Inspection·April 26, 2023

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation dated, 12/22, the P&P indicated, Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record. details, including items such as: a. The date and time the for the individual(s) who provided the care; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable.e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documenting. Event ID: Facility ID: 056423 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was assessed by a nurse, in a timely manner after a fall incident. This failure resulted in Resident 1 experiencing a delay in care and the potential for staff to be unaware of injuries. Residents Affected - Few Findings: During a review of Resident1's Change in Condition Evaluation (COCE) dated 3/6/23, at 3:09 PM, indicated, The change in condition, symptom or sign.Falls.this started on 3/3/23.Were the change in condition and notifications reported to primary care clinician.Yes.Date and time of clinician notification: 3/6/23 (3 days post fall). During a concurrent interview and record review, on 3/15/23, at 1:55 PM, with Administrator, Resident 1's Progress Notes (PN) dated 3/6/23, at 10:26 AM, was reviewed. The PN indicated, Late entry for unwitnessed fall 3/3/23 2 AM Per staff CNA (Certified Nursing Assistant) interview: Resident was observed on floormat nedt [sic] to bed. There was no documentation regarding the 3/3/23 fall incident until 3/6/23 (3 days later) by the Director of Nursing. Administrator confirmed the findings and stated the nurse did not do anything when the resident fell. Administrator stated when Resident 1 fell, it was the responsibility of the nurse to assess the resident, do a change of condition, notify the physician and the Responsible Party (RP) and document all the communication. During an interview on 4/18/23, at 5:52 AM, with CNA 1, CNA 1 stated on 3/3/23 between 2 AM and 3 AM, he was called to Resident 1's room to assist Licensed Vocational Nurse (LVN) 1 with putting Resident 1 back to bed. CNA 1 stated Resident 1 had fallen from the bed and was face down on the floor mat. CNA 1 stated LVN 1 told him because Resident 1 had fallen on a mat, nothing needed to be documented regarding the fall incident. CNA 1 stated he told the oncoming CNA (CNA 2) about the fall incident and asked her to monitor Resident 1 for any delayed injuries. During an interview on 4/18/23, at 10:12 AM, with LVN 1, LVN 1 stated on 3/3/23 around 2 AM, Resident 1 had an unwitnessed fall and was found down on a fall mat beside the bed. LVN 1 stated she and CNA 1 assessed Resident 1 for injuries. LVN 1 stated at the time of the fall incident the nurse was responsible to assess the resident, notify the physician and RP then document in the medical record regarding the fall incident and the notifications that were made. LVN 1 stated she had documented in the medical record but had no explanation as to why the documentation was not in the medical record. During a concurrent interview and record review, on 4/18/23, at 10:22 AM, with Assistant Director of Nursing (ADON), ADON reviewed Resident 1's clinical record and was unable to provide any documentation on Resident 1's 3/3/23 fall incident prior to 3/6/23. ADON stated there was no documentation until 3/6/23, when a late entry was made by the Director of Nursing. ADON stated, when Resident 1 fell the nurse should have assessed Resident 1 for injuries, notified the physician and the RP, document the incident and continue to monitor the resident for 72 hours after the fall incident. During an interview on 4/18/23, at 10:39 AM, with LVN 2, LVN 2 stated CNA 2 had reported Resident 1's fall incident to her. LVN 2 stated when CNA 2 reported the fall incident, there was no documentation or initiation of the fall incident in the medical record. During an interview on 4/19/23, at 10:18 AM, with CNA 2, CNA 2 stated she was made aware of Resident 1's fall incident on 3/3/23, by CNA 1 and she notified LVN 2. CNA 1 stated when she notified LVN 2 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 056423 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/26/2023 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 0684 of the fall incident, LVN 2 was unaware Resident 1 had fallen. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's policy and procedure (P&P) titled, Falls and Fall Risk, Managing dated 3/18, the P&P indicated, The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation dated, 12/22, the P&P indicated, Any notable changes in the resident's medical, physical, functional, or psychosocial condition observed by staff, should be documented in the resident's medical record. details, including items such as: a. The date and time the for the individual(s) who provided the care; b. The name and title of the individual(s) who provided the care; c. The assessment data and/or any unusual findings obtained during the procedure/treatment, if applicable.e. Notification of family, physician or other staff, if indicated; and f. The signature and title of the individual documenting. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056423 If continuation sheet Page 4 of 4