Inspection·November 4, 2022

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a concurrent interview and record review, on 11/3/22, at 3:09 PM, with AC, the facility's P&P titled, Advance Directives, dated 9/22, was reviewed. The P&P indicated, The resident has the right to formulate an advance directive . Determining Existence of Advance Directive 1. Prior to or upon admission of a resident, the social services director or designee inquires of the resident, his/her family members and/or his or her legal representative, about the existence of any written advance directive. 2. The resident or representative is provided with written information concerning the right to refuse or accept medical or surgical treatment and to formulate an advance directive if he or she chooses to do so . If the Resident Does not have an Advance Directive 1. If the resident or representative indicates that he or she has not established advance directives, the facility staff will offer assistance in establishing advance directives. a. The resident or representative is given the option to accept or decline assistance, and care will not be contingent on either decision. B. Nursing staff will document in the medical record the offer to assist and the residents decision to accept or decline assistance. 2. Information about whether or not the resident has executed an advance directive is displayed prominently in the medical record in a section of the record that is retrievable by any staff. If the Resident has an Advance Directive 1. If the resident or the residents representative has executed one or more advance directive(s), or executes one upon admission, copies of these documents are obtained and maintained in the same section of the residents medical record and are readily retrievable by any facility staff. AC confirmed the findings and stated, documentation if a resident had an advance directive or wanted assistance to formulate one should be in the medical record and none were found. AC stated, the facility did not follow its policy and procedure for advance directives. Event ID: Facility ID: 056423 If continuation sheet Page 2 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to: Residents Affected - Few 1. Follow its policy and procedure (P&P) for administering medications through an enteral tube (GTGastrostomy tube, surgically placed through the abdominal wall to the stomach) by gravity flow for one of 33 sampled residents (Resident 2). This failure had the potential for Resident 2 to experience aspiration pneumonia (occurs when food or liquid is breathed into the airways or lungs). 2. Follow physician's orders for administration of oxygen (a colorless, odorless reactive gas, a life-supporting component of the air) for one of 33 sampled residents (Resident 14). This had the potential to result in unmet care needs and adversely affect resident's health. Findings: 1. During an observation on 11/4/22, at 8:54 AM, outside Resident 2's room, Licensed Vocational Nurse (LVN ) 2 was observed preparing Resident 2's medication administration . LVN 2 crushed each of the following tablets with a pill crusher and placed separately in a 30 milliliter (ml - unit of measure) medication cup: Magnesium Oxide (dietary supplement) 500 milligrams (mg-unit of measure) tablet, Metformin (anti-diabetic medication) 850 mg tablet, Cholecalciferol (dietary supplement)1000 International Units (IU-unit of measurement); She poured Active liquid (protein supplement) 30 ml into a medication cup; She was observed inside resident 2's room, poured water on each of the three medication cups containing crushed tablets and mixed each medication using an irrigation syringe; LVN 2 drew each mixed medication from the medication cup using the tip of irrigation syringe and connected onto the tip of Resident 2's G-tube. Then she pushed each medication by using the plunger of irrigation syringe into the G-tube and pushed with water before and after each medication. During a concurrent observation and interview on 11/4/22, at 9:30 AM, with Director of Nursing (DON), in the hallway outside Resident 2's room, each of the used four medication cups were observed on top of the medication cart. DON stated, yes, there were still remaining chunks of medication left in three of four medication cups and it was not all fully given to the resident. During an interview on 11/4/22, at 9:35 AM, with LVN 2, LVN 2 stated, I should administer the medications via enteral feeding by flow of gravity, but because there was a resistance already which is why I pushed the med's with the plunger. During a review of the facility's policy and procedure (P&P) titled, Administering medications through an enteral tube, dated 11/18, the P&P indicated, Purpose: The purpose of this procedure is to provide guidelines for the safe administration of medications through an enteral tube . Steps in the procedure . 10. Administer medication separately, 11. Reattach syringe (without plunger) to the end of the tubing, 12. Administer medication by gravity flow. a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clamp and deliver the medication slowly. c. Begin flush before the tubing drains completely. 2. During a concurrent observation and interview on 11/2/22, at 9:38 AM, with Registered Nurse (RN) 1, in Resident 14's room, Resident 14 was observed awake, lying-in bed, without a nasal cannula (a small tube in the nose used to deliver supplemental oxygen), or oxygen tank (a small tank containing oxygen), or oxygen concentrator (a medical device that gives you extra oxygen) observed in the room. RN 1 confirmed [Resident 14] was not receiving oxygen and no oxygen tank or concentrator was (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 3 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few observed in the resident's room. RN 1 stated, [Resident 14] had not been receiving oxygen for a while. The resident does not receive oxygen on a regular basis, only when she needs it. During a concurrent interview and record review, on 11/2/22, at 9:40 AM, with RN 1, Resident's 14's Physician's order (PO), dated 8/2/22, was reviewed. Resident 14's PO indicated, O2 [oxygen] @ 2 Liter per min [a unit of measurement] via nasal cannula continuous per concentrator/tank. Frequency every shift, for Acute respiratory failure [a serious condition that makes it difficult to breath] with hypoxia [low oxygen]. RN 1 confirmed the orders. During a review of the facility's policy and procedure (P&P) titled, Oxygen Administration, dated 10/2010, the P&P indicated, 1. Verify that there is a physician's order for this procedure. Review the physician's orders or facility protocol for oxygen administration. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 4 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to provide care and services to maintain good oral hygiene for one of 33 sampled residents (Resident 2). This failure resulted in Resident 2's having poor oral hygiene with presence of cracked dry lips and can lead to dental and gum disease. Residents Affected - Few Findings: During a concurrent observation and interview on 11/1/22, at 11 AM, with Certified Nursing Assistant (CNA) 2, inside Resident 2's room, Resident 2 was observed in bed with dry cracked lips. CNA 2 stated, Residents with G-tubes (GT- Gastrostomy tube, surgically placed through the abdominal wall to the stomach) should be provided with oral care every two hours by swabbing with a green sponge soaked with Listerine (mouthwash) to prevent cracked dry lips. During a concurrent observation and interview on 11/1/22, at 11:10 AM, with Licensed Vocational Nurse (LVN) 1, Resident 2 was in bed with dry cracked lips. LVN 1 stated, He [Resident 2] should not have dry cracked lips and oral care should be done every shift; otherwise, he [Resident 2] may have something accumulating in his mouth if it was not cleaned. During a review of the facility's policy and procedure (P&P) titled, Activities of Daily Living (ADLs), Supporting, the P&P indicated, Policy- Statement - Residents will be provided with care, treatment and services as appropriate, to maintain or improve their ability to carry out activities of daily living (ADLs). Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, personal and oral hygiene. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 5 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0678 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to clearly document in the clinical record for one of 33 sampled residents (Resident 35's) wishes in the event of cardio-pulmonary arrest (heart stops, no breathing). This had the potential for staff not knowing if they should perform cardio-pulmonary resuscitation (CPR, when trained staff give chest compressions and rescue breathing) to Resident 35. Findings: During a review of the facility Policy and Procedure (P&P) titled, Emergency Procedure - Cardiopulmonary Resuscitation, dated 2/18, the P&P indicated, If an individual. is found unresponsive and not breathing normally, a licensed staff member who is certified in CPR . shall initiate CPR unless: a. it is known that a Do Not Resuscitate (DNR) order that specifically prohibits CPR . exists for that individual. During a review of Resident 35's Physician's Orders for Life-Sustaining Treatment (POLST), dated [DATE], the POLST indicated, Do Not Attempt Resuscitation/DNR. During a review of Resident 35's Care Plan, dated as Last Care Plan Review Completed on [DATE], the Care Plan indicated, POLST/Full Code Status will be followed [CPR will be attempted], and Full Code POLST form will be in the medical records at all times. During a concurrent interview and record review on [DATE], at 3:05 PM, with Director of Nursing (DON), Resident 35's POLST and Care Plan were reviewed. The DON stated, It is confusing for me to determine if staff is to perform CPR on Resident 35 in the event he experienced a cardio-pulmonary arrest. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 6 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0679 Provide activities to meet all resident's needs. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to provide appropriate activities based on interest and preferences for one of 33 sampled residents (Resident 34). This failure had the potential to negatively impact Resident 34's psycosocial well-being. Residents Affected - Few Findings: During a concurrent observation and interview on 11/1/22, at 2 PM, with Resident 34, inside Resident 34's room, Resident 34 was observed in bed scratching his arms and rubbing his back against his bed. Resident 34 stated, I cannot get out of bed because the nurses complained that it was a hassle to bring in the machine [Hoyer lift patient lift used by caregivers to safely transfer patients from one place to another] to help lift me out from the bed to the chair. During an interview on 11/3/22, at 3:30 PM, with Activity Assistant (AA), AA stated, Resident 34 came down to activities for Bible study every Wednesday at 2 PM, but not anymore. During a review of Resident 34's Minimum Data Set (MDS assessment- screening tool), Section F-Activity Preferences, dated 3/27/22, MDS indicated, the following: Doing his favorite activities - was somewhat important. Going outside to get fresh air when the weather is good - was somewhat important. Participating in religious services or practices - was somewhat important. Resident 34 required extensive one-person assistance from staff during transfers to or from bed or wheelchair. During an interview on 11/3/22, at 3:35 PM, with Certified Nursing Assistant (CNA) 2, CNA 2 stated, Resident 34 was not participating in the activities because according to Resident 34 the facility did not have a chair for him and the staff complained that the lift machine was a pain to bring in his room. During an interview on 11/4/22, at 8:45 AM, with Activity Director (AD), AD stated, the goal for Resident 34's activities was to ask him to come over to the activities and participate, but if Resident 34 was refusing to participate, it should have been communicated with the Interdisciplinary Team (IDT). No IDT notes provided from AD. During a review of the facility's policy and procedure (P&P) titled, Activities Attendance, dated 06/18, the P&P indicated, Policy statement: the activity department records activities attendance and participation of all residents . 2. Records are reviewed on a regular basis, and at least quarterly, to determine any changes in resident participation that might indicate a change in condition and lead to reassessment and care plan review. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 7 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0685 Assist a resident in gaining access to vision and hearing services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to facilitate an audiology consult for one of 33 sampled residents (Resident 160). This failure resulted in a delay in the provision of assisstive hearing devices which hindered Resident 160's ability to communicate effectively. Residents Affected - Few Findings: During a concurrent observation and interview on 11/1/22, at 10:15 AM, with Resident 160, Resident 160 was observed in bed and had difficulty hearing. Resident 160 stated, I cannot hear you. I don't have a hearing aid. When asked if he (Resident 160) would like a hearing aid, Resident 160 stated, Yes. During a concurrent interview and record review, on 11/4/22, at 11:30 AM, with Social Service Director (SSD), Resident 160's Social Service Notes (SSN) dated 9/2/22 were reviewed. The SSN indicated, Resident 160 observed to be a little hard of hearing. SSN, dated 9/15/22, indicated, no ancillary service concern at this time for Resident 160. SSD confirmed, Resident 160 was hard of hearing at the time of assessment. During a review of the facility's policy and procedure (P&P) titled, Audiology Consult, dated 4/07, the P&P indicated, Policy statement, audiology care shall be provided through the service of a consultant audiology. Policy interpretation and implementation . 2.b. Providing audiology assessment of each resident within 90 days of admission. c. performing or supervising an annual audiology reevaluation for each resident. d. providing staff in-service education. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 8 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm Based on observation and interview, the facility failed to refer and provide podiatry (treatment of the feet) service for two of 33 sampled residents (Resident 2 and Resident 160). This failure resulted on not meeting the care needs of Resident 2 and 160. Residents Affected - Few Findings: During an concurrent observation and interview on 11/1/22, at 10:30 AM, with Resident 160, inside Resident 160's room, Resident 160 was observed with long and crooked toenails. Resident 160 stated, Yes, both were too long and my son have to get something to clip it. During a concurrent observation and interview on 11/1/22, at 11 AM, with Certified Nursing Assistant (CNA) 1, inside Resident 160's room, Resident 160 was observed in bed with long and crooked toenails. CNA 1 confirmed the findings and stated, His toenails were long, and it should not be that way. During a concurrent observation and interview on 11/4/22, at 9:30 AM, with the Director of Nursing (DON), inside Resident 2's room, Resident 2 was observed in bed with long toenails. DON confirmed, Resident 2's toenails were long. Policy and procedure was requested and not provided by the facility. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 9 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. Based on interview and record review, the facility failed to ensure nursing competency assessments for 2 of 5 sampled staff (LVN 7 and CNA 8) were completed. This failure had the potential for unqualified nursing staff to provide the health care needs of Residents. Findings: During a concurrent interview and record review, on 11/4/22, at 11:42 AM, with Director of Staff Development (DSD), five personnel file's (for the year 2020, 2021) were reviewed. The personnel files indicated, there were no assessments of the level of competencies for Licensed Vocational Nurse (LVN) 7 and Certified Nursing Assistant (CNA) 8. DSD stated, she could not locate the competency/assessments in the personnel file. DSD confirmed the findings and stated the competency assessments should be done annually. DSD stated, there was no documentation that annual in-service training on abuse prevention and reporting was conducted for LVN 7 and CNA 8. The facility was not able to provide a copy of policy and procedures for nursing competencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 10 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0730 Observe each nurse aide's job performance and give regular training. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to conduct a performance review at least once a year for one of five sampled Certified Nursing Assistant (CNA) 8. This failure had the potential for CNA 8 to not provide the appropriate care to residents. Residents Affected - Few Findings: During a concurrent interview and record review, on 11/4/22, at 11:42 AM, with Director of Staff Development (DSD), CNA's 8 personnel file for the year 2020, 2021 were reviewed. It was noted there were no annual performance review for CNA 8 in 2021. DSD confirmed the findings and stated she could not locate the annual performance review in the personnel file. She also stated there was no documentation on annual in-service training in abuse prevention and reporting was conducted for CNA 8. The facility was not able to provide a copy of the policy and procedures for nursing competencies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 11 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure each resident must receive and the facility must provide necessary behavioral health care and services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) to provide necessary behavioral health services for one of 33 residents (Resident 45). This failure had the potential to result in Resident 45's inability to attain the highest practicable physical, mental, and psychosocial well-being. Findings: During a review of Resident 45's admission Record (AR), dated 11/22, the AR indicated, Resident 45 was [AGE] years old and had the following diagnoses: End Stage Renal Disease, Dependence on Renal Dialysis (a procedure used to remove fluid and waste products from the blood), Cirrhosis of Liver (late stage of scarring of the liver), Diabetes Mellitus (body's inability to regulate sugar in the bloodstream), Hypertension (high blood pressure), Anxiety Disorder (a disorder causing one to feel nervous, restless, tense, have a sense of impending danger or panic, trouble sleeping, trouble concentrating, feeling weak or tired, and/or avoiding things that trigger anxiety), Legal Blindness, Patient's Noncompliance with Renal Dialysis, and Patient's Noncompliance with other Medical Treatment and Regimen. During a concurrent observation and interview on 11/1/22, at 2:47 PM, in Resident 45's room, with Resident 45 and Certified Nursing Assistant (CNA) 3, Resident 45 was observed sitting on the edge of his bed wearing a dirty blue t-shirt, unshaved, with dirty fingernails, and a wet brief. A hemodialysis (a procedure used to remove fluid and waste products from the blood) catheter (a thin, flexible tube used to carry blood into and out of the body) was observed hanging out of the left side of the brief on the thigh. Resident 45 was observed to be unable to answer interview questions. Resident 45 stated, Malo (Spanish word for bad) when asked how he was doing. CNA 3 stated, Resident 45 goes out for dialysis on Monday, Wednesday, and Friday. CNA 3 stated, Resident 45 refuses a lot of care. He refuses most showers and hates bed baths. CNA 3 stated, Resident 45 might shower three times a month. CNA 3 stated, He hates our food. He only wants Mexican food and gets really upset if it isn't Mexican food. CNA 3 stated, Resident 45 was recently in the hospital because of his non-compliance. During a concurrent interview and record review, on 11/4/22, at 10:51 AM, with Director of Nursing (DON), the following records were reviewed: Resident 45's Care Plans (CPs), dated 2/22, indicated, Non-compliance with MD [physician] orders. Refuses medications, therapy, weight measurements, diet order compliance, makes false accusation, refusing ADL [activities of daily living] care, refuses staff assistance with eating, Hitting Staff, cursing at staff, self-limiting behaviors, non-compliant with fluid restriction, will attempt to self-transfer and ambulate without assistance . resident will refuse dressing changes on port and can be very negative making false accusations . Date initiated 2/23/22. Resident 45's CPs indicated, [Resident 45] is at risk for decreased psychosocial well being related to: DX [diagnosis] End stage renal disease . being blind, anxiety, sadness due to decline in health and being away from home, refusing care/ medications/ ADL care . Interventions . Psych [psychologist/psychiatrist consult as needed. Date initiated: 2/25/22. Social Services Progress Notes (SSPN), dated 5/10/22, indicated, IDT [interdisciplinary team] care plan team met with resident at bedside for scheduled care conference . resident was defensive right (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 12 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few away when asked why he is refusing his medication and not wanting to shower. Resident verbalized that we are all lying and that he doesn't get offered showers. Resident was reminded that social Services has been present many times with staff in many attempts to convinces resident to shower and the importance of doing so and resident refused every time. Resident gave no reasons why he keeps refusing his medication . Resident reported that facility is starving him and not feeding him or sending lunches to Dialysis. Resident reassured that he gets meals 3 times a day, lunches made for sending with him to dialysis that he refuses to take due to not liking the food . Brother is aware and was present to talk to resident yesterday about his behaviors, resulting in no positive outcome considering resident continued behaviors and negative attitude . Continue plan of care in place. The facility's P&P titled, Behavioral Assessment, Intervention and Monitoring, dated 3/19, indicated, Policy Statement 1. The facility will provide and residents will receive behavioral health services as needed to attain or maintain the highest practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care. DON stated, When we do their care conference, we discuss behavior. If the team feels that a resident needs outside referral, then the team would get an order. DON stated, based on Resident 45's IDT care conference notes, his documented symptoms of non-compliance, and his care plans, Resident 45 should have been sent for a psych evaluation. DON stated the facility did not follow the P&P for Resident 45 to receive behavioral health services as indicated in his plan of care. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 13 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to maintain a medication error rate of less than five percent (%) when three medication errors occurred out of 30 opportunities during gastrostomy tube (GT- surgically placed tube through the abdominal wall and into the stomach) medication pass for one of five sampled residents (Resident 2). The medication error rate was 10%. This failure had the potential to cause serious harm and injury to resident for not receiving the full dosage of medications ordered by the physician. Residents Affected - Few Findings: During a concurrent observation and interview on 11/4/22, at 8:54 AM, outside Resident 2's room, Licensed Vocational Nurse (LVN) 2 was observed preparing medication administration for Resident 2 when: a. LVN 2 crushed each of the following tablets with a pill crusher and placed separately in a 30 milliliter (ml unit of measure) medication cup: Magnesium Oxide (dietary supplement) 500 milligrams (mg-unit of measure) tablet, Metformin (anti-diabetic medication) 850 mg tablet, Cholecalciferol (dietary supplement) 1000 International Units (IU-unit of measurement) b. LVN 2 poured Active liquid (protein supplement) into a 30 ml medication cup. c. LVN 2 was observed inside Resident 2's room, poured water on each of the three medication cups containing crushed tablets, and mixed each medication using an irrigation syringe. d. LVN 2 drew each mixed medication from the medication cup using the tip of irrigation syringe and connected onto the tip of Resident 2's G-tube, pushed each medication by using the plunger of irrigation syringe into the G-tube, and pushed with water before and after each medication. LVN 2 confirmed the findings. During a concurrent observation and interview on 11/4/22, at 9:30 AM, with the Director of Nursing (DON), in the hallway outside Resident 2's room, each of the used four medication cups were observed on top of the medication cart. DON stated, There were still remaining medications left in three of four medication cups and it was not all fully given to the resident. During a review of the facility's policy and procedure (P&P) titled,Medication Administration-General Guidelines, (undated), the P&P indicated, Policy, Medications are administered as prescribed in accordance with good nursing principles and practices and only persons legally authorized to do so . Procedures A. Preparation . 5. d. If the resident is tube-fed, medications are crushed finely to prevent clogging the tube. This is best accomplished using a mortar and pestle. If it is not possible to use paper cups to prevent direct contact of medications with the mortar and pestle, the mortar and pestle are cleaned thoroughly each use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 14 of 15 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 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/04/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Gateway Post Acute 661 West Poplar Porterville, CA 93257 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide the required minimum square footage (sq. ft. - 80 sq. ft. per resident for multiple resident rooms is the minimum required by regulation) in two of 26 rooms. This failure had the potential to affect the care of the residents in those rooms. Findings: During a concurrent observation and interview on 11/2/22, at 2:30 PM, of the facility with the Administrator, the following rooms did not provide the minimum sq. ft. as required by regulation for the following resident rooms: room [ROOM NUMBER]: 279 square feet; 4 residents room [ROOM NUMBER]: 283 square feet; 4 residents The Administrator verified the finding. Although they did not provide the minimum sq. ft. as required by regulation, variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage were adequate. Bedside stands were available. There was sufficient space for nursing care and for residents to ambulate or use wheelchairs. Toilet facilities were accessible. The health and safety of the residents will not be adversely affected by a room waiver. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 15 of 15