/18/23, 9/25/23, 10/9/23, 10/16/23, and 10/23/23. Residents Affected - Few This failure resulted in Resident 6 unmonitored weight loss. During a concurrent observation and interview on 11/7/23 at 11:57 a.m. with Resident 6 at the bedside, Resident 6 was lying in bed with the noon meal tray in front of her. Resident 6 took a bite of pasta and stated she likes to eat steak and thought she was in her grandparents' home. During an interview on 11/8/23 at 9:15 a.m. with Resident 6 at Resident 6's bedside. Resident 6 stated her appetite was not good, and she preferred liquid foods for breakfast. During a review of Resident 6's admission Face Sheet (a document containing resident profile information which includes patient identification, past medical history, insurance status, care providers, family contact information), indicated Resident 6 was admitted to the facility on [DATE] with diagnoses included Morbid Obesity (Body Mass Index (BMI- is a screening tool used to assess whether an individual's weight is within a healthy range based on their height) of 40 or higher due to excess calories, dementia (a progressive impairment of intellectual functioning, memory, and abstract thinking), and major depressive disorder (a mental health condition that causes persistent feeling of sadness and loss of interest in activities that once brought joy). During a review of Resident 6's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 2/25/23, the MDS indicated Resident 6 had a BIMS (Brief Interview for Mental Status) score of 6 (0-7: severely impaired cognition), and very important for Resident 6 to have snacks available between meals; active Diagnoses with Malnutrition. During a concurrent interview and record review on 11/8/23 at 11:37 a.m. with the Family Nurse Practitioner (FNP), Resident 6's Weights and Vital Summary (WVS), dated was reviewed. The WVS indicated Resident 6's weight was not done on 7/17/23, 7/24/23, 8/7/23, 8/14/23, 8/21/23, 9/4/23, 9/11/23, 9/18/23, 9/25/23, 10/9/23, 10/16/23, and 10/23/23. The FNP stated she was not aware Resident 6 was not weighed weekly. The FNP stated it was important to monitor Resident 6's weight and recommend interventions for Resident 6's weight loss. During an interview on 11/9/23 at 8:16 a.m. with CNA 5. CNA 5 stated she noticed Resident 6 had been losing weight and had loose skin on her face and arms. CNA 5 stated Resident 6 eats poorly. During a concurrent interview and record review on 11/9/23 at 1:14 p.m. with Registered Nurse (RN), Resident 6's Physician Weight Order, dated 6/8/23 was reviewed. The Physician Weight Order indicated, . Monitor Weekly Weights . The RN stated the expectation was to follow the physician's weekly weight order and to document resident's refusal including interventions done to successfully performed the order. RN stated Resident 6 was refusing the weekly weight order and the Director of Nursing and Physician should have been notified. During a concurrent interview and record review on 11/9/23 at 1:23 p.m. with the DON, Resident 6's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 7 of 47 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 11/09/2023 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 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Physician Weight Order, dated 6/8/23 was reviewed. The Physician Weight Order indicated, . Monitor Weekly Weights . The DON stated the expectation was for staff to follow the physician's order. The DON stated Resident 6 refused the weekly weight order and staff should have to notify the physician. During a review of the facility's policy and procedure titled, Weighing and Measuring the Resident, dated March 2011, indicated, .The purpose of this procedure is to determine the resident's weight . to provide a baseline and an ongoing record of the resident's body weight and as an indicator of the nutritional status and medical condition of the resident . The following information should be recorded in the resident's medical record . if the resident refused the procedure, the reason(s) why and the intervention taken .Notify the Nurse Supervisor if the resident refuses the procedure . During a review of the facility's job description titled, Registered Nurse, dated 8/31/23, the job description indicated, .the RN is responsible for assisting with resident care under the medical direction and supervision of the residents' attending physicians .Perform nursing duties as directed and in accordance with appropriate scope of the Nurses Practice Act, including . performing treatments ordered by physician . observe residents and collect data pertinent to resident care. Communicate all relevant resident information with physicians and other healthcare professionals as needed . During a professional reference review titled, Lippincott Manual of Nursing Practice 11th Edition dated 2020, pages 15 indicated, . Standards of Practice . General Principles . These standards describe what nursing is, what nurses do, and the responsibilities for which nurses are accountable . A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation. This should be done at the time the care is rendered because passage of time may lead to a less than accurate recollection of the specific events . Common Departures from the Standards of Nursing Care . Legal claims most commonly made against professional nurses include the following departures from appropriate care: .follow physician orders, follow appropriate nursing measures, communicate information about the patient . document appropriate information in the medical record . and follow physician's orders that should have been questioned or not followed . Common Legal Claims for Departure from Standards of Care . Failure to implement a physician's . order properly . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 8 of 47 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 11/09/2023 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 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to monitor the effectiveness of nutrition interventions and recommend interventions to maintain acceptable parameters of nutritional status for one of three sampled Residents (Resident 6), during which time weight loss continued. Residents Affected - Few These failures resulted in Resident 6 experiencing an unhealthy, unplanned, and undesired severe weight loss of 33 pounds (lb) or 15 percent in six months and a 54 lb weight loss of 22.5 percent in eight months, which placed Resident 6 at risk for further health status decline. Findings: During a concurrent observation and interview on 11/7/23 at 11:57 a.m. with Resident 6 at the bedside, Resident 6 was lying in bed with the noon meal tray in front of her. Resident 6 took a bite of pasta and stated she likes to eat steak and thought she was in her grandparents' home. During an interview on 11/7/23 at 12:09 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 6 had about 25 % meal intake most of the time and always finished her Oral Nutrition Supplement (ONS-Nutrition drinks that has high calories and protein). CNA 1 stated she documented the ONS intake under the task for supplement intake. During a concurrent observation and interview on 11/7/23 at 12:45 p.m. with CNA 1, observed Resident 6 as she finished eating her lunch. CNA 1 stated Resident 6 only ate half of the Jell-O, half of the salad and a few bites of pasta, which was approximately 25 % of the meal. During an interview on 11/8/23 at 8:44 a.m. with CNA 1. CNA 1 stated Resident 6 was a little confused but communicated well. CNA 1 stated Resident 6 ate better for lunch, eating 25 -50 % but not breakfast. During breakfast Resident 6 would only drink the ONS. Resident 6 normally drinks100 % of ONS. CNA 1 stated Resident 6 was not a feeder, refused feeding assistance and would get angry when encouraged to eat. During an interview on 11/8/23 at 9:15 a.m. with Resident 6 at Resident 6's bedside. Resident 6 stated her appetite was not good, and she preferred liquid foods for breakfast. Resident 6 could not express her opinion regarding her weight loss. During an interview on 11/9/23 at 8:16 a.m. with CNA 5. CNA 5 stated she noticed Resident 6 had been losing weight and had loose skin on her face and arms. CNA 5 stated Resident 6 eats poorly. Sometimes Resident 6 gets mad and frustrated when she was encourage to eat and drink. CNA 5 stated Resident 6 gets ONS and milk during lunch and she always drinks the ONS and milk. CNA 5 stated she documented the ONS intake. CNA 5 stated she did not document the intake of milk or fortified cereal. During a review of Resident 6's admission Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 6 was admitted to the facility on [DATE] and readmitted on [DATE]. Resident 6's diagnoses included Morbid (Severe) Obesity [means that Body Mass Index (BMI) of 40 or higher; BMI is a screening tool used to assess whether an individual's weight is within a healthy range based on their height] due to excess calories, Non pressure Chronic ulcers of left and right thigh, Dementia (a chronic or persistent disorder of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 9 of 47 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 11/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), Chronic Kidney Disease [ (CKD) means that your kidneys are damaged and can't filter blood as they should]. During a review of Resident 6's Minimum Data Set (MDS), a standardized assessment and care-planning tool, dated 2/25/23, the MDS indicated Resident 6 had a BIMS (Brief Interview for Mental Status) score of 6 (0-7: severely impaired cognition), and very important for Resident 6 to have snacks available between meals; active Diagnoses with Malnutrition. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a BIMS score of 3 (0-7: severely impaired cognition), poor eating with 7-11 days over the last 2 weeks, with active Diagnoses with Malnutrition. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a BIMS score of 4 (0-7: severely impaired cognition), with poor eating with 2-6 days over the last 2 weeks, weighed 203 lb and had a Weight Loss of 5 % or more in the last month or loss of 10% or more in the last 6 months. , and was not on physician-prescribed weight-loss regimen [a program that is supervised by a medical professional that specializes primarily in weight loss for individuals that have a hard time losing weight despite their efforts]. During a review of Resident 6's MDS, dated [DATE], the MDS indicated Resident 6 had a BIMS score of 6 (0-7: severely impaired cognition), active Diagnoses with Malnutrition, weighed 202 lb and had a Weight Loss of 5% or more in the last month or loss of 10% or more in the last 6 months. During a review of Resident 6's weights (wts.) showed: 2/22/23: 240 lb (admission wt.) from Registered Dietitian Nutrition assessment 3/1/23: 242 lb 3/7/23: 242 lb 3/25/23: 235 lb (readmission wt.) 4/4/23: 225 lb 4/11/23: 223 lb 4/17/23: 224 lb 4/25/23: 220 lb (20 lb, 8.3 % severe weight loss in two month, severe since admission) 5/2/23: 219 lb 5/9/23: 218 lb 5/16/23: 217 lb (23 lb, 9.5 % severe weight loss in three month, severe since admission) 6/1/23: 207 lb (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 10 of 47 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 11/09/2023 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 0692 6/8/23: 204 lb Level of Harm - Minimal harm or potential for actual harm 6/12/23: 202 lb 6/19/23: 203 lb (37 lb, 15.4% weight loss in 4 months, severe since admission) Residents Affected - Few 6/26/23: 201 lb 7/1/23: 203 lb 7/11/23: 202 lb 8/2/23: 199 lb 9/1/23: 202 lb 10/2/23: 193 lb 11/2/23: 186 lb (54 lb, 22.5 % since admission in 8 months which indicated severe wt. loss) Based on the weight history, Resident 6 lost 20 lb in two months and 23 lb in three months. Resident 6 lost 33 lb (15%) from 5/2/23-11/2/23 severe weight loss in 6 months. Resident 6 lost a total of 54 lb (22.5 %) from 2/22/23 -11/2/23 is considered as severe weight loss in 8 months. According to the Journal of the American Dietetic Association (currently called the Academy of Nutrition and Dietetics), indicated Unintended weight loss is defined as a gradual, unplanned weight loss that may occur slowly over time or have a rapid onset. In older adults, a 5% or more unplanned weight loss in 30 days often results in protein-energy undernutrition as critical lean body mass is lost. (Journal of the American Dietetic Association, October 2010/Volume 110, Number 10). During a review of the physician's orders dated, showed on 2/21/23, No Added Salt diet, regular texture, Regular consistency until discontinued on 4/10/23. During a review of Resident 6's Nutrition Assessment dated 2/22/23, completed by the RD indicated, Resident 6's estimated nutritional needs were 1800 -2190 calories and 109 grams of protein. The assessment also indicated the physician ordered diet would meet Resident 6's nutritional needs. Resident 6 was also admitted with one State 3 pressure injury. The documented nutrition diagnosis listed the need for increased vitamins, minerals and protein related to the need for wound healing. The nutritional diagnosis also included morbid obesity. The plan of care was listed as wound healing and a Body Mass Index (BMI) of less than 40, however there was no documented plan on how the BMI would be reduced. During a review of Resident 6's Physician Orders for Life-Sustaining Treatment (POLST), dated 3/24/23, the POLST indicated, Trial period of artificial, including feeding tubes. During a review of Resident 6's readmission Nutrition Assessment dated 3/29/23, RD documented the estimated nutrient needs as 1855 -2165 calories and 85-107 grams of protein. The assessment indicated Resident 6's total nutritional intake, which was listed as an average of 39 %, did not meet estimated nutrition needs and also acknowledged a recent weight loss of 5# in 30 days. Nutrition (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 11 of 47 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 11/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions included offering healthy snacks between meals however there was no snacks ordered for Resident 6. During a review of Resident 6's Interdisciplinary team (IDT-a group of health care professionals all working toward a common goal) Malnutrition /At Risk for Malnutrition note, dated 3/29/23, the IDT Malnutrition /At Risk for Malnutrition note indicated, Date admitted : 3/24/23. Discussion/Review: Resident presents with High Risk for Malnutrition due to recent hospitalization, abnormal labs, Dx: Morbid Obesity, CKD 3, CHF, Hypothyroidism, Hyperlipidemia (HLD), Dementia, requires therapeutic diet order, significant wt. fluctuations related Dx: CHF, and skin impairment receiving treatment and supplements. While the IDT listed current malnutrition risks, there was no documentation of Resident 6's poor meal intake or recommend additional interventions for the decreased intake. During a review of the facility's nutrient analysis for the menu, indicated on average the No Added Salt (NAS) diet provided 2204 calories per day. During a review of Resident 6's meal intake record from 3/25/23 to 4/1/23, Resident 6's oral intake had an average range from 21 % to 38 % providing an average 651 calories, an average daily deficit of 1359 calories. During a review of Resident 6's Nutritional Management Committee Weight Note (NMCWN), dated 4/5/23, the NMCWN indicated, A 17 lb (7%) loss from initial weight and a 10 lb 4.25 % wt. l week (3/25/23 - 4/4/23). Resident 6's meal intake was listed as 10%. The plan was for staff to encourage and assist PRN with all PO intakes.IDT recommendations: Resident likes oatmeal and will try to give fortified cereal in a.m. for added calories (kcals). 4/10/23 No Added Salt diet with Fortified (enriched with adding extra calories and protein) cereal at breakfast, regular texture, Regular consistency. During a review of Resident 6's Monthly weight note by CDM, dated 4/10/23, the weight note indicated, Resident states she has not been feeling good with decrease intake notes. Was 10 % PO intake last week but upon review today it is up to 25 % PO intake. Still poor but improving. Started resident on fortified cereal last week and monitoring for acceptance. During a review of Resident 6's NMCWN, dated 4/17/23, the NMCWN indicated, . (4/4/23) Wt. 225 lb. Current body weight (CBW) 223 lb (4/11/23). A 2 lb wt. loss this week. While the facility recognized additional weight loss, there was no evaluation of the effectiveness of current interventions or recommendations of additional interventions. During a review of Resident 6's NMCWN, dated 4/19/23, indicated, a stable 1 lb weight gain per week, however intake was poor. IDT recommendations: . change 2 % milk to whole milk with all meals for added kcals. With a plan to continue to monitor. During a review of Resident 6's RD note, dated 4/26/23, RD documented, .Resident has been losing weight since admission.Resident intakes very low 0- 50 % most of the time. Resident is being monitored by wt. variance.Provided a sample of no sugar added house supplement. Resident liked it and agreed to add to for a month with meals to supplement diet and prevent significant weight loss.Will continue to monitor though weight variance committee. While the RD recommended a nutritional supplement there was no assessment of whether the additional supplements would adequately meet Resident 6's nutritional needs. During a review of Resident 6's meal intake record from 4/3/23 to 5/1/23, Resident 6's oral intake (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 12 of 47 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 11/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few had an average range from 12 % to 25 %. Resident 6's meal intake provided approximately on average 424 calories and 18 grams of protein an average daily deficit of 1586 calories. During a review of Resident 6's NMCWN, dated 5/11/23, the NMCWN indicated, . (3/1/23) Wt. 242 lb, (5/2/23) Wt. 219 lb. CBW 218 lb (5/9/23). A 1 lb wt. loss from last week following 24 lb (9.9%) loss since admit. Diet: NAS. Oral Intake 7 % . IDT recommendations: . Continue to monitor.Weekly weight stable. Continue with current interventions. While the facility recognized additional weight loss and poor po intake, there was no evaluation of the effectiveness of current interventions or recommendations of additional interventions. During a review of Resident 6's NMCWN, dated 5/18/23, the NMCWN indicated, . (5/9/23) Wt. 218 lb. CBW 217 lb (5/16/23). A 1 lb wt. loss from last week . resident had previously stated weight loss OK. Diet: NAS. Oral Intake 11 % . IDT recommendations: . Continue to monitor.Weekly weight stable. Continue with current interventions. Discontinue from weekly monitoring. During a review of Resident 6's meal intake record from 5/4/23 to 6/1/23, Resident 6's oral intake had an average range from 6 % to 15 %. Resident 6's meal intake provided approximately on average 198 calories when compared to the facility menu's nutrient analysis. And Resident 6's Sugar free house supplement intake record from 5/4/23 to 6/1/23 had an average range from refused to 360 ml which provided approximately on average 535 calories daily. Resident 6 had a deficit of 1277 calories. During a review of Resident 6's NMCWN, dated 6/8/23, the NMCWN indicated, .Wt.: Admit Wt. (3/1/23) 242 lb, (4/4/23) 225 lb, (5/2/23) 219 lb, (6/1/23) 207. A 35 lb (14 %) loss noted from admit. A 12 lb 5.4 % loss noted in the past month. Diet order: NAS oral intake: 4 %.Antidepressant medication changed to Mirtazapine (medication used to treat depression) 7.5 mg PO every evening (HS). Labs TSH (a test to find out how well the thyroid is working) ordered, Levothyroxine (medication used to treat hypothyroidism [a condition where the thyroid gland does not produce enough thyroid hormone]) decreased to 50 mcg (Microgram- a unit of measurement), will do follow up TSH level on 6/22/23. Social service: Mirtazapine 7.5 mg for depression as evidence by poor po intake of meals. IDT recommendation: .RD recommended give Ensure plus twice per day with breakfast and dinner daily.Will continue to monitor to see if new interventions will help increase intake and prevent further wt. loss. During a review of Resident 6's meal intake record from 6/3/23 to 7/1/23, Resident 6's oral intake had an average range from 7 % to 16 %. Resident 6's meal intake provided approximately on average 237 calories. Resident 6's ONS intake had range from refused to 480 ml from 6/5/23 to 7/1/23 which provided approximately average intake 467 calories. Resident 6 had an average daily deficit of 1306 calories. During a review of Resident 6's meal intake record from 7/4/23 to 8/1/23, unable calculate Resident 6's oral intake related to provided meal intake record indicated no data is available. Confirmed with CDM, no data was available for meal intake record from 7/4/23 to 8/1/23. During a review of Resident 6's meal intake record from 8/4/23 to 9/1/23, Resident 6's oral intake had an average range from 8 % to 14 %. Resident 6's meal intake provided approximately on average 247 calories. Resident 6's ONS intake had a range from refused to 480 ml from 8/4/23 to 9/1/23 which provided approximately average intake 640 calories. Resident 6 had an average daily deficit of 1123 calories. During a review of Resident 6 weights, showed on 8/2/23, Resident 6 weighed 199 lb which was a loss (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 13 of 47 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 11/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few of 20 lb (5/2/23 wt.: 219 lb - 8/2/23 wt.: 199 lb), 9% weight loss in 3 months, which is a severe weight loss. On 9/1/23, Resident 6 was 202 lb, which was a loss of 40 lb (3/1/23 wt.: 242 lb - 9/1/23 wt.: 202 lb) and 16.5% severe weight loss in 6 months. While the facility continuously monitored the weight loss there was no assessment of Resident 6's meal and supplement intake in comparison to estimated nutritional needs. During a review of Resident 6's discontinue medications, Resident 6 received [brand name appetite stimulator] 20 mg daily started on 9/28/23 until discontinued on 10/28/23. During a review of Resident 6's meal intake record from 9/3/23 to 10/1/23, Resident 6's oral intake had an average range from 8 % to 24 %. Resident 6's meal intake provided approximately on average 270 calories. Resident 6's ONS intake had a range from refused to 500 ml from 9/3/23 to 10/1/23 which provided approximately average intake 623 calories. Resident 6 had an average daily deficit of 1117 calories. During a review of Resident 6 weight record, showed on 10/2/23, Resident 6 weighed 193 lb, which was a loss of 32 lb (4/4/23 wt.: 225 lb; 10/2/23 wt.: 193 lb) and 14% severe weight loss in 6 months. There was no documentation from the IDT or RD addressing the weight loss. During a review of Resident 6's meal intake record from 10/4/23 to 11/1/23, Resident 6's oral intake had an average range from 6 % to 10 %. Resident 6's meal intake provided approximately on average 187 calories. Resident 6's ONS intake had a range from refused to 240 ml from 10/2/23 to 11/1/23 which provided approximately average intake 633 calories. Resident 6 had an average daily deficit of 1190 calories. During a review of Resident 6's meal intake record from 11/2/23 to 11/7/23, Resident 6's oral intake had an average range from 8 %. Resident 6's meal intake provided approximately on average 176 calories. Resident 6's ONS intake had a range from 180 to 237 ml from 11/2/23 to 11/5/23 which provided approximately average intake 671 calories. Resident 6 had an average daily deficit of 1163 calories. During a review of the physician's orders dated, showed on 11/6/23 [Brand name] high calories Oral Nutrition Supplement 2 times a day. During an interview on 11/8/23 at 10:20 a.m. with Registered Nurse (RN) 1. RN 1 stated she aware of Resident 6 had weight loss for a few months and was on appetite stimulator. RN 1 stated CNA documented fortified Cereal as part of breakfast meal intake, there was no separate individual monitoring for fortified cereal intake. RN 1 aware Resident 6 received whole milk with her meals. RN 1 stated she and CNA did not specifically monitor the whole milk intake. RN 1 stated she was not aware whole milk was part of nutrition intervention for Resident 6 wt. loss and it was documented in Resident 6 weight loss care plan. During an interview on 11/8/23 at 10:57 a.m. with Dietary Service Director (CDM). CDM stated 2 percent milk was changed to whole milk on 4/20/23. CNAs only document intake for house supplement and Oral Nutrition Supplements. CNAs did not separate documented whole milk and fortified cereal intake. During a concurrent interview and record review on 11/8/23 at 11:38 a.m. with Family Nurse Practitioner (FNP), Resident 6's weigh history was reviewed. FNP stated Resident 6 had poor po intake and depression. FNP stated Resident 6 weight loss desired by Resident and daughter as resident diagnosed with obesity. FNP was not aware of Resident 6's admission weight. After review Resident 6's weigh (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 14 of 47 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 11/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few history, FNP acknowledged Resident's 6 loss of 54 # with poor po intake was an unhealthy, unplanned and undesired weight loss. FNP stated she participated in IDT wt. variance on Wednesday. FNP could not recall when Resident 6 was discussed on IDT wt. variance. FNP stated Resident 6 should not have been discontinued on weekly IDT wt. variance on 5/18/23 since Resident 6 had an unhealthy, unplanned, and undesired wt. loss with poor po intake. FNP stated Resident 6 was not stable enough to remove her from IDT weekly weight variance. FNP further explained it was important to put Resident 6 on IDT weekly wt. variance consecutively to monitor Resident 6, implement interventions, provide her or IDT team more data and information to analyze Resident 6 and evaluate the effectiveness of interventions. During a concurrent interview and record review on 11/8/23 at 12:11 p.m. with Assistant Director of Nurses (ADON), Resident 6's NMCWN, dated 4/5/23, 4/10/23, 4/17/23, 4/19/23, 4/26/23, 5/4/23, 5/11/23, 5/18/23 and physician orders were reviewed. ADON stated Resident 6 was confused with Dementia and often refused meals intake and facility staff has a hard time encouraging Resident 6 to eat. Resident 6 had poor appetite with 0-25 % intake. ADON stated Resident 6 wt. loss has been happening since admission and her appetite had not been great. ADON stated IDT recommended fortified cereal for extra calories as part of intervention to help wt. loss. ADON stated the fortified cereal was not monitor, there is no way to tell whether Resident 6 was eating the fortified cereal, as a result there was no way to tell the effectiveness of the intervention. Reviewed NMCWN, dated 4/19/23, ADON stated change 2 percent milk to whole milk with each meal were to increase calories as part of intervention. ADON confirmed there was no monitoring intake whole milk intake so there was no way to tell the effectiveness of intervention. ADON stated she participated in IDT wt. variance. ADON stated the criteria for Residents who qualify to be on IDT wt. variance was residents who experienced weight loss and poor po intake. The IDT wt. variance committee would continue to monitor Residents weekly weights until the resident was stable, gaining weight, and eating meals. Review Resident 6's NMCWN, dated on 5/18/23 with ADON. ADON stated IDT recommended discontinued from IDT weekly weight variance monitoring because weight was stable with 1 # weight loss from last week and Resident 6 had previously stated that her wt. loss ok. ADON stated, As a nurse and clinical judgment. I would not take the resident's word for wanting to lose weight. ADON acknowledged Resident 6 only had BIMS score of 6 (0-7: severely impaired cognition). ADON stated Resident 6 loss 54 # since admission was unhealthy, unplanned and undesired. ADON acknowledged with poor appetite and weight loss, it would be beneficial to continue close monitoring on the IDT weekly wt. variance committee and should not have been discontinued on 5/18/23. ADON stated it is important to keep Resident 6 on IDT weekly weight variance for monitoring the effectiveness of interventions and making sure Resident 6 was offered enough nutrition. ADON acknowledged if IDT recommended some other interventions like increased frequency of ONS, started Megace (a medication used to improved appetite) earlier than September, discuss feeding tube with the family it could have helped Resident 6 to prevent continue wt. loss. During a concurrent interview and record review on 11/8/23 at 2:22 p.m. with Director of Nurses (DON), Resident 6's NMCWN, dated 4/5/23,4/19/23 and 5/18/23 were reviewed. DON stated the purpose of the IDT wt. variance committee was to discuss Residents who had weight changes, analyze the cause of wt. changes, and attempt new interventions. DON stated the criteria for Residents who qualify to be on IDT wt. variance included residents who experienced 5% weight change in 1 month, 10% weight change in 6 months, 3 lb per week wt. change depending on the resident's comorbidity, and to continue monitoring those residents until their weight stabilized, same wt. within 2 lb over a month, or they reach their desired weight or the family's goal weight. Review Resident 6's NMCWN, dated 4/5/23 and 4/19/23. DON stated fortified cereal and whole milk as an interventions were not monitor. He could not say if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 15 of 47 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 11/09/2023 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 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few interventions were working or not for Resident 6 to help her weight loss. Review NMCWN, dated 5/18/23, DON stated IDT discontinue Resident 6 on IDT weekly wt. variance because Resident 6 wt. stable. The surveyor reviewed the past 4 weeks of wts. (wt.: 4/17/23: 224 lb - 5/16/23: 217 lb), demonstrating Resident 6's weight was not stable, rather exhibited a loss of 7 lb. DON stated his expectation was the IDT went back to 4 weeks at time to review the weights. He stated the IDT committee should have kept Resident 6 on weekly wt. variance to see the whole picture and closely monitor and should not have discontinue Resident 6 on IDT weekly wt. vagrancies on 5/18/23. DON acknowledged the Wt. loss for Resident 6 was an unplanned and undesired weight loss. DON Acknowledged there were other interventions such as increasing the frequency of ONS to three time per day, providing snacks, or discussing the tube feeding option with family. During a concurrent interview and record review on 11/8/23 at 3:57 p.m. with RD, Resident 6's NMCWN, dated 4/5/23, 4/10/23, 4/17/23, 4/19/23, 4/26/23, 5/4/23, 5/11/23, 5/18/23, RD note on 4/26/23, 5/11/23, and Monthly weight note by CDM,, dated 4/10/23. RD stated she recommended fortified cereal and whole milk as part of interventions for Resident 6 wt. loss. RD stated CNAs or nurses did not document the intake of fortified cereal and whole milk. RD acknowledged without documentation as part of monitoring fortified cereal and whole milk intake, there was no way she could know whether Resident 6 accepted the interventions (fortified cereal and whole milk), or whether the interventions (fortified cereal and whole milk) were effectively helping Resident 6 gain weight. RD also acknowledged she could not do nutrition analysis for Resident 6 without monitoring intake of fortified cereal and whole milk. RD acknowledged Resident 6 weight loss is unhealthy, unplanned, and undesired related to insufficient calorie intake. RD stated Resident 6 should not have been discontinued on IDT weekly weight variance on 5/18/23. RD acknowledged if the IDT had recommended other interventions like increase the frequency of ONS to three time per day or between meals, adding snacks, liberalizing the diet and evaluating the effectiveness of the interventions, and continue monitoring Resident 6, it could have slowed or prevented further weight loss. During a review of the facility's Policy and Procedure (P&P) titled Weight Assessment and Intervention, Revised September 2008, the P&P indicated, The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents .negative trends will be evaluated by the treatment team .The threshold for significant unplanned and undesired weight loss will be based on the following criteria a. 1 month - 5% weight loss significant ; greater than 5 % is severe. b. 3 months - 7.5 % weight loss significant; greater than 7.5 % is severe. c. 6 months - 10 % weight loss significant; greater than 10 % is severe.Analysis: 1. Assessment information shall be analyzed by the multidisciplinary team and conclusions shall be made regarding: .b. the appropriate calories .needs compared with the resident's current intake. c. the relationship between current medical condition or clinical situation and recent fluctuation in weight; . According to the American Academy of Family Physician journal, indicated Elderly patients with unintentional weight loss are at higher risk for infection, depression and death. (American Family Physician, February 15, 2002/Volume 65, Number 4) According to the American Academy of Family Physician journal, indicated Involuntary weight loss can lead to muscle wasting, .depression and an increased rate of disease complications. Various studies demonstrated a strong correlation between weight loss and morbidity and mortality. One study showed that nursing home patients had a significantly higher mortality rate in the six months after losing 10 percent of their body weight, irrespective of diagnoses or cause of death. In another study, institutionalized elderly patients who lost 5 percent of their body weight in one month were found to be four times more likely to die within one year. (February 15, 2002/Volume 65, Number 4 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 16 of 47 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 11/09/2023 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 0692 www.aafp.org/afp American Family Physician) 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: 056338 If continuation sheet Page 17 of 47 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 11/09/2023 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 0697 Provide safe, appropriate pain management for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pain management services consistent with professional standards of practice for one of 53 residents (Resident 2) when Resident 2 was making loud noise and yell during nighttime and was assess for pain by the License Vocational Nurses (LVNs) using the numerical pain scale (a pain assessment tool in which the resident picks or draw a circle around the number that best describes their pain, 0 no pain, 1-3 mild pain, 4-6 moderate pain, and 7-10 severe pain) which was the wrong pain assessment tool because Resident 2's had severe cognitive impairment. Residents Affected - Few This failure resulted in Resident 2's experienced of pain not accurately assess and manage which could have resulted for Resident 2's increased in making loud noise and yelling during nighttime. Findings: During a record review of Resident 2's admission Record (AR), dated 11/8/23, the AR indicated, Resident 2 was admitted to the facility on [DATE] with the diagnoses of Unspecified Dementia (loss of thinking, remembering, and reasoning to the extent that it interferes with daily life), Cognitive Communication Deficit (difficulty with thinking and how someone uses language) Attention and Concentration Deficit (Difficulties in focusing, sustaining attention and maintaining concentration) and Pain. During a review of Resident 2's Minimum Data Set (MDS), dated 10/20/23, the MDS Section C indicated resident 2 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 with 15 being the highest score) of 5 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which indicated Resident 2 has severe cognitive impairment. During an interview on 11/6/23 at 12:20 p.m. with Resident 23 (Resident 2's roommate), Resident 23 stated Resident 2 was loud at night. Resident 23 stated sometimes at night the noise level from Resident 2 was unbearable. Resident 23 stated, Why don't they help her, give her something like they give me, medicine. During an interview on 11/6/23 at 12:27 p.m. with Resident 36 (Resident 2's roommate), Resident 36 stated Resident 2 yells and kept everyone up all night. Resident 36 stated she would get up at night and ask the license nurses to administer medicine to Resident 2 to help with Resident 2's yelling. Resident 36 stated she requested LVN 5 to administer medications to Resident 2 on 11/3/23 and 11/4/23 around midnight. During a record review of Resident 2's Order Summary Report (OSR), dated 11/8/23, the OSR indicated, Resident 2 had a doctor's order for Acetaminophen (a medication used to relieve pain) 325 MG (milligram unit of measure) give two tablets by mouth every six hours as needed for pain. During a review of Resident 2's Medication Administration Record (MAR), dated 11/1/23 through 11/30/23, the MAR indicated, LVN 5 administered two tablets of Acetaminophen 325 MG to Resident 2 on 11/4/23, at 11:45 p.m. During an observation on 11/8/23 at 3:31 p.m. in room [ROOM NUMBER], Resident 2 was lying in bed, looking straight at the curtains, talking to herself, and goes between yelling and talking in normal (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 18 of 47 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 11/09/2023 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 0697 tone. Resident 2 was making animated faces, smiling, and furrowing her eyebrows. Level of Harm - Minimal harm or potential for actual harm During an observation on 11/8/23 at 3:39 p.m. in room [ROOM NUMBER], Resident 2 was lying in bed. Resident 2 would yell at Resident 36 every time Resident 36 passed by her bed going to the bathroom. Residents Affected - Few During a concurrent interview and record review on 11/8/23 at 3:10 p.m. with LVN 3, Resident 2's Weights and Vitals Summary, dated 11/8/23 was reviewed. The Weights and Vitals Summary indicated, Resident 2 had her pain assessed using the numerical pain scale on 9/16/23, 9/22/23, 10/1/23, 10/4/23, 10/21/23, and 11/4/23. LVN 3 stated Resident 2 was confused and talks to herself. LVN 3 stated Resident 2 would start yelling at around 8 p.m. till 10 p.m. LVN 3 stated Resident 2's roommates would complain to the license nurses. LVN 3 stated the license nurses would redirect Resident 2 or administer pain medications. LVN 3 stated the license nurses used the numerical pain scale on 9/16/23, at 11:31 p.m., 9/22/23 at 2:23, 10/1/23, at 1 a.m., 10/4/23, at 6 p.m., 10/21/23, at 11:30 p.m., and 11/4/23 at 11:45 p.m. LVN 3 stated Resident 2's pain level was documented by license nurses between 3 out of 10 to 4 out of 10 which indicated mild to moderate pain. LVN 3 stated Resident 2 was cognitively impaired and unable to pick a number that best describes her pain. LVN 3 stated license nurses should have use the PAINAD scale (a pain assessment tool that uses five behaviors; breathing, negative vocalization, facial expression, body language, and the ability to be consoled) to assess Resident 2's pain accurately. LVN 3 stated it was important to use the correct pain assessment tool to accurately assess and adequately manage Resident 2's pain. LVN 3 stated the use of the wrong pain assessment tool had the potential for Resident 2 to experienced continues pain which could result to increased making of loud noise, yelling, and declined in activities of daily living. During a review of Resident 2's Medication Administration Record (MAR), dated 9/1/23 through 9/30/23, the MAR indicated, LVN 5 administered two tablets of Acetaminophen 325 MG to Resident 2 on 9/16/23, at 11:31 p.m. The MAR, indicated LVN 7 administered two tablets of Acetaminophen 325 MG to Resident 2 on 9/22/23, at 2:23 a.m. During a review of Resident 2's Medication Administration Record (MAR), dated 10/1/23 through 10/31/23, the MAR indicated, LVN 5 administered two tablets of Acetaminophen 325 MG to Resident 2 on 10/1/23, at 1:24 a.m. and on 10/21/23, at 11:30 p.m. The MAR indicated LVN 6 administered two tablets of Acetaminophen 325 MG to Resident 2 on 10/4/23, at 6 p.m. During an interview on 11/9/23 at 10:58 a.m. with the Director of Nursing (DON). The DON stated residents who are confused and unable to describe their pain should be assessed for pain using the PAINAD scale. The DON stated license nurses should have not used the numerical pain scale for residents who are confused. The DON stated Resident 2 was confused and unable to pick a number that best describes her pain intensity. The DON stated license nurses should have use the PAINAD scale to assess Resident 2's pain level. The DON stated it was important for license nurses to use the correct pain scale to accurately assess residents' pain. The DON stated this resulted for Resident 2's experienced of pain not accurately assessed and not properly manage. During a review of the facility's policy and procedure (P&P) titled, Pain Assessment and Management dated, 3/2020, the P&P indicated, . The purpose of this procedure are to help staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain . Pain management is a multidisciplinary care process that includes the following: a. Assessing the potential for pain; b. Recognizing the presence of pain; c. Identifying the characteristics of pain . Cognitive, cultural, familial or gender-specific influences on the resident's ability or willingness to verbalize pain are considered when assessing (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 19 of 47 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 11/09/2023 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 0697 Level of Harm - Minimal harm or potential for actual harm and treating pain . Recognizing Pain . Observe the resident (during rest and movement) for physiologic and behavioral (non-verbal) signs of pain . Possible Behavioral Signs of Pain, including: a. Verbal expressions such as groaning, crying, screaming; b. Facial expressions such as grimacing, frowning, clenching of the jaw . insomnia . Assess pain using a consistent approach and a standardized pain assessment instrument appropriate to the resident's cognitive level . Residents Affected - Few During a review of Professional Reference from National Library of Medicine https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8544573/, titled, Pain Assessment for Individuals with Advanced Dementia in Care Homes: A Systematic Review, dated. 10/2019, indicated, . Pain is prevalent in older people, especially in those with advanced dementia who have communication impairments. Although pain is recognized to be present in this population, it is often under-assessed and ineffectively managed. The assessment of pain in advanced dementia is extremely challenging and complex, particularly in institutional setting such ad care homes . The detection of pain in individuals with advanced dementia presents unique challenges associated with the reduced ability to comprehend information and reliably communicate pain. In t his group, behavioral indicators provide more reliable signs of pain . The six behavioral domains of pain . Facial expressions such as grimacing; Verbalizations and vocalizations such as groaning; Body movements, such as rocking; Changes in interpersonal interactions such as aggression; Changes in activity patterns and routines such as sleep; and Changes in mental state such as confusion . A recommendation by an expert group that focused on nursing homes recommended . PAINAD . , but the first two were the most clinically relevant. Use of these recommended pain scales is reflected in findings of this review, with . PAINAD being the most widely used in studies for this specific population and setting . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 20 of 47 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 11/09/2023 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 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the policy and procedure for dialysis (procedure to remove wastes and excess fluids from the body) was followed and professional standards of quality were met when one of three sampled residents (Resident 307) did not have documentation of completed post-dialysis weight assessments on multiple dates. Residents Affected - Few This failure placed Resident 307 at risk for delayed identification, reporting, and management of complications from dialysis. Findings: During a review of Resident 307's admission Record, undated, the admission record indicated, Resident 307 was admitted to the facility on [DATE] with diagnoses which included spinal stenosis, diabetes mellitus type 2, fluid overload, end stage renal disease and dependence on renal dialysis. During a concurrent observation and interview on 11/6/23 at 9:22 a.m. with Resident 307 in room [ROOM NUMBER], Resident 307 had a sign hanging above his bed which indicated, .no BP (blood pressures), Sticks (blood withdrawals) to left arm . Resident 307 stated he had a dialysis graft to his left forearm and was scheduled for dialysis every Tuesday, Thursday, and Saturday. During a concurrent interview and record review on 11/9/23 at 9:23 a.m. with Licensed Vocational Nurse (LVN) 4, Resident 307's Physician Orders (PO) dated 11/9/23 was reviewed. The PO indicated, .Pre and Post Dialysis Weight Only Per MD (Refer to Dialysis Communication Form) . Resident 307's Fluid Overload Care Plan, dated 10/12/23, was reviewed. The care plan indicated, .resident has fluid overload or potential fluid volume overload and weight changes related to the end stage renal disease . Interventions . Monitor residents post dialysis weight .Resident 307's Dialysis Communication Forms (DCF) titled Dialysis/Observation Communication Form, dated 11/2/23, 11/4/23, and 11/7/23 were reviewed. LVN 4 stated the PO indicated Resident 307's weight should be performed and documented on the DCF. LVN 4 stated the DCF was incomplete and did not have Resident 307's weights. LVN 4 stated the dialysis provider did not document Resident 307's on the DCF and the charge nurse on duty should have called the dialysis provider to request the information. During a concurrent interview and record review on 11/9/23 at 10:23 a.m. with the Director of Nursing (DON), Resident 307's DCF's dated 10/26/23, 10/28/23, 10/31/23, 11/2/23, 11/4/23, and 11/7/23 were reviewed. The DON stated the DCFs did not have Resident 307's weight post dialysis. The DON stated the expectation was for the charge nurse to call the dialysis provider for missing information and complete the DCF to help identify potential complications. During a review of the facility's policy and procedure (P&P) titled Hemodialysis Access Care, dated 9/2010, the P&P indicated, .The general medical nurse should document in the resident's medical record every shift as follows . Any part of report from dialysis nurse post-dialysis being given . During a review of Professional Reference from National Kidney Foundation https://www.kidney.org/atoz/content/dry-weight#:~:text=It%20will%20also%20make%20you,tell%20your%20healthcare%20 titled, What is Dry Weight?, undated, indicated, Your normal weight without any extra fluid in your body is called dry weight. Extra fluid can be dangerous and cause extra strain on your body, including your heart and lungs. When you have kidney failure, your body depends on dialysis to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 21 of 47 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 11/09/2023 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 0698 Level of Harm - Minimal harm or potential for actual harm get rid of the extra fluid and wastes that build up in your body between treatments . Keep track of your daily weight. Keeping track of your weight is important between dialysis sessions. If you see sudden weight gain between sessions, you should tell your healthcare provider immediately . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 22 of 47 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 11/09/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure expired medications were discarded and not available for use when a stool softener was stored and available for use in one of one medication cart. This failure had the potential to result in the administration of expired medication that may have lost their potency and may be ineffective. Findings: During a concurrent observation and interview on 11/8/23 at 10:05 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 identified one bottle of a stool softener medication with an expiration date of 8/2023. LVN 1 stated the expired stool softener medication should have been discarded to avoid giving the expired medications to residents. LVN 1 stated expired medications had the potential to lose its efficacy. During an interview on 11/8/23 at 10:18 a.m., with Registered Nurse (RN) 1, RN 1 stated, . checking the expiration date of medication is important because medication can lose it's efficacy and possibly cause unwanted side effects . During an interview on 11/8/23 at 10:28 a.m., with Director of Nurses (DON), the DON stated the expired stool softener medication should have been discarded and not stored in the medication cart ready for residents use. During a concurrent interview and record review on 11/9/23 at 11:14 a.m., with the ADM, the facility's policy, and procedure (P&P) titled, Storage of Medications dated 11/2020 was reviewed. The P&P indicated, . The facility stores all drugs and biologicals in a safe, secure, and orderly manner . 4. Drug containers that have missing, incomplete, improper, or incorrect labels are returned to pharmacy . Discontinued, outdated, or deteriorated drugs . are returned to the dispensing pharmacy or destroyed . ADM stated the expired stool softener medication should not have been stored in the medication cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 23 of 47 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 11/09/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure dietary staff were able to carry out the functions of food and nutrition services safely and effectively when: 1. [NAME] 2 was unable to properly calibrate the thermometer. This failure had the potential to cause foodborne illness for 50 out of 51 sampled residents who received foods from the kitchen. 2. [NAME] 2 did not follow manufacturer's guideline time length for testing the red bucket Quaternary (Quat) sanitizer (sanitizing solution used for sanitizing food contact surfaces). This failure had the potential to cause foodborne illness for 50 out of 51 sampled residents who received foods from the kitchen. 3. [NAME] 1 did not follow the Cooks spreadsheet (the menu document used to guide dietary staff on food items, portions, texture of foods and therapeutic diet) portion size to make pureed chicken during the noon meal on 11/7/23. This failure had the potential risk of compromised residents' nutrition status for four of four sampled residents (Resident 1, 18, 34, and 309) who received pureed meat from the kitchen. 4. [NAME] 2 served regular texture Brussels sprouts to mechanical soft diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) residents during the noon meal on 11/6/23. This failure had the potential risk of choking for two of two sampled residents (Resident 33 and 45) who received mechanicals soft diet from the kitchen. 5. [NAME] 1 served chunks pureed (pureed foods' texture should be smooth for residents who have difficulty chewing and/or swallowing) chicken to purred diet residents during the noon meal on 11/7/23. This failure had the potential risk of choking for four of four sampled residents (Resident 1, 18, 34, and 309) who received puree diet from the kitchen. Findings: During a concurrent observation and interview on 11/7/23 at 10:07 a.m., in the kitchen with [NAME] (CK) 2 and Dietary Service Director (CDM). Observed CK 2 calibrated thermometer. CK 2 got a cup of 8 ounces (oz- a unit of measurement) ice cube water. CK 2 put the thermometer into the ice water. CK 2 stated she needed to calibrate thermometer to 35 degrees Fahrenheit (°F - a unit of measurement). The CDM stated the thermometer supposed to calibrate to 32 °F not 35 °F. The CDM stated thermometers were not properly calibrated and the dietary staff would get wrong food temperature reading. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 24 of 47 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 11/09/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During an interview on 11/7/23 at 10:15 a.m., with the Registered Dietitian (RD) and CDM. Both stated they did not provide in service for Dietary staff regarding how to calibrate thermometer. During an interview on 11/7/23 at 3:06 p.m., with the RD. The RD stated the thermometer needed to be calibrate to 32 °F. The RD stated the potential risk for thermometers which were not properly calibrated was when the dietary staff would used it to check the food temperature and gets the wrong temperature food reading. The RD stated wrong food temperature could cause foodborne illnesses. During a review of the facility's policy and procedure (P&P) titled, CALIBRATING A PROBE OR DIGITAL THERMOMETER, revised 8/31/2018, the P&P indicated, .thermometer should read 32 ?. During a review of the facility's policy and procedure (P&P) titled, Food preparation and Service, revised April 2019, the P&P indicated, Policy Statement: Food and nutrition service employees prepare and serve food in a manner that complies with safe food handling practices.Food Preparation, Cooking and Holding Time/Temperatures .5. Food thermometers used to check food temperatures are .calibrated for accuracy. During a review of the professional reference retrieved from Centers for Disease Control and Prevention (CDC) document titled, Food Safety, dated 10/15/21, the reference indicated, .Food is safely cooked when the internal temperature gets high enough to kill germs that can make you sick. The only way to tell if food is safely cooked is to use a food thermometer. You can't tell if food is safely cooked by checking its color and texture .Use a food thermometer to ensure foods are cooked to a safe internal temperature . 2. During a concurrent observation and interview on 11/7/23 at 10:04 a.m., in kitchen with CK 2. CK 2 tested red bucket Quat sanitizer with Quat sanitizer test strip. CK 2 stated she needed to dip Quat sanitizer test strip into red bucket for 10 seconds. CK 2 tested the red bucket Quat sanitizer with Quat sanitizer test strip with 4 attempts. First and second attempts, CK 2 only dip Quat sanitizer test strip into red bucket for 5 seconds, 3rd attempt was for 6 seconds and 4th attempt was 7 seconds. During an interview on 11/7/23 at 10:15 a.m., with the RD and CDM. Both stated they did not provide in service for Dietary staff regarding testing the red bucket Quat sanitizer. During an interview on 11/7/23 at 4:52 p.m., with the RD. The RD stated the [NAME] test strip was supposed to be dipped for 10 seconds. The RD stated if Quat sanitizer test strip dip into Quat sanitizer with shorter length than manufacturer's instructions, it could potentially lead to the dietary staff not get the right concentration [NAME] sanitizer. The RD stated if the [NAME] sanitizer not in the right concentration which could cause for the food contact surfaces not properly sanitized and could lead to foodborne illness. The RD stated her expectation was dietary staff to follow manufacturer instructions dip Quat sanitizer test strip for 10 seconds. During a review of the Quat sanitizer test strip bottle's instructions, undated, the instructions indicated, Dip paper in quat solution, .for 10 seconds. According to the USDA Food Code 2022, Section 3-304.14 Wiping Cloths, Use Limitation, . Proper sanitizer concentration should be ensured by checking the solution periodically with an appropriate chemical test kit. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 25 of 47 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 11/09/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many According to the USDA Food Code 2022, Section 4-501.114 Manual and Mechanical Ware washing Equipment, Chemical Sanitization -Temperature, pH, Concentration, and Hardness, (C) A quaternary ammonium compound solution shall (2) Have a concentration as specified under § 7-204.11 and as indicated by the manufacturer's use directions included in the labeling. During a review of the facility's Job Description titled, Cook, dated 1/1/23, the Job Description indicated, Responsible for preparing meals .in accordance with the . standards, and federal, state, and local regulations.ESSENTIAL DUTIES: Successful performance requires satisfactory completion of all essential duties and responsibilities. The essential duties described below are representative of all the skills and ability necessary while performing the basic functions of the position. Follow all sanitation .and regulations . During a review of the facility provided CK 2's competency checklist titled, Cook, signed by CK 2 and evaluator was CDM on 3/30/23, the competency checklist indicated CK 2 met job expectations in all job categories including Proper sanitizer solutions range, sanitizing strip . 3. During a concurrent observation and interview on 11/7/23 at 9:41 a.m., with the CK 1 in the Kitchen, CK 1 put some dice chicken into blender to make pureed meat. CK 1 stated he put 6 ounces (oz- a unit of measurement) of dice chicken to make 5 portions of pureed meat for noon meal. During a concurrent interview and record review on 11/7/23 at 3:13 p.m., with the RD, the Cooks Spreadsheet dated 11/7/23 was reviewed. The Cooks Spreadsheet indicated, 1 portion of Lemon Chicken Piccata is 3 oz . The RD stated 1 portion of pureed meat is 3 oz of chicken. If CK 1 needed to make 5 portions of pureed meat, then CK 1 supposed put 15 oz of dice chicken into blender not 6 oz of dice chicken. The RD stated CK1 could run out pureed meat during lunch meal serving. The RD stated residents who received pureed meat did not get the amount of the portion size on the menu which could lead to weight loss and nutrient deficiency. The RD stated the expectation was for Cooks to follow the Cooks Spreadsheet. During a review of the facility's Job Description titled, Cook, dated 1/1/23, the Job Description indicated, Responsible for preparing meals .in accordance with the menu, approved recipes, standards, and federal, state, and local regulations. Provide high quality food .ESSENTIAL DUTIES: Successful performance requires satisfactory completion of all essential duties and responsibilities. The essential duties described below are representative of all the skills and ability necessary while performing the basic functions of the position.Adhere to all guidelines and approved menus and recipes when preparing meals, .Follow guidelines for preparing special diet meals. 4. During a concurrent observation and interview on 11/6/23 at 12:06 p.m., with Resident 33 and 45 in dining room. Resident 33 and Resident 45's meal ticket showed both on Mechanical Soft diet. Observed Resident 33 and Resident 45 received not chopped, tender, round shape, approximate 1-inch regular texture Brussels sprouts on their meal tray. Resident 45 stated the Brussels sprouts was hard for him to chew. During a concurrent interview, and record review on 11/6/23 at 12:22 p.m., with the RD, Residents 33 and Resident 45 in the dining room, the Cooks Spreadsheet dated 11/6/23 was reviewed. The Cooks Spreadsheet indicated, Mechanical Soft Brussels sprouts chopped ½ inch. The RD stated Residents 33 and Resident 45 should have receive chopped ½ inch Brussels sprouts not the regular texture Brussels sprouts. The RD stated residents on mechanical soft diet who was served regular texture Brussels sprouts could have difficulty chewing and swallowing which could lead to choking. The RD (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 26 of 47 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 11/09/2023 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated the expectation was for dietary staff to follow the menu, cook spreadsheet and recipe for serving chopped ½ inch Brussels sprouts for mechanical soft residents. During a review of the facility's Job Description titled, Cook, dated 1/1/23, the Job Description indicated, Responsible for preparing meals .in accordance with the menu, approved recipes, standards, and federal, state, and local regulations. Provide high quality food .ESSENTIAL DUTIES: Successful performance requires satisfactory completion of all essential duties and responsibilities. The essential duties described below are representative of all the skills and ability necessary while performing the basic functions of the position.Adhere to all guidelines and approved menus and recipes when preparing meals, .Follow guidelines for preparing special diet meals. 5. During a concurrent observation and interview on 11/7/23 at 12:45 p.m., with the RD, CDM and Speech therapist (ST), a test meal was performed for food palatability and food texture of the regular, mechanical soft and puree diets. The purred chicken had chunks of meat. ST acknowledged there was some chunks in the pureed chicken. The RD stated CK 1 should have left the chicken in the blender for a longer period to reach the smooth consistency with no chunks. During a concurrent interview and record reviewed on 11/7/23 at 3:22 p.m., with the RD. The Recipe: Pureed Meats dated 4/17/23 was reviewed. The Recipe: Pureed Meats indicated, .Puree should reach a consistency slightly softer than whipped topping. The RD stated pureed chicken needs to be smooth like whipped topping as indicated in the recipe with no chunks. The RD stated the potential risks for residents on purred diet and was served chunks of meat on their pureed diet was choking. The RD stated the expectation was for the Cooks to follow the recipe. During a review of the facility's Job Description titled, Cook, dated 1/1/23, the Job Description indicated, Responsible for preparing meals .in accordance with the menu, approved recipes, standards, and federal, state, and local regulations. Provide high quality food .ESSENTIAL DUTIES: Successful performance requires satisfactory completion of all essential duties and responsibilities. The essential duties described below are representative of all the skills and ability necessary while performing the basic functions of the position.Adhere to all guidelines and approved menus and recipes when preparing meals, .Follow guidelines for preparing special diet meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 27 of 47 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 11/09/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. Based on observation, interview, and record review, the facility failed to ensure the nutritional needs for four of four sampled residents (Residents 1, 18, 34, and 309) was met for lunch on 11/7/23 when the meal was not plated in accordance with menu guidance for purred diet portion size for purred meat. This failure had the potential to result in under nutrition further compromising the medical status of Residents 1, 18, 34, and 309 who received pureed meat from the kitchen. Findings: During a concurrent observation and interview on 11/7/23 at 9:41 a.m., with [NAME] (CK)1 in the kitchen, CK 1 pour a bowl of dice chicken into blender to make pureed meat. CK 1 stated he weighed the dice chicken and was 6 ounces (oz- a unit of measurement). CK 1 stated he put 6 oz of dice chicken in the blender to make 5 portions of pureed meat for lunch meal. During a concurrent interview and record review on 11/7/23 at 3:13 p.m., with the Registered Dietitian (RD), the Cooks Spreadsheet Fall Menus dated 11/7/23 was reviewed. The Cooks Spreadsheet Fall Menus indicated, 1 portion of Lemon Chicken Piccata is 3 oz . The RD stated 1 portion of pureed meat is 3 oz of chicken. The RD stated CK I should have put 15 oz of dice chicken in the blender to make 5 portions of purred meat. The RD stated CK 1 could run out of purred meat for the lunch meal serving. The RD stated residents who received pureed meat did not get the amount of the portion size on the menu which could lead to weight loss and nutrients deficiency. The RD stated the expectation was for CK 1 to follow the Cooks Spreadsheet. During a review of the facility's provided physician diet orders, dated 11/7/23, the physician diet orders indicated, Residents 1, 18, 34, and 309 had physician's orders for pureed meat texture diet. During a review of the facility's provided recipe titled, PUREED MEATS, dated 4/17/23, the PUREED MEATS recipe indicated, .6. Follow the portion size to serve as per the cook's spreadsheet. During a review of the facility's policy and procedure (P&P) titled, Menus, revised October 2017, the P&P indicated, Menus are developed and prepared to meet resident .needs while following established national guidelines for nutritional adequacy.1. Menus meets the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy Sciences). During a review of the facility's Job Description titled, Cook, dated 1/1/23, the Job Description indicated, .ESSENTIAL DUTIES: .Adhere to all guidelines and approved menus and recipes when preparing meals, .Follow guidelines for preparing special diet meals. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 28 of 47 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 11/09/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for six of six residents (Resident 33, Resident 45, Resident 1, Resident 18, Resident 34, and Resident 309) when: 1. [NAME] 2 served Resident 33 and Resident 45 a regular textured Brussels sprouts for lunch instead of the physician ordered mechanical soft diet (a diet with food texture of chopped and ground designed for residents who have trouble chewing and swallowing). 2. [NAME] 1 served Resident 1, Resident 18, Resident 34, and Resident 309 chunks of chicken for lunch instead of the physician ordered puree diet (a diet with food texture of soft pudding-like consistency). These failures placed Residents at risk for aspiration (accidentally inhaling food or liquid into the lungs) and choking. Findings: 1. During a review on 11/6/23 at 12:00 p.m. of Resident 45 & Resident 33's Meal Tray Ticket (menu based on the resident's diet physician order and food preference), dated 11/6/23, the Meal Tray Ticket indicated Resident 45 & Resident 33 had a diet order for Mechanical Soft diet. During a concurrent observation and interview on 11/6/23 at 12 p.m. with Resident 45 in the dining room, Resident 45's lunch meal was observed to have a whole Brussels sprouts with a length of 1 inches (unit of measurement). Resident 45 stated it was difficult for him to chew the served Brussels sprouts, due to having missing teeth. During a concurrent observation, interview, and record review on 11/6/23 at 12:22 p.m., with the Registered Dietitian (RD) in dining room, the Cooks Spreadsheet dated 11/6/23 was reviewed. The Cooks Spreadsheet indicated, Mechanical Soft Brussels sprouts chopped ½ inch. The RD confirmed Resident 45 and Resident 33 received regular texture Brussels sprouts which measured at 1 inch in length. The RD stated Residents 33 and Resident 45 should have received chopped Brussels sprouts with a measurement of ½ inch or less than ½ inch. The RD stated Resident 33 and Resident 45 with a physician order for mechanical soft diet and were served with regular texture Brussels sprouts could have difficulty chewing and swallowing which could lead to choking . The RD stated the expectation was for dietary staff to follow the menu, cook spreadsheet and recipe for serving chopped ½ inch Brussels sprouts for residents on mechanical soft diet. During a concurrent interview and record review on 11/7/23 at 12:13 p.m. with the Speech Therapist (ST), the photo of Resident 45's lunch tray which contained a whole Brussels sprouts taken on 11/6/23 at 12:27 p.m. was reviewed. The ST stated Resident 45 had an order for mechanical soft diet and was served Brussels sprouts which were not chopped into smaller pieces. The ST stated the Brussels sprouts could cause aspiration, which could lead to aspiration pneumonia or even death for Resident 45 who had missing teeth and difficulty in chewing. During a concurrent interview and record review on 11/9/23 at 10:39 a.m. with Registered Nurse (RN) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 29 of 47 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 11/09/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm 1, the photo of Resident 45's lunch tray which contained a whole Brussels sprouts taken on 11/6/23 at 12:27 p.m. was reviewed. RN 1 stated Resident 45 had an order for mechanical soft diet and was served Brussels sprouts which were not chopped into smaller pieces. RN 1 stated the expectation for mechanical soft diet was for vegetables to be chopped into small pieces. RN 1 stated Resident 45 could have aspirated and choked from the large pieces of Brussels sprouts. Residents Affected - Some During a review of Resident 45's admission Face Sheet (a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), indicated Resident 45 was admitted to the facility on [DATE]. Resident 45's diagnoses included, .Dysphagia (residents who have difficulty swallowing), oral phase . During a review of Resident 45's physician diet order, dated 6/8/23, the physician diet order indicated, . Mechanical Soft Texture . During review of Resident 33's admission Face Sheet, indicated Resident 33 was admitted to the facility on [DATE]. The admission Record indicated Resident 33's diagnosis information included, . Hemiplegia (function loss of one side of body), unspecified affecting left nondominant side . During a review of Resident 33's physician diet order, dated 9/16/22, the physician diet order indicated, . Mechanical Soft Texture . During a review of facility's Regular Mechanical Soft Diet document, dated 2023, the Regular Mechanical Soft Diet document indicated, .The mechanical soft diet is designed for residents who experience chewing or swallowing limitations . modified by mechanically altering, chopped, or ground. Food that may need to be modified include .Cooked Vegetables . Chopped soft Brussels sprouts - ½ inch or less . 2. During a concurrent observation and interview on 11/7/23 at 12:30 p.m. with the ST in Resident 34's room, Resident 34's was served chicken for lunch meal. The ST stated the chicken meat looks minced and not pureed. During a concurrent observation and interview on 11/7/23 at 12:45 p.m., with the RD, Certified Dietary Manager (CDM) and ST, a test meal was performed for food palatability and food texture of the regular, mechanical soft and puree diet meals. The pureed chicken was observed to have chunks of meat. The ST acknowledged there were some chunks of meat in the pureed chicken. The RD stated the Dietary Cooks should have left the chicken in the blender for a longer period to reach the smooth consistency with no meat chunks. During a concurrent interview and record reviewed on 11/7/23 at 3:22 p.m., with the RD. The Recipe: Pureed Meats dated 4/17/23 was reviewed. The Recipe: Pureed Meats indicated, .Puree should reach a consistency slightly softer than whipped topping. The RD stated pureed chicken needs to be smooth like whipped topping as indicated in recipe with no chunks. The RD stated residents who had physician's order for pureed diet and received chunks of meat on their meal could have difficulty in chewing and could choke. The RD stated the expectation was for the Dietary Cooks to follow the recipe to serve smooth pureed foods. During a review of the physician diet orders, dated 11/7/23, the physician diet orders indicated, Residents 1, 18, 34, and 309 had physician's order for pureed meat texture diet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 30 of 47 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 11/09/2023 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 0805 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's Pureed Diet document, the Pureed diet indicated, The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 31 of 47 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 11/09/2023 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 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 maintain a sanitary environment, prepare, and served food in accordance with professional standards for food service safety when: Residents Affected - Many 1. The 3-compartment sink did not have an air gap (is vertical space between the end of a pipe and the top of a nearby sink that prevents the backflow of contaminated water). 2. [NAME] debris was observed on the wall next to the milk refrigerator, cook freezer, above the steam table, door frame of the dry storage door and a black fan located next to clean water pitchers. 3. Milk refrigerator and produce refrigerator shelves had chipped paint. 4. Two floor holes observed underneath the ice machine. 5. The inside of two microwaves, one located by the hand wash station and the other next to the three-compartment sink had brown sticky substance. 6. The Dietary aide (DA) had exposed facial hair and [NAME] (CK) 2 had exposed hair during meal preparation. These failures had the potential to result in cross contamination (bacteria are unintentionally transferred from one substance or object to another with harmful effect) and foodborne illnesses (are illnesses that results from ingesting contaminated foods) for 50 out of 51 sampled residents who received foods from the kitchen. Findings: 1.During a concurrent observation and interview on 11/7/23 at 9:12 a.m. with [NAME] (CK) 1, in front of the three-compartment sink (three sinks used for washing kitchenware, one for washing, one for rinsing and one for sanitizing). The three-compartment sink was observed not having an air gap. CK 1 stated the middle sink was used for washing meats and produce and acknowledged there was no air gap. During an interview on 11/7/23 at 9:19 a.m. with the Registered Dietitian (RD), the RD stated she was aware the food production sink did not have an air gap. During a concurrent observation and interview on 11/7/23 at 9:30 a.m. with Director of Maintenance (DOM), in front of the three-compartment sink. The DOM confirmed food production sink did not have an air gap. During an observation on 11/7/23 at 10:50 a.m. in front of the three-compartment sink, CK 1 used the middle rinsing sink for washing salad. During an interview on 11/7/23 at 3:30 p.m. with the RD, the RD stated the production sink without an air gap had the potential to cause cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 32 of 47 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 11/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the professional reference titled, FDA Food Code 2022, section 5-202.14 Backflow Prevention, Device, indicated, A PLUMBING SYSTEM shall be installed to preclude backflow of a solid, liquid, or gas contaminant into the water supply system at each point of use at the FOOD ESTABLISHMENT, . backflow prevention is required by LAW . 2. During a concurrent observation and interview on 11/6/23 at 9:37 a.m., with the RD, in the kitchen, the RD confirmed brown debris was on the wall next to the milk refrigerator. During a concurrent observation and interview on 11/6/23 at 9:54 a.m. with the RD, in the kitchen, the RD confirmed the black fan located next to the clean water pitchers was covered with brown debris. The RD stated there was a potential for cross contamination for the fan blowing dust to the clean water pitchers. During a concurrent observation and interview on 11/6/23 at 10:05 a.m. with RD, the RD confirmed the wall next to the cook's freezer and above the steam table had brown debris. The RD stated the wall next to the cook's freezer and above the steam table should have been cleaned t prevent the dust to fall on clean surfaces and cause cross contamination. During a concurrent observation and interview on 11/6/23 at 10:23 a.m. with Dietary Service Director (CDM), the CDM confirmed the door frame to the dry food storage room had brown debris. The CDM stated the brown debris was dust on the door frame and had a potential for cross contamination. During an interview on 11/07/23 03:27 p.m. with RD, the RD stated the expectation was for the dietary staff, housekeeping and maintenance to keep the kitchen clean, and free of dust. During a review of the facility's policy and procedure titled, Sanitization, dated October 2008, indicated, .The food service area shall be maintained in a clean and sanitary manner . All kitchens, kitchen areas . shall be kept clean . 3. During a concurrent observation and interview on 11/6/23 at 9:34 a.m. with RD, the RD confirmed the nine white shelves on the milk refrigerator had chipped paint. The RD stated the 9 white shelves should have been removed and replaced to prevent cross contamination. During a concurrent observation and interview on 11/6/23 at 10:32 a.m. with RD, the RD confirmed the 5 white shelves on the produce refrigerator had chipped paint. The RD stated the 5 white shelves should have been removed and replaced to prevent cross contamination. During a review of the facility's policy and procedure titled, Sanitization, dated October 2008, indicated, .All shelves and equipment shall be . maintained in good repair and shall be free from breaks, corrosions, open seams, cracks, and chipped areas . During a review of facility's policy and procedure titled, Refrigerators and Freezers, dated December 2014, indicated, .Supervisors will inspect refrigerators and freezers monthly for any other damage or maintenance needs . 4. During a concurrent observation and interview on 11/6/23 at 9:48 a.m. with RD, there was two holes (one hole was approximately tennis ball size and another hole was approximately 4-inch length by 4-inch width) on the floor underneath the ice machine. The RD stated the two holes underneath the ice machine was hard to clean and should have been sealed to prevent the deposits of debris which (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 33 of 47 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 11/09/2023 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 0812 could harbor bacteria. Level of Harm - Minimal harm or potential for actual harm During a review of professional reference titled, FDA Food Code 2022, section 6-201.11 Floors, Walls, and Ceilings, indicated, . floors, floor coverings, walls, wall coverings, and ceilings shall be designed, constructed, and installed so they are SMOOTH and EASILY CLEANABLE. Residents Affected - Many 5. During a concurrent observation and interview on 11/6/23 at 10:12 a.m. with the RD, the inside of the microwave located by the hand wash station had brown sticky substance. The RD stated the brown sticky substance was food particles. The RD stated the microwave should have been clean to prevent bacterial growth inside the microwave which could lead to cross contamination of food. During a concurrent observation and interview on 11/6/23 at 10:15 a.m. with the RD, the inside of the microwave located next to the three-compartment sink had brown substance. The RD stated the microwave was dirty, with food particles which resembles sauce or gravy. The RD stated there was a potential for bacteria growth inside the microwave. During an interview on 11/7/23 at 3:28 p.m. with the RD, the RD stated the microwaves should be wiped and clean after each use. The RD stated the microwaves were not cleaned and should have been clean to prevent bacterial growth and cross contamination. During a review of the facility's policy and procedures titled, Food Preparation and Service, dated April 2019, indicated, .Appropriate measures are used to prevent cross contamination. These include .cleaning and sanitizing . food-contact equipment between uses . During a review of the facility's policy and procedure titled, Sanitization, dated October 2008, indicated, .All equipment, food contact surfaces and utensils shall be washed to remove or completely loosen soils by using he manual or mechanical means necessary . 6. During a concurrent observation and interview on 11/7/23 at 10:49 a.m. with the RD, the RD confirmed CK 2's hair was not fully covered, and the Dietary Aide (DA) had facial hair with no cover. CK 2 and the DA were preparing noon meal for residents. The RD stated CK 2's hair should have been fully covered and the DA should have worn a beard net for his facial hair. During an interview on 11/7/23 3:32 p.m. with the RD, the RD stated the expectation was for the kitchen staff to cover all hair, beards, or shave to prevent cross contamination. During a review of the facility's policy and procedure titled, Food Preparation and Service, dated April 2019, indicated, .Food and nutrition services staff wear hair restraints (hair net, hat, beard restraint, etc.) so that hair does not contact food . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 34 of 47 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 11/09/2023 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 0814 Dispose of garbage and refuse properly. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to dispose of garbage under sanitary condition when the facility's trash dumpster was left uncovered and overfilled. Residents Affected - Few This failure had the potential to attract rodents, insects, and flies which could place residents at risk for cross contamination (the process by which bacteria are unintentionally transferred from one substance or object with harmful effect) and foodborne illness (illnesses cause from ingestion contaminated food). Findings: During an observation on 11/6/23 at 8:33 a.m. outside the facility. The facility green recycle dumpster was not fully closed and was overflowing with boxes, tree branches, leaves and landscaping materials. During a concurrent observation and interview on 11/6/23 at 8:38 a.m. with the Dietary Service Director (CDM), in front of the green recycle dumpster. The CDM confirmed the facility dumpster was not fully close and was overfilled with boxes, tree branches, leaves and landscaping materials. The CDM stated the facility dumpster was to be used for recycling boxes only and should not be used for [NAME] branches and landscaping materials. The CDM stated the facility dumpsters was left open and had the potential to attract pests or rodents into the facility. During an interview on 11/7/23 at 3:33 p.m. with the Registered Dietitian (RD), the RD stated the dumpster was not fully close and was overfilled with trash. The RD stated the dumpster had the potential to attract rodents, flies, and bacteria growth that could spread into the facility. The RD stated the expectation was for all dumpsters in the facility to be fully closed. During a review of the facility's policy and procedure titled, Food-Related Garbage and Refuse Disposal, dated October 2017, indicated, .outside dumpsters provided by garbage pickup services will be kept closed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 35 of 47 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 11/09/2023 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infections when: Residents Affected - Many 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene during medication administration to Resident 51. 2. The clean linen room door was left open to the hallway, and the room was unoccupied. 3. The linen cart located in the east hallway containing clean gowns was left open and a crumpled paper tissue was left on the bottom shelf of the cart. 4. The north shower room had washcloth hanging on the soap holder and the handheld shower head was left on the floor. These deficient practices placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect). Findings: 1. During a concurrent observation and interview on 11/7/23 at 12:15 p.m., with LVN 1 in room [ROOM NUMBER], LVN 1 was preparing Resident 51's medications for administration. LVN 1 touched the top of the medication cart, the drawers, and the lock during the medication preparation. LVN 1 entered Resident 51's room and administered the medications to Resident 51 without performing hand hygiene. A hand gel sanitizer wall dispenser was on Resident 51's doorway with a sign indicating gel in, gel out (sign that helps raise awareness to perform hand hygiene to prevent the spread of disease). LVN 1 stated she touched the surface areas of the medication cart during medication preparation and administered medications to Residents 51 without performing hand hygiene. LVN 1 stated she should have performed hand hygiene to prevent the spread of infection. During an interview on 11/8/23 at 9:38 a.m. with the Infection Preventionist (IP), the IP stated the facility expectation was for the license nurses to perform hand hygiene using the hand sanitizer gel prior to medication preparations, upon entering and exiting resident's room. The IP stated the medication cart could be contaminated and the license nurse could unintentionally transfer bacteria from the medication cart surfaces to the residents. The IP stated LVN 1 should have perform hand hygiene prior to administering medication to Resident 51 to prevent cross contamination which can lead to infection. During a concurrent interview and record review on 11/8/23 at 12:12 p.m. with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled Administering Medications, dated 4/2019 was reviewed. The P&P indicated, .Medications are administered in a safe and timely manner . Staff follows established facility infection control procedures (e.g., handwashing .) for the administration of medications, as applicable . the DON stated the license nurse was expected to perform hand hygiene using the sanitizer gel in between residents care, during medication administration, and going in and out of residents room. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 36 of 47 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 11/09/2023 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 - Many 2. During an observation on 11/6/23 at 9:40 a.m. in the east hallway, the clean linen storage room door was left open. There was no staff present inside the linen room. During an interview on 11/8/23 at 9:04 a.m. with the Laundry Specialist (LS), the LS stated all the linens stored in the linen room were clean. The LS stated the clean linen storage room door should be kept close to prevent the linens from contamination. During a concurrent interview and record review on 11/8/23 at 9:38 a.m. with the IP, the photo taken on 11/6/23 at 9:46 a.m. in the east hallway of the clean linen storage room with the door open was reviewed. The IP sated the clean linen storage room door should be kept close to prevent cross contamination and maintain the cleanliness of the linens. The IP stated if a resident with an infection goes inside the room and touched the linens it could potentially spread a variety of infections to other residents. The IP stated, it could cause a widespread infection outbreak. During a concurrent interview and record review on 11/8/23 at 12:12 p.m. with the Director of Nursing (DON), The facility's policy and procedure (P&P) titled Laundry and Bedding, Soiled, dated 9/2022, was reviewed. The P&P indicated, .clean linen is protected from dust and soiling during transport and storage to ensure cleanliness . The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination . the DON stated, I know the door was open on Monday [11/6/23]. The DON stated the clean linen room door should be kept closed to protect the clean linen from contamination and for infection control. The DON stated the P&P was not followed. 3. During an observation on 11/6/23 at 9:43 a.m. in the east hallway, the clean linen cart was left uncovered. The linen cart stored clean gowns and linens. The linen cart bottom shelf had a crumpled paper tissue. During a concurrent observation and interview on 11/6/23 at 9:50 a.m. in the east hallway with Certified Nursing Assistant (CNA) 5, CNA 5 confirmed the linen cart was left uncovered. CNA 5 stated the linen cart stored clean resident's gown and linens. CNA 5 stated that [linen cart] is supposed to be fully covered. CNA 5 stated the linen cart should have been fully covered to prevent contamination and was an infection control issue. During a concurrent observation and interview on 11/6/23 at 9:55 a.m. with the Housekeeping Manager (HKM) in the east hallway, the HKM confirmed the linen cart was left uncovered. The HKM stated the linen cart should be fully covered to prevent contamination. The HKM confirmed the crumpled paper tissue inside the linen cart. The HKM stated it looks like a snot rag. The HKM stated the linen cart left uncovered and the crumpled paper tissue inside the linen cart was an infection control issue. During a concurrent interview and record review on 11/8/23 at 9:38 a.m. with the Infection Preventionist (IP), the photo taken in the east hallway of the uncovered clean linen cart with a crumpled paper tissue inside on 11/6/23 at 9:47 a.m. was reviewed. The IP stated the clean linen cart should have been covered completely and the clean resident gowns and linens inside the cart should not be visible. The IP stated if someone with an infection touched the clean gowns and linens it could spread a variety of infections to other residents. The IP stated, it could cause a widespread outbreak. The IP sated crumpled paper tissue on the bottom shelf of the linen cart it looks like a used napkin. That is gross. The IP stated the napkin should not be on the linen cart. During a concurrent interview and record review on 11/8/23 at 12:12 p.m. with the DON, the photo (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 37 of 47 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 11/09/2023 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 - Many taken in the east hallway of the uncovered clean linen cart with a crumpled paper tissue inside on 11/6/23 at 9:47 a.m. was reviewed. The DON stated, the cart should be fully covered. The DON stated, that looks like a used napkin. That is an infection control issue, and the cart should be covered. The facility's policy and procedure (P&P) titled Laundry and Bedding, Soiled, dated 9/2022, was reviewed with the DON. The P&P indicated, .clean linen is protected from dust and soiling during transport and storage to ensure cleanliness . The use of separate rooms, closets, or other designated spaces with a closing door are used to reduce the risk of accidental contamination . The DON stated the P&P was not followed. 4. During an observation on 11/6/23 at 11:00 a.m. in the north hallway shower room, there was a washcloth hanging on the soap holder. The handheld shower head was lying on the floor. During a concurrent observation and interview on 11/6/23 at 11:05 a.m. in the north hallway shower room with CNA 8, CNA 8 confirmed the washcloth hanging on the soap holder and the shower head left on the floor. CNA 8 stated the washcloth was stiff and was used. CNA 8 stated the used washcloth should not be left in the shower room and the shower head should not be left on the floor because they were both infection control issue. During a concurrent observation and interview on 11/6/23 at 12:10 p.m. with the HKM in the north hallway shower room. The HKM stated the shower head should have not been left on the floor. The HKM stated the used washcloth was stiff and appeared to have been wet and dried. The HKM stated the washcloth should not have been left hanging on the soap holder. During a concurrent observation and interview on 11/7/23 at 10:05 a.m. with the Director of Maintenance (DOM), in the north shower room. The DOM confirmed the shower head was on the floor. The DOM stated he had installed a new holder for the shower head on 11/6/23 and he did not know why staff is not using it. During a concurrent observation and interview on 11/7/23 at 11:02 a.m. with the DOM in the north hallway shower room, the handheld shower head was observed on the floor. The DOM picked up the shower head and hung it up on the shower holder. The DOM stated the shower head should not touch the ground for disinfectant reasons. During a concurrent interview and record review on 11/8/23 at 9:38 a.m. with the IP, the photos taken of the north hallway shower room where a washcloth was left hanging on the soap holder and the shower head left on the floor 11/6/23 at 10:58 a.m. were reviewed. The IP stated the washcloth left in the shower room appeared used and was unacceptable to leave it on the soap holder because it was an infection control issue. The IP stated the shower head should have not been left on the floor. The IP stated the expectation was for the CNAs to clean the shower room completely after each residents use. The IP stated the CNAs were supposed to keep the shower head off the ground and hung on the shower head holder and removed all used washcloths. During a concurrent interview and record review on 11/8/23 at 12:12 a.m. with the DON, the photos taken of the north hallway shower room where a washcloth was left hanging on the soap holder and the shower head left on the floor 11/6/23 at 10:58 a.m. were reviewed. The DON stated the washcloth hanging on the soap holder appeared to be used and should not have been left there. The DON stated it could cause cross contamination and infection to residents. The DON stated the shower head should have not been left on the floor and should been hung on the shower head holder to prevent cross contamination. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 38 of 47 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 11/09/2023 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 0911 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, during the survey period of 11/6/23 through 11/9/23, the facility failed to ensure each bedroom accommodated no more than four residents in three of 16 rooms (rooms 11, 12 and 14). This failure had the potential for residents to not have reasonable privacy or adequate space. Findings: During a concurrent observation and interview on 11/7/23 at 9:55 a.m. with Resident 23 in room [ROOM NUMBER], Resident 23 was lying in bed watching television. Resident 23 had a dresser within her curtained area and had personal belongings within reach. Resident 23 stated she had her own area in the room and 8 residents in the room did not affect her privacy. During a concurrent observation and interview on 11/07/23 at 10:05 a.m. with the Director of Maintenance (DOM) in rooms 11, 12 and 14, 8 resident beds were observed in each room. The DOM stated the facility needed a waiver if there were more than 4 residents per room. There was adequate closet and storage space observed for each resident and wheelchairs and bathrooms were accessible. There was sufficient room for nursing care and for residents to ambulate. The health and safety of residents would not be adversely affected by the continuance of this waiver. During an interview on 11/8/23 at 8:00 a.m. with the Administrator (ADM), the ADM stated he was aware the regulations required a waiver for more than four residents per resident room. The ADM stated rooms 11, 12 and 14 housed 8 residents each. During an interview on 11/8/23 at 11:40 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she had worked for the facility for 30 years. CNA 1 stated rooms 11, 12 and 14 each had eight residents per room. CNA 1 stated the residents had their own space and it was adequate for resident care. CNA 1 stated the residents in rooms 11, 12 and 14 had not complained to her regarding the number of residents in each room. Room Number Number of Beds 11 8 12 8 14 8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 39 of 47 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 11/09/2023 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 0911 Recommend waiver continue in effect. Level of Harm - Minimal harm or potential for actual harm ______________________________________________ HFES Signature Date Residents Affected - Some Request waiver continue in effect. _______________________________________________ Facility Administrator Signature Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 40 of 47 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 11/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an observation on 11/06/23 at 9:26 a.m. in Resident 18's room, a black oscillating stand up floor fan was against the wall under Resident 18's television. During a concurrent observation and interview on 11/07/23 at 10:25 a.m. with Resident 18's family member (FM), in Resident 18's room, the FM stated she requested to have a fan placed in Resident 18's room a few weeks ago to help circulate the air in the room. The FM stated the fan electrical cord was plugged into the four-socket outlet on the wall next to resident's bed, together with the television electrical cord, and the bed electrical cord. The FM stated the fan electrical cord had a plastic packaging wrapped around the end of the cord and was touching the four-socket outlet. The plastic packaging had instructions in bold black lettering indicating WARNING and REMOVE THIS TAG. The FM stated the plastic wrapped around the electrical cord touching the four-socket outlet could start a fire which could burn her family member and the other seven residents in the room. During a concurrent interview and record review on 11/07/23 at 10:39 a.m., with the DOM and the ADM, the photos taken in Resident 18's room on 10/06/23 at 9:26 a.m. and 10/7/23 a.m. 10:32 a.m., were reviewed. The DOM stated the plastic packaging should have been removed prior to using the fan to prevent it from touching the four-socket outlet. The DOM stated outlet could get warm and melt the plastic packaging and start a fire. The ADM stated the plastic packaging on electrical cord should have been removed prior to used. The ADM stated the plastic packaging on the cord was a fire hazard. During a concurrent interview and record review on 11/08/23 at 12:9 p.m. with DOM, the facilities policy and procedure (P&P), titled Fire Safety and Prevention dated 5/2011, was reviewed. The policy indicated, . 3. The following fire safety precautions must be followed in the facility at all times . e. Do not overload circuits . The DOM stated, the plastic on the cord was a safety hazard, if the plastic gets hot it could melt and cause the circuits to overload and start a fire. The DOM stated the plastic packaging should not have been on the cord. During a concurrent interview and record review on 11/08/23 at 12:11 p.m. with DOM, the facilities policy and procedure (P&P), titled Maintenance Service dated 12/2009, was reviewed. The policy indicated, . 1. The maintenance department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . The DOM stated he walks through the whole facility as soon as he comes to work to check for hazards and he did not see the plastic on the cord during his morning safety rounding on 11/6/23 and 11/7/23. During a concurrent interview and record review on 11/9/23 at 11:13 a.m., with ADM, the photos taken in Resident 18's room on 10/6/23 at 9:26 a.m. and 10/7/23 at 10:32 a.m., were reviewed. The ADM stated he was aware it was a deficient practice because it was a safety hazard. 3. During a concurrent observation and interview on 11/6/23 at 11:05 a.m. with CNA 8 in the north hallway shower room, there were darkened areas on the grout in the shower floor. The CNA stated the grout was dark brown in some areas. During a concurrent observation and interview on 11/6/23 at 12:10 p.m. with the HKM in the north hallway shower room. the HKM confirmed the darkened areas on the grout. The HKM stated the darkened areas were black. The HKM scratched one of the darkened areas and it scratched off. The HKM stated it (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 41 of 47 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 11/09/2023 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 0921 was dirt and mold. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 11/7/23 at 10:05 a.m. with the DOM in the north hallway shower room. The DOM confirmed the darkened areas on the grout. The DOM stated he had cleaned the darkened areas on 11/6/23. The DOM declined to comment on what the dark areas on the grout. Residents Affected - Some During a concurrent interview and record review on 11/8/23 at 9:38 a.m. with the Infection Preventionist (IP), photos of the north hallway shower room, taken on 11/6/23 were reviewed. The IP stated, that is black, it looks like mold. The IP stated the floors should not be soiled or have mold on them because it was an infection control issue. During an interview on 11/9/23 at 11:19 a.m. with the Director of Nursing (DON), the DON stated it was important to have clean shower to prevent the spread of bacteria and potential infections. The DON stated the showers should have been clean and free of debris. During a review of the facility's policy and procedures (P&P) titled Floors, dated 12/2009 was reviewed. The P&P indicated, .floors shall be maintained in a clean, safe, and sanitary manner . Based on observation, interview and record review, the facility failed to provide a safe, functional, and sanitary environment for (19 of 51 residents (1, 2, 4, 6, 7, 8, 10, 18, 24, 25, 29, 31, 32, 34, 36, 38, 46, 51, and 307) when: 1. Two resident shower rooms had black residue on the tile floors and walls, gaps in between the tiles and the call light pull cords had pink and black substance. 2. Oscillating (rotating) fan with a plastic packaging wrapped at the end of the electrical cord was plugged into a four-socket wall and the plastic packaging was touching the outlet. 3. The shower room in the north hallway had darkened areas on the tile grout. These failure placed residents in a unsanitary environment which could lead to potential health problems and created a fire hazard. Findings: 1. During an observation on 11/6/23 at 9:55 a.m. in room [ROOM NUMBER]'s bathroom, the shower room had areas of a black substance on the tile and in between the tiles on the floor. The shower walls had areas gap spaces in between the tiles. The showers call light pull cord was white with areas of a pink substance and areas of black substance. During an observation on 11/6/23 at 10:19 a.m. in room [ROOM NUMBER]'s bathroom, the shower room has areas of a black substance on the floor and on the walls in between the tiles. The shower walls had areas of gap spaces in between the tiles. The shower call light pull cord was white with areas of black substance. During a concurrent observation and interview on 11/6/23, at 10:25 a.m. with Certified Nursing Assistant (CNA) 5 in room [ROOM NUMBER]'s bathroom, there were areas of a black substance on the floor and black substances on the white call light pull cord. CNA 5 stated the areas with the black substance on the shower floor and the call light pull cord was mold. CNA 5 stated the shower was not clean. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 42 of 47 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 11/09/2023 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 0921 CNA 5 stated the shower should have been clean. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 11/6/23, at 10:27 a.m. with CNA 2 in room [ROOM NUMBER]'s bathroom, there were areas of black substance on the floor and black substances on the white call light pull cord. CNA 2 stated the areas with the black substance on the floor was mold/mildew. CNA 2 stated the black substance on the call light cord was mold. CNA 2 stated the residents in room [ROOM NUMBER] used the shower for bathing. CNA 2 stated the shower was not clean. CNA 2 stated the shower should have been clean. Residents Affected - Some During a concurrent observation and interview on 11/6/23, at 10:30 a.m. with the Housekeeping Manager (HKM), in room [ROOM NUMBER]'s bathroom, the shower walls had gap spaces in between the tiles, the floor had areas of a black substance, the call light pull cord had areas of a black substance. The HKM stated the gap spaces in-between the tiles on the wall were areas where grout was missing. The HKM stated the areas of black substance on the floor were black grout. The HKM stated the areas of black substance on the call light pull cord was dirt and the call light pull cord needed to be replaced. During a review of JOB DESCRIPTION TITLE: Environmental Services (EVS) Account Manager, [undated], the JOB DESCRIPTION TITLE: Environmental Services (EVS) Account Manager indicated, . ESSENTIAL FUNTIONS OF THE JOB . Ensures that established sanitation and safety standards are maintained . Develops, maintains and implements infection control and universal precautions policies and procedures to ensure that a sanitary environment is maintained at all times . During an interview on 11/6/23, at 12:07 p.m. with the HKM, the HKM stated the areas of black substance on the floor in room [ROOM NUMBER]'s shower was dirt, not black grout. The HKM stated, the shower in room [ROOM NUMBER] was not clean. The HKM stated the residents' shower rooms should have been clean and free from dirt. During an interview on 11/8/23 at 11:41 a.m. with the Housekeeping (HK), The HK stated the HKM was responsible for the deep cleaning of the shower rooms. The HK stated the residents shower room should not have molds, mildew, or dirt. The HK stated it was important for residents' shower room not have mold, mildew, and dirt because the residents at the facility had weaker immune systems and could become sick from the mold, mildew, and dirt. During a concurrent interview and record review on 11/8/23 at 11:59 a.m. with the Director of Maintenance (DOM), photos taken of room [ROOM NUMBER]'s shower dated, 11/6/23, were reviewed. The photos indicated, gap areas between tiles on the walls of the shower and a call light pull cord with a pink and black substance. The DOM stated the gap areas between the tiles on the wall were areas that were missing grout. The DOM stated he did visual checks of the bathrooms at the facility every morning Monday through Friday. The DOM stated he was not aware the grout was missing in the shower rooms. The DOM stated he missed the areas of missing grout during his visual checks of the shower rooms. The DOM stated he was responsible for repairing grout in the shower rooms. The DOM stated it was not the practice of the facility to have grout missing in the shower rooms. The DOM stated the missing areas of grout should be filled. The DOM stated the call light pull cord was rotting and should be replaced. During a review of Job Description Position Title: Maintenance Director, dated 7/1/23, the Job Description Position Title: Maintenance Director, indicated . POSITION SUMMARY . Implementing and planning an organized system to maintain the operations of the property and maintain it in a good, clean, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 43 of 47 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 11/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and safe order . ESSENTIAL DUTIES . Able to clean . Maintain a safe and secure environment for all staff, residents and guests . During a concurrent interview and record review on 11/8/23 at 12:18 p.m. with the Infection Preventionist (IP), photos taken of room [ROOM NUMBER]'s shower dated, 11/6/23, were reviewed. The photos indicated open areas between tiles on the walls of the shower, a call light pull cord with a pink and black substance, the floor had areas of a black substance and two pests with wings. The photos taken of room [ROOM NUMBER]'s shower dated 11/6/23 were reviewed. The photos indicated, black substance between tiles on the floor, areas of a black substance on the pull call light cord and gap areas between tiles on the walls. The IP stated the black areas on shower 12 and 14's floors was mold. The IP stated the shower floor was not clean. The IP stated the shower floor should have been clean. The IP stated the black areas on the call light pull cords in room [ROOM NUMBER] and 14's shower were bacteria (microscopic living organisms). The IP stated the pink areas on the pull call light cord in room [ROOM NUMBER] were soap residue (a small amount of something that remains after the main part has gone, been taken or used). The IP stated the call light pull cord was not clean. The IP stated the call light cord should have been replaced. The IP stated the gap areas between the wall tiles of room [ROOM NUMBER] and 14's shower was missing grout. The IP stated the shower tiles should have been sealed with grout to prevent the buildup of bacteria getting into the gap areas. The IP stated it was important to seal the open areas with grout for infection prevention (a practical approach preventing patients and health workers from being harmed by avoidable infections). The IP stated there was a potential for residents with vulnerable immune systems at the facility to become sick from the bacteria in the shower rooms. During concurrent interview and record review on 11/9/23 at 11:19 a.m. with the Director of Nursing (DON), photos taken of room [ROOM NUMBER]'s shower dated 11/6/23, were reviewed. The photos indicated open areas between tiles on the walls of the shower, a call light pull cord with a pink and black substance and floors with areas of black substance. The DON stated the HKM was responsible for cleaning the showers. The DON stated the pull light cord had black and pink areas. The DON stated the call light pull cord was not clean and should have been replaced. The DON stated the shower was not clean. The DON stated the open areas in between tiles on the shower wall had areas of missing grout. The photos taken of room [ROOM NUMBER]'s shower dated 11/6/23 were reviewed. The photos indicated black substance between tiles on the floor, areas of black substance on the pull call light cord and gap areas in between tiles on the walls. The DON stated the call light pull cord had black area and was not clean and should have been replaced. The DON stated there was missing grout between the tiles on the walls. The DON stated it was important to have clean resident shower rooms to prevent the spread of bacteria in the facility. The DON stated the residents shower room was not clean and could have resulted to spread of infection to residents in the facility. During an interview on 11/9/23, at 3:45 p.m. with the Administrator (ADM), the ADM stated his expectation was for the resident shower rooms to be clean and sanitary. The ADM stated his expectation was for the residents' showers to be in good repair and have no areas of missing grout between tiles. The ADM stated Resident 14's shower and call light pull cord and Resident 12's shower and call light pull cord were not clean. During a review of the facility's policy and procedure (P&P) titled, Floors, dated 12/2009, the P&P indicated, . Floors shall be maintained in a clean, safe and sanitary manner . During a review of the facility's P&P titled, Maintenance Service, dated 12/2009, the P&P indicated, . Maintenance service shall be provided to all areas of the building . The Maintenance department (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 44 of 47 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 11/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times . Functions of the maintenance personnel include, but are not limited to: . Maintaining the building in good repair and free of hazards . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 45 of 47 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 11/09/2023 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility remained free of pests when two winged bugs were found in a resident's shower. Residents Affected - Some This failure had the potential for bacteria to spread from flies which could cause illness in a medically vulnerable population of residents. Findings: During an observation on 11/6/23, at 9:55 a.m. in room [ROOM NUMBER]'s bathroom, the shower room had two black winged bugs on the wall. During a concurrent observation and interview on 11/6/23, at 10:25 a.m. with Certified Nursing Assistant (CNA) 5 in room [ROOM NUMBER]'s bathroom, CNA 5 confirmed the two black winged bugs were on the shower wall. CNA 5 stated the two black winged bugs on the wall were moths. During a concurrent observation and interview on 11/6/23, at 10:27 a.m. with CNA 2 in room [ROOM NUMBER]'s bathroom, CNA 2 confirmed the two black winged bugs were on the shower wall. CNA 2 stated the two black bugs on the wall were fruit flies. During a concurrent observation and interview on 11/6/23, at 10:30 a.m. with the Housekeeping Manager (HKM), in room [ROOM NUMBER]'s bathroom, the HKM confirmed there were two black winged bugs on the shower wall. The HKM stated the two bugs with wings on the wall were flies that were coming from the shower drain. During a concurrent interview and record review on 11/8/23, at 11:59 a.m. with the Director of Maintenance (DOM), photos taken of room [ROOM NUMBER]'s shower dated, 11/6/23, were reviewed. The photos indicated, two winged bugs on the shower wall. The DOM stated he did visual checks of the bathrooms at the facility every morning Monday through Friday. The DOM stated he was not aware of any bugs in the facility. The DOM stated there should not be any bugs in the resident's shower. During an interview on 11/09/23, at 10:33 a.m. with the DOM, the DOM stated his expectation was for the facility to be always a pest free environment. The DOM stated the bugs in the shower came from the drain. The DOM stated the facility should not have bugs. The DOM stated it was important not to have pests in the facility to keep residents healthy. The DOM stated pests in the facility could potentially bring in diseases to residents. During a review of PEST CONTROL LOG, [undated], the PEST CONTROL LOG indicated no reports of pests from 7/27/23 through 10/23. The PEST CONTROL LOG indicated, . Date Reported 11/7/23 . What Type of Pest . [small] black bug . Where (be specific) and what time was the pest seen . Bathroom . [DOM signature] . During an interview on 11/09/23 at 3:45 p.m. with the Administrator (ADM), the ADM stated his expectation was for the facility to have a strong pest control program to ensure the facility was free from pests. The ADM stated there should be no bugs in the shower. During a concurrent interview and Policy and Procedure (P&P) review on 11/09/23, at 11:16 a.m. with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 46 of 47 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 11/09/2023 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 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the Director of Nursing (DON) the P&P Pest Control, dated 12/2009 was reviewed. The P&P indicated, . This facility maintains an on-going pest control program to ensure that the building is kept free of insects . The DON stated his expectation was for the facility not have bugs in the shower. The DON stated the facility was not free of insects. During a review of the facility's document Pest Control Company Name, [undated], the document indicated a log of service dates and services provided. The Pest Control Company Name indicated, . Date of Service 9/6/23 . Fly's . Target Pest Fly's . Quantity Applied [blank area] . Pesticide Application Site [blank area] . Method [blank area] . Rate of application or dosage [blank area] . Time treated [blank area] . Applicators Signature [blank area] . During a review of Professional Reference from University of California Agriculture and Natural Resources https://ipm.ucanr.edu/PMG/PESTNOTES/pn74167.html, titled, Moth or Drain Flies, [undated], indicated, . Moth flies, often called drain flies, are small about 1/8 inch in length and often dark-colored. Their wings are covered with fine hairs, which give them a moth-like appearance . In an [NAME] environment, moth fly development often occurs in the slimy organic matter coating sink or shower drains, giving these flies an alternate common name drain flies used by many pest management professionals . DAMAGE . because these flies develop in the decaying organic matter found in sink and sewer drains or even wet manure and raw sewage, they have the potential to carry pathogens acquired at these developmental sites to areas where sterility is important, such as health care facilities . Inspection and Prevention . The key to managing moth flies is the elimination of breeding sites . In commercial facilities and restaurants common developmental sites include sink and floor drains . The presence of adults within a drain or resting on walls near a drain is a clear sign that this drain is a development site . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056338 If continuation sheet Page 47 of 47