Other·November 15, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of one facility reported incident during an annual Recertification survey conducted October 9-12, 2017. Facility Reported Incident: 556448 Representing the Department: 36543, HFEN 34401, HFEN 37697, HFEN 38993, HFEN 38729, HFEN Bed Capacity: 97 Census: 88 Sample: 18 Entity Reported Incident 556448: Refer to F tag 309.

F164 SS=D PERSONAL PRIVACY/CONFIDENTIALITY OF F164 RECORDS CFR(s): 483.10(h)(1)(3)(i); 483.70(i)(2) 10/31/2017 483.10 (h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (h)(3)The resident has a right to secure and confidential personal and medical records. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 1 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. §483.70 (i) Medical records. (2) The facility must keep confidential all information contained in the resident’s records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to secure confidential personal health information for one random Resident (20) which had the potential to result in a breach of medical information for Resident 20. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 2 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During the observation of the medication administration on 10/9/17, at 4:12 PM, Registered Nurse (RN) 2 was observed in the hallway preparing multiple medications for Resident 20. After comparing Resident 20's medication with the electronic medical record on the lap-top attached to the medication cart, RN 2 proceeded to lock the medication cart, gathered all prepared medications, and walked to Resident 20's room. RN 2 did not log off on the lap-top and/or did not close the lap-top. The lap-top remained open and left unattended with Resident 20's confidential personal health information visible to several staff, residents, and family members observed walking past the medication cart. During an interview with the Director of Staff Development, on 10/10/17, at 3:50 PM, she stated "The nurses' are supposed to either close the lap-top when not in use and away from the cart or use the option to minimize and close the screen." The facility policy and procedure titled "Electronic Medical Records" dated 2014, indicated "The facility will make reasonable efforts to limit the use of disclosure of protected health information to only the minimum necessary to accomplish the intended purpose of the use or disclosure...Our electronic medical records system has safeguards to prevent unauthorized access of electronic protected health information (e-PHI). These safeguards include administrative, technical and physical safeguards..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 3 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F241 DIGNITY AND RESPECT OF INDIVIDUALITY F241 CFR(s): 483.10(a)(1) SS=D ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 11/03/2017 (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure privacy for two Random Residents (22 and 23) when broken and missing slats in the window blinds were not replaced. This resulted in violation of Residents 22 and 23's right to privacy. Findings: During the initial tour of the facility with the Director of Staff Development (DSD) , on 10/9/17, which started at approximately 9:40 AM, Resident 22 and 23's rooms, located in the dementia unit, had multiple broken and missing slats in the window blinds. Resident 22's room had two broken slats and three missing slats. Resident 23's room had six slats missing. Through the missing slats, staff, residents, and visitors are able to see inside Resident 22 and 23's room during care and/or hours of sleep. The DSD confirmed the findings. No policy was provided.

F252 SS=E SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT CFR(s): 483.10(e)(2)(i)(1)(i)(ii)

F252 11/03/2017 (e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 4 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would infringe upon the rights or health and safety of other residents. §483.10(i) Safe environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a clean home like environment when: 1. One of 18 sampled residents (8) was wearing clothing that did not belong to him. 2. One random Resident 19 used a trash can at the end of his bed to keep the mattress from sliding down. 3. A package of disposable washcloths for personal use were not labeled and stored with resident's belongings. 4. Multiple bathrooms smelled of urine and were found with orange-red, rust stain on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 5 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE toilet base. These failures resulted in residents having an uncomfortable and non-homelike environment. Findings: 1. During an observation and concurrent interview with the Director of Staff Development (DSD) on 10/9/17, at 4:15 PM, in Resident 8's room, Resident 8 was laying in bed with socks that were labeled with a different Residents' name. The DSD confirmed they were not Resident 8's socks and stated "Those are [the] roommates socks." During an interview with the Social Service Designee, on 10/12/17, at 9:54 AM, she stated "Residents do not share clothes." The facility policy and procedure titled "Personal Property" revised 9/12, indicated "Residents are permitted to retain and use personal possessions and appropriate clothing. .." 2. During an observation and concurrent interview with Resident 19, in his room, on 10/9/17, at 2:29 PM, his trash can was observed sitting on top of his comforter between the foot board and mattress, with soiled tissues in the trash can. Resident 19 stated his trash can was being used to keep the mattress from slipping down and his pillow from falling off the mattress. During an observation and concurrent interview, with the DSD and Resident 19 in Resident 19's room, on 10/9/17, at 4:23 PM, Resident 19 stated the trash can had been at the foot of his bed since he was admitted to the facility. He also stated the mattress was too FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 6 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE short for the bed and he preferred to have a mattress that fits the bed. The DSD confirmed the mattress was too short for the bed. 3. During an observation, on 10/9/17, at 9:49 AM, in the shared bathroom between Rooms 21 and 23, an unlabeled package of disposable washcloths for personal use was noted on the back of the toilet tank. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, on 10/9/17, at 10:19 AM, she was unable to identify to which resident the washcloths belonged. She confirmed the washcloths were unlabeled and should be labeled with the resident's name. 4. During the initial tour of the facility with the DSD, on 10/9/17, which started at approximately 9:40 AM, the shared bathroom, in the dementia unit, between Rooms 53 and 54, and Rooms 51 and 49, were noted with a strong urine smell. Both bathrooms were noted with multiple areas of yellow stains on the floor. An orange-red, rust stain was noted around the toilet base. The DSD confirmed the findings and stated, "It's stained, I will let housekeeping know."

F253 SS=E HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.10(i)(2)

F253 11/17/2017 (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure effective housekeeping and maintenance services to provide a safe, comfortable, home-like environment when several areas throughout the facility had nonFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 7 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE intact and or black marked floor tiles. This failure had the potential to negatively impact residents' environment and were an obstacle to promoting residents' homelike environment. Findings: During the environmental tour observation and concurrent interview with the Plant Supervisor (PS), on 10/10/17, from 9:11 AM through 11:30 AM, several areas in the facility were noted with damaged and discolored floor tiles. On A Wing, it was noted 13 floor tiles, in the hallway between rooms four and six, had black marks at the seams, and five of them were cracked and lifting. On B Wing, it was noted there were two tiles, in front of the shower room, had a hole about the size of a quarter at the tile seam. There were five tiles near Room 28 were discolored and bubbling at the seams. Near Room 24, there were five tiles noted to have cracked, holes and discoloration. On C Wing, it was noted the bathroom attached to the small dining room had four damaged, lifting tiles at the doorway and three additional floor tiles near the toilet and sink. The flooring had a orange-red stain. It was noted there were seven floor tiles in the nurse's station had separation at the tile seam and long black streak down the side of the tiles. The PS confirmed the findings and stated the black marks were caused by the buffer (machine used to polish tile floor).

F272 SS=D COMPREHENSIVE ASSESSMENTS CFR(s): 483.20(b)(1)

F272 11/03/2017 (b) Comprehensive Assessments (1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 8 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident’s needs, strengths, goals, life history and preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and non-licensed direct care staff members on all shifts. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 9 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one Random Resident (21) was evaluated and assessed for the modification of a merry walker (walker/chair combination to promote ambulation). This has the potential to result in a physical restraint. Findings: During an observation on 10/10/17, at 12 PM, in the C-wing Dementia Unit, Resident 21 was observed walking in the hallway with a merry walker. Two iron dumbbells were attached with multiple zip ties and duct taped on both sides of the lower portion of the merry walker in between the front and back wheels. During a review of the clinical record for Resident 21, the current Physicians Order indicated "Mobility status: May use a merry walker for locomotion with nursing supervision. Order start date 10/24/11." No documented evidence of any modification, evaluation and assessment was found for the merry walker. During an interview with Certified Nursing Assistant (CNA) 7, on 10/10/17, at 12:11 PM, she stated the merry walker was used to help Resident 21 walk. CNA 7 stated the dumbbells tied to the merry walker weighed a total of 20 pounds (10 pounds each side). CNA 7 stated, "She was walking too fast, so they put [on] the weights to slow her down." During an interview with License Vocational Nurse (LVN) 3, on 10/10/17, at 11:44 AM, she stated the two 10 pound weights had been added to the merry walker many years ago by facility maintenance. LVN 3 stated, "It [merry walker] was tipping over because she [Resident 21] walks fast." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 10 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with Physical Therapy Aide 2 on 10/11/17, at 9 AM, she was unable to find documented evidence of an evaluation for the use and added two 10 pound weights to the merry walker. During an interview with the Minimum Data Set Coordinator (MDSC), on 10/12/17, at 9:18 AM, she was unable to find documented evidence of an evaluation for the use and addition of weights to the merry walker. The MDSC stated, "No evaluation since weights were placed. Yeah, I don't know when it [weights] was put on." The facility policy and procedure titled "Use of Restraints" dated 2011, indicated "Restrained individuals shall be reviewed regularly (at least quarterly) to determine whether they are candidates for restraint reduction, less restrictive methods of restraints, or total restraint elimination."

F278 SS=D ASSESSMENT ACCURACY/COORDINATION/CERTIFIED CFR(s): 483.20(g)-(j)

F278 11/03/2017 (g) Accuracy of Assessments. The assessment must accurately reflect the resident’s status. (h) Coordination A registered nurse must conduct or coordinate each assessment with the appropriate participation of health professionals. (i) Certification (1) A registered nurse must sign and certify that the assessment is completed. (2) Each individual who completes a portion of the assessment must sign and certify the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 11 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accuracy of that portion of the assessment. (j) Penalty for Falsification (1) Under Medicare and Medicaid, an individual who willfully and knowingly(i) Certifies a material and false statement in a resident assessment is subject to a civil money penalty of not more than $1,000 for each assessment; or (ii) Causes another individual to certify a material and false statement in a resident assessment is subject to a civil money penalty or not more than $5,000 for each assessment. (2) Clinical disagreement does not constitute a material and false statement. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure accuracy of assessments for two of 18 sampled residents (7 and 8). This failure had the potential for unmet care needs. Findings: 1. During a review of the clinical record for Resident 7, the "Medication Administration Record (MAR)" dated 8/17, indicated Resident 7 had received Keflex (medication used to treat a wide variety of bacterial infections) beginning 8/8/17 and ending 8/18/17 for Urinary Tract Infection (UTI). During a review of the clinical record for Resident 7, the "Minimum Data Set (MDS-an assessment tool), dated 8/10/17, did not indicate Resident 7 had been treated for a UTI in the last 30 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 12 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview and concurrent record review with the Minimum Data Set Coordinator (MDSC), on 10/12/17, she confirmed the MDS, dated 8/10/17, did not indicate Resident 7 had been treated for a UTI and it should have been indicated during the assessment. The CMS's (Center for Medicare and Medical Services) RAI [resident assessment instrument] titled "Coding Tips"dated 10/11, read in part "The UTI has a look-back period of 30 days for active disease. . ." 2. During a review of the clinical record for Resident 8, the "Nursing Notes" dated 1/17/17, at 10:49 AM indicated Resident 8 was found during medication pass laying between the wall and bed. At 11:45 AM the "Nursing Notes" indicated Resident 8 complained of pain to left elbow. During a review of the clinical record for Resident 8, the "FACILITY REPORTED INCIDENT" dated 1/17/17, indicated Resident 8 had, "...lost his balance and fell down to the floor hitting his left arm on the bed frame." During a review of the clinical record for Resident 8, the "Radiology Interpretation" dated 1/17/17, at 1:03 PM indicated "Impression: 1. Mildly displaced transverse distal humeral fracture likely subacute [break extending across the lower end of the upper arm bone that moved from its proper or usual place that is between acute and chronic] with adjacent soft tissue swelling and a moderate elbow joint effusion [an escape of fluid into a body cavity]." During a review of the clinical record for Resident 8, the MDS, dated 3/3/17, indicated Resident 8 had one fall with no injury, one fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 13 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE with injury except major and no major injury fall during the assessment period. During an interview and concurrent record review with the MDSC, on 10/12/17, at 11:43 AM, she confirmed Resident 8 had a fracture and the MDS did not indicate Resident 8 had a major injury. She also confirmed the facility followed the RAI MDS manual for coding. During an interview with the MDSC, on 10/12/17, at 12:22 PM, she stated the fracture was not coded as a major injury because it was determined the fracture was an old healing sub acute fracture. She also stated minor injury was coded due to the complaints of pain to the elbow from Resident 8. During an interview with the Director of Nursing (DON), on 10/12/17, at 2:09 PM, she stated the "fracture was not known prior to x-ray obtained" and "considered it an old fracture." She also stated Resident 8 did not have pain prior to the fall and that is why minor injury was coded. The CMS's RAI titled "Section J Health Conditions" dated 4/12, indicated "Determine the number of falls that occurred since admission/entry or reentry or prior assessment...and code the level of fall-related injury for each. Code each fall only once. If the resident has multiple injuries in a single fall, code the fall for the highest level of injury." It also indicated the definition of an injury related to a fall is a "documented injury that occurred as a result of, or was recognized within a short period of time (e.g., hours to a few days) after the fall and attributed to the fall."

F309 SS=G PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l) FORM CMS-2567(02-99) Previous Versions Obsolete

F309 Event ID: MLCW11 10/31/2017 Facility ID: CA040000032 If continuation sheet 14 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to assess one of 18 sampled residents (15) on multiple opportunities after the resident's fall incident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 15 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Such failure resulted in Resident 15's hip fracture to go unnoted for six days and sustained severe pain for six days. Findings: During an observation on 10/09/17, at 10:20 AM, Resident 15 was in bed lying on her right side facing the wall. At 12 PM, the resident was in bed awake lying on her right side. Certified Nursing Assistant (CNA) 2 was at the bedside attempting to feed Resident 15 her lunch. Resident 15 refused lunch and pushed CNA 2's hand away. CNA 2 stated Resident 15 had only eaten 50 percent of her breakfast, "I don't know why she refuses her food now." During a review of the clinical record for Resident 15, Minimum Data Set (MDS-an assessment tool), dated 9/18/17, indicated Resident 15 had a diagnosis of dementia (disease that affects memory, thinking, and social abilities severely enough to interfere with daily functioning), was cognitively severely impaired, never/rarely made decisions, and had short-term and long-term memory problems. The Nurses Notes, dated 10/6/17, at 6:49 PM, was reviewed. It indicated Resident 15 had a witnessed fall at 6:40 PM. Resident 15 had "lost her balance while stepping backwards and landed on her left side." Resident 15 sustained a skin tear to her right hand and was placed on a 72 hour monitoring (observing and checking any change in medical/mental condition and level of care) after the fall on 10/6/17. The clinical records indicated Resident 15 had no complaints of pain, but her behaviors of crying, yelling out, and restlessness prompted the staff to administer Ativan (anti-anxiety medication) for three consecutive days (10/7/17, 10/8/17, and 10/9/17). The clinical records also indicated Resident 15 had no episodes of these FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 16 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE behaviors prior to the fall incident. There was no documented evidence during the behavior episodes, the physician was notified for further assessment and evaluation of Resident 15's change of condition. During an interview with Restorative Nursing Assistant (RNA) 1, on 10/12/17, at 10:35 AM, she stated an attempt was made to transfer Resident 15 into a wheelchair for her scheduled weight on 10/9/17. RNA 1 stated, "She [Resident 15] was screaming during the process of getting up in the chair with one leg on the floor. She was in pain." RNA 1 stated she had reported the incident to the Director of Nursing (DON). During an interview with CNA 2, on 10/12/17, at 11:10 AM, she stated she worked with Resident 15 on 10/9/17, three days after the witnessed fall. CNA 2 stated Resident 15 was scheduled to be showered and would usually have no difficulty standing up for showers, but on 10/9/17, "She couldn't stand up, she was in pain. She was screaming, saying 'pain' and touching her right leg and then both legs. I think she was in a lot of pain that she didn't know where the pain was anymore." CNA 2 stated she had reported the incident to the the nurse on duty. During an interview with CNA 4 on 10/12/17, at 2:16 PM, she stated she worked with Resident 15 on 10/10/17, four days after the witnessed fall. CNA 4 stated it was unusual for Resident 15 to stay in bed all day, "She is usually up walking." The Nurses Notes, dated 10/9/17, at 2:45 PM, were reviewed. The notes indicated "Upon entering room resident [Resident 15] was in bed lying on right side with eyes closed, no apparent distress. Upon assessment of lower FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 17 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE extremities, resident began to yell. . . Upon passive ROM (range of motion), resident started to cry out. When asked where the pain was resident did not reply only continued to cry." Resident 15 was placed on 72 hour monitoring for lower extremity pain. During an interview with a Registered Nurse (RN) 2, on 10/12/17, at 2:29 PM, she stated, "She [Resident 15] was restless that morning [10/9/17], she was given Ativan. She was guarded when moving her lower extremities." RN 2 stated she notified the physician, and was given an order for Norco (pain medication) every 6 hours. RN 2 stated, "I told the doctor she was crying during passive range of motion, I didn't tell him she was guarding her lower extremities. No I didn't tell him she couldn't stand up." The Rehabilitation Referral note, dated 10/10/17, was reviewed. It indicated "Pt [patient-Resident 15] in bed-refused to follow any requests to get OOB (out of bed)-crying and very agitated-unable to assess at this time." The Nurses Notes, dated 10/11/17, at 11:44 AM, indicated "Writer and therapy assistant attempted to assess resident due to not wanting to ambulate, became upset, crying, holding right lower extremity. . . noted right knee to be slightly swollen. . . staff provides needed care with occ [sic] episodes of guarding her extremities and crying." The clinical records indicated Resident 15 was only given Norco on 10/9/17 at 1:31 PM. During an interview with Licensed Vocational Nurse (LVN) 1, on 10/12/17, at 3:01 PM, she stated she observed Resident 15 on 10/11/17 (six days after the witness fall), in her room, lying in bed, her right side facing the wall, in a fetal position, holding both legs. LVN 1 stated, "She didn't let me assess her, she was crying, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 18 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE saying leave me alone. She wouldn't let me turn her or anything." During further review of the Nurses Notes, dated 10/11/17, at 1:02 PM, it indicated Resident 15's attending physician was notified and gave an order for Resident 15 to be sent out to the hospital for "treatment and evaluation, due to resident diagnosis of dementia and history or [sic] refusing care." The radiology report from the hospital, dated 10/11/17, indicated Resident 15 had sustained a right intertrochanteric fracture (hip fracture). Resident 15 had a surgical operation done on 10/12/17 to repair the hip fracture. During an interview with the Director of Nurses (DON), on 10/12/17, at 3:30 PM, she stated she was notified of the fall on 10/6/17. The DON stated, "I was told she [Resident 15] fell and was able to move all extremities. I wasn't aware she was crying during the passive range of motion until I went through the notes on Monday [10/9/17]." The DON stated she had not assessed Resident 15 after she was made aware of Resident 15's complaint of pain, crying, and pushing staff away. The DON stated, "I was told she was crying, was able to move both legs, no one told me she was guarding her legs. That's new for her. Yeah, she should have been sent out sooner." The facility policy and procedure titled "Change in a Resident's Condition or Status" undated, indicated "A significant change of condition is a decline or improvement in the resident's status that: Ultimately is based on the judgement of the clinical staff. . . Acute changes include: Incident with injury of any kind this includes skin tear, bruise or pain. Change in baseline condition. . . New behavior." The policy and procedure titled "Pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 19 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Assessment and Management" undated, indicated "Possible Behavioral Signs of Pain: a. Verbal expressions such as groaning, crying, screaming; c. Changes in gait; d. Behavior such as resisting care, irritability, depression, decreased participation in usual activities; e. Guarding, rubbing or favoring a particular part of the body; f. difficulty eating or loss of appetite; Review the resident's clinical record to identify conditions or situations that may predispose the resident to pain, including; (4) Fractures."

F313 SS=D TREATMENT/DEVICES TO MAINTAIN HEARING/VISION CFR(s): 483.25(a)(1)(2)

F313 11/02/2017 (a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident(1) In making appointments, and (2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 18 sampled residents (8) was referred to an optometrist, when he was assessed to have impaired vision. This failure had the potential for unmet care needs. Findings: During an observation on 10/10/17, at 8:59 AM, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 20 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 8 was observed in the B wing sitting area watching television without glasses on. During a review of the clinical record for Resident 8, the Minimum Data Set (MDS-an assessment tool), dated 3/3/17 and 3/16/17, indicated Resident 8 had impaired vision and did not use corrective lenses. During an interview with the Social Service Designee (SSD), on 10/12/17, at 11:31 AM, she stated Resident 8 could only see shadows. During a concurrent record review and interview with the SSD, on 10/12/17, at 2:22 PM, she reviewed the "Optometrist Consent" dated 11/26/16, it indicated "The letter is written to request our choice and permission for treatment." The SSD confirmed optometry services were requested and the consent was signed by the responsible party. The SSD stated she normally asked upon admit when the resident was last seen by an optometrist and scheduled the resident to be seen two years from that date. The SSD stated she had never contacted Resident 8's family. She confirmed Resident 8 had not been seen by an optometrist since admission and stated he should have been seen.

F362 SS=F SUFFICIENT DIETARY SUPPORT PERSONNEL CFR(s): 483.60(a)(3)(b)

F362 11/03/2017 (a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. (b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 21 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to: 1. Ensure a blender container was completely dry before storing. 2. Ensure accurate interpretation of sanitation level test strips. These failures had the potential to effect resident safety when eating and cause food borne illness. Findings: 1. During an observation with the Dietary Services Supervisor (DSS), on 10/9/17, at 10:08 AM, in the facility kitchen, a blender reported to be clean and ready for use was found with approximately one fourth of a cup of water inside the container portion. The DSS confirmed the finding and stated the blender container needs to be re-washed and dried. The facility policy and procedure titled "SANITATION AND INFECTION CONTROL" dated 2011, indicated "POLICY: Equipment will be cleaned and sanitized to prevent food borne illness...Subject: CLEANING SMALL APPLIANCES/EQUIPMENT...PROCEDURES: 1. Blenders, Food processors and Mixers will be cleaned and sanitized after each use...b. Remove all parts, wash in hot, soapy water, rinse, sanitize and air dry..." The Food Code, dated 2013, indicated "...(B) Clean equipment and utensils shall be stored as specified under [paragraph] (A) of this section and shall be stored: (1) In a selfFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 22 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE draining position that allows air drying; and (2) Covered or inverted." 2. During a concurrent observation and interview with Dietary Aide (DA) 2, on 10/12/17, at 8:28 AM, in the facility kitchen, DA 2 confirmed she was assigned dishwashing duties, and demonstrated how she would test the chlorine level utilized in the dishwasher (chlorine is a chemical used for sanitizing dishware, in which a level of 50 to 100 parts per million [PPM] should be indicated on a test strip after coming out of the dishwasher). The test strip color guide indicated the test strip was only able to indicate a reading of 10, 50, 100, and 200 PPM. DA 2 placed a test strip on the dishes immediately out of the dishwasher. The test strip indicated a reading of 100 PPM. DA 2 incorrectly read the test strip as 150 PPM. DA 2 could not state how she got a reading of 150 PPM when the only options given were 10, 50, 100, and 200 PPM. During a concurrent observation and interview with Cook 1, on 10/12/17, at 8:45 AM, in the facility kitchen, Cook 1 confirmed she was assigned to manually dish wash in a three compartment sink (a sink with three compartments. The first for washing, the second for rinsing, and the third for sanitizing with chlorine. To check sanitation level on a three compartment sink, a test strip was used. The test strip color guide indicated the test strip was only able to indicate a reading five options - zero, 150, 200, 400, and 500 PPM). Cook 1 demonstrated how she would check the chlorine PPM in the three compartment sink using a test strip. The test strip read 400 PPM. Cook 1 stated the test strip read 220 PPM. Cook 1 could not state how she got a reading of 220 PPM when the only options given were zero, 150, 200, 400, and 500. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 23 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility policy and procedure titled "SANITATION AND INFECTION CONTROL" dated 2011, indicated "SUBJECT: DISHWASHING PROCEDURES (DISHMACHINE)...PROCEDURES...Use a chemical sanitizing rinse to achieve and maintain 50-100 PPM of chlorine at the dish surface..." The facility policy and procedure titled "SANITATION AND INFECTION CONTROL" dated 2011, indicated "SUBJECT: WAREWASHING (HANDWASHING METHOD)...PROCEDURES...THREE COMPARTMENT SINK...immersion for at least 30 seconds in solution containing 100 ppm chlorine..." The facility job description titled "COOK" dated 2011, indicated "...9. Cleans and sanitizes equipment and food preparation area using recommended cleaning agents and cleaning methods, and following established procedures..." The facility job description titled "DIETARY AIDE/ DISHWASHER" dated 2011, indicated "...6. Cleans and sanitizes utensils and food preparation area...utilizes proper sanitation and cleaning methods..."

F364 SS=D NUTRITIVE VALUE/APPEAR, PALATABLE/PREFER TEMP CFR(s): 483.60(d)(1)(2)

F364 11/03/2017 (d) Food and drink Each resident receives and the facility provides(d)(1) Food prepared by methods that conserve nutritive value, flavor, and appearance; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 24 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (d)(2) Food and drink that is palatable, attractive, and at a safe and appetizing temperature; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide butter as indicated on the menu to one of 18 sampled residents (7) which resulted in less nutritive value. Findings: During a review of the facility menu for 10/9/17, it indicated the evening meal would consist of Beef Strogonoff, Noodles, Carrots and a Roll with Butter. During a concurrent observation and interview with Resident 7, on 10/9/17, at 5:50 PM, Resident 7 had a roll in his hand, he stated he was not given butter on his tray and would like to have butter for his roll to make it a little bit more tasty. He also stated he usually does not get butter on his dinner tray. During an interview with Director of Staff Development, Certified Nursing Assistant 8, 9, and 10, and the Social Service Designee, on 10/9/17, at 5:50 PM, staff confirmed no butter was provided during the meal. The facility's "Cook-Job Description" undated, indicated "Function: The cook prepares and serves food including texture modified and therapeutic diets. . . Responsibilities: . . . 2. Supervises Dietary Aides in the preparation and serving of foods and beverages." The facility's "Director of Food Services-Job Description" dated 2003, indicated "Duties and Responsibilities. . . Make daily rounds to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 25 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE assure that food services personnel are performing required duties and to assure that appropriate food services procedures are being rendered to meet the needs of the facility."

F367 SS=D THERAPEUTIC DIET PRESCRIBED BY PHYSICIAN CFR(s): 483.60(e)(1)(2)

F367 11/03/2017 (e) Therapeutic Diets (e)(1) Therapeutic diets must be prescribed by the attending physician. (e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident’s diet, including a therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide: 1. The appropriate diet texture, as ordered by the physician, for one of 18 sampled residents (8), which had the potential to put Resident 8 at risk for choking and unmet calorie needs. 2. The diet ordered by the physician to provide additional calories to two of 18 sampled residents (8 and 10), which had the potential to contribute to their weight loss. Findings: 1. During a review of the clinical record for Resident 8, the "Order Summary Report," dated 9/22/17, at 3:06 PM, indicated Resident 8 had a diagnosis of "dysphagia [difficulty in swallowing]" and had an order for a mechanical soft diet with ground meat texture for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 26 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE diagnosis of dysphagia. During a concurrent observation and interview with the Director of Staff Development (DSD) and Certified Nursing Assistant (CNA) 8, on 10/9/17, at 5:50 PM, in the assisted dining room, Resident 8 was observed being assisted with his meal. The meal provided contained whole cubes of beef on top of noodles. CNA 8 was unable to state Resident 8's correct diet texture. The DSD was assisting at the table next to Resident 8, she then reviewed Resident 8's diet order, removed his meal and confirmed Resident 8 had received the regular texture meat, not ground meat texture. 2a. During a review of the facility menu for 10/9/17, it indicated the evening meal would consist of Beef Stroganoff, Noodles, Carrots and a Roll with Butter. During a review of the clinical record for Resident 8, the Nutritional Care Plan revised on 4/27/17, indicated Resident 8 had unintentional weight loss of 7.5% and the interventions (action taken to improve a situation) included house formula 4 oz. [ounces] BID [twice a day] with lunch and dinner. The "Order Summary Report" dated 9/22/17, indicated a physician's order for "Health Shakes (given to increase calorie intake) two times a day **4 oz [ounces] with lunch and dinner." During a concurrent dining observation and interview with the DSD, on 10/9/17, at 5:40 PM, Resident 8 had not received butter with his meal as indicated on the menu for 10/9/17 and did not receive the four-ounce health shake as ordered by the physician. The loss of these calories could contribute to continued weight loss. The DSD confirmed the observation. 2b. During a review of the facility menu for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 27 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/9/17, it indicated the evening meal would consist of Beef Stroganoff, Noodles, Carrots and a Roll with Butter. During a review of the clinical record for Resident 10, on 10/9/17, the diet order, dated 5/4/17, indicated Resident 10 was to receive mechanical soft diet with ground meat, soup for lunch and dinner; Resource drink (high calorie drink) four ounces five times per day. During a concurrent dining observation and interview with the DSD, on 10/9/17, at 5:40 PM, Resident 10 did not receive butter with her roll as indicated on the menu for 10/9/17 nor did she receive the soup as ordered by the physician. The loss of these calories could contribute to continued weight loss. The DSD confirmed the observation. No one provided the soup or butter for Resident 10 at this meal. The facility job description titled "Cook" undated, indicated "Function: The cook prepares and serves food including texture modified and therapeutic diets. . . Responsibilities: . . . 2. Supervises Dietary Aides in the preparation and serving of foods and beverages." The facility job description titled "Director of Food Services" dated 2003, indicated "Duties and Responsibilities. . . Make daily rounds to assure that food services personnel are performing required duties and to assure that appropriate food services procedures are being rendered to meet the needs of the facility." The facility job description titled "DIETARY SERVICE SUPERVISOR" dated 2011, indicated "Supervises the preparation of food...Ensures food is prepared by methods that conserve nutritional value and is palatable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 28 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and attractive to residents...Maintains all dietary records, i.e., temperature records, tray cards, profile cards, nutritional assessments, MDS, care plans,...Coordinates and gathers the information required by the Registered Dietician, i.e. resident./patient weights...Ensures residents/patients receive the proper food items to meet their dietary needs..."

F371 SS=F FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.60(i)(1)-(3) 11/03/2017 (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 29 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review, the facility failed to implement a systemic approach to maintain the kitchen in a safe, clean, and sanitary manner when: 1. Opened food items were not dated and expired foods were not discarded. 2. Kitchen cleanliness was not routinely checked and documented per policy. 3. The kitchen was not maintained in a clean, sanitary, and pest free condition. 4. Kitchen staff were not provided training on cleaning schedules/procedures per facility policy. 5. Residents were not served food in a clean and sanitary manner. 6. Dietary supplies were not stored in a sanitary condition. These failures resulted in a systemic failure, which had the potential to negatively impact and compromise the safety of the residents and contribute to food borne illness. Findings: 1. During a concurrent interview with the Dietary Services Supervisor (DSS), and observation of the facility kitchen, on 10/9/17, at 9:48 AM, the following food items were noted in the "reach in refrigerator": a. An unlabeled, and undated 64 ounce (oz) pitcher of orange colored fluid. b. An unlabeled, and undated 64 oz pitcher of iced tea. c. A container of applesauce was dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 30 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/3/17. d. Container of chicken noodle soup was dated 10/6/17. e. An undated and opened 64 oz container of margarine. The DSS confirmed the above findings and stated it was her expectation, and the policy of the facility to date all items to be re-used once opened. The DSS stated the apple sauce and chicken soup found in the "reach in refrigerator" should have been discarded after three days. During a concurrent interview with the DSS, and observation of the facility kitchen, on 10/9/17, at 10 AM, the following opened and unlabeled food items were noted in the spice cabinet: a. 4.5 pound (lb) container of traditional sea salt. b. 16 oz container of celery seed. c. 4 oz container of dehydrated cilantro. d. 10 oz container of poultry seasoning. e. 16 oz container of imitation banana flavoring. f. 32 oz container of red food coloring. g. 16 oz container of imitation almond flavor. h. 16 oz container of ground cloves. i. 24 oz container of lemon pepper. j. 1 oz container of ground rosemary. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 31 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE k. 10 oz container of Italian seasoning. l. 16 oz container of ground cumin. m. 10 oz bottle of hot sauce. n. 11 oz container of ground thyme. o. 1 lb container of cinnamon. p. 16 oz container of mustard powder. q. 20 oz container of salt free seasoning. r. 4 lb container of beef base flavor. The DSS confirmed the above findings and stated it was her expectation, and the policy of the facility to date all items to be re-used once opened. The facility policy and procedure titled 'Refrigerated Storage" dated 2011, indicated "...9. Leftover food or unused portions of packaged foods should be covered, labeled and dated..." The facility's diet policy and procedure, effective 2011, read: "Metal, plastic containers with tight fitting lids and NSF (National Science Foundation-an organization develops all of our public health and safety standards) approved, or resealable plastic bags will be used for staples and opened packages of item such as pastas, dry cereals, etc. Food items will be labeled and dated when placed into containers." 2. During an interview with the Registered Dietitian (RD) on 10/11/17, at 11 AM, she stated the cleanliness of the kitchen had periods of, "fluctuation (an irregular rising and falling in number or amount; a variation)." The RD stated the fluctuations included dirty cabinets, and kitchen areas not cleaned very FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 32 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE well. The RD could not speak to how she follows up with any recommendations or concerns with the cleanliness or sanitary condition of the kitchen. During a concurrent interview with the Director of Clinical Operations (DCO) on 10/11/17, at 5 PM, and review of the facility policy and procedure titled "Sanitation and Infection Control" dated 2011, the policy indicated, "...7. The Dietary Service Supervisor should routinely check cleaning schedules and cleanliness of the kitchen using the Food Service Evaluation Checklist...8. The Registered Dietitian will check the cleanliness of the kitchen and dining area using the Food Service Evaluation Checklist and make recommendations to the facility as needed to maintain a sanitary environment." The DCO stated it was her expectation for the facility to use this form. The DCO confirmed the facility had not been using the form as indicated per policy. The DCO confirmed there were no cleaning logs being used and no other form of documentation to show how, and when sanitary cleaning of the kitchen is accomplished. During an interview with the DSS, on 10/12/17, at 11:28 AM, she stated cleaning schedules and the cleanliness of the kitchen were not routinely checked and documented on the "Food Service Evaluation Checklist" as required according to the facility's policy. The DSS stated she had worked in the facility kitchen for 30 years and had never been told to use a checklist to document kitchen cleanliness before. The facility job description titled "Dietitian", dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 33 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintained in a clean, safe, and sanitary manner...Develop, implement, and maintain a procedure for reporting hazardous conditions..." The facility job description titled "Director of Food Services" dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner...Develop, implement, and maintain a procedure for reporting hazardous conditions..." 3. During a concurrent observation and interview with the DSS, on 10/9/17, at 9:35 AM, in the facility kitchen the following was noted: a. Heavy accumulation of thick gray/brownish particles on a three-blade portable fan that blew toward the food preparation area of the kitchen. b. Heavy accumulation of thick gray/brownish particles on the filter of the "reach in refrigerator." c. "#8 scoop" (used to serve resident's food) with dried food particles was stored in a drawer with other clean scoops. d. Food particles and debris were seen inside a drawer used to store clean scoops and inside a drawer where clean utensils are stored. e. Mouse feces in the kitchen store room. f. Mouse feces around the freezer area of the kitchen. In between freezer "1" and "2", and behind freezer "3". g. Mouse feces in the storage rack area of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 34 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE kitchen. h. Mouse feces in all corners of the "all purpose room". i. A hole, in the insulation around the kitchen swamp cooler, provided direct access for mice to enter into the kitchen storage area. The DSS confirmed the above findings and stated the facility kitchen was not cleaned per her expectations, and the kitchen had a mouse problem. During an interview with Cook 1, on 10/9/17, at 1:46 PM, she stated she had noticed mouse feces in the facility kitchen for about a month. Cook 1 stated she informed the DSS of the mouse feces when she first noticed it. During an interview with the DSS, on 10/9/17, at 1:50 PM, she stated the kitchen had an ongoing mouse problem. The DSS confirmed staff had reported mouse feces to her when fresh droppings were noted after sweeping. The DSS stated staff cleaned the kitchen but would notice fresh droppings right after any cleaning was done. The DSS stated, "We know we've got a mouse, it is ongoing. I always see [mouse feces]. We keep our food in tubs because of the mice. Other than put more glue traps out and clean we did nothing else [to correct kitchen mouse issue]." During an interview with the Administrator on 10/9/17, at 2:10 PM, he stated he was aware of the kitchen having rodent issues. The Administrator was not able to state whether pest control was informed of the mouse feces found in the kitchen. The Administrator was not able to identify any other interventions done other than placing glue traps to catch the mice. The Administrator confirmed there was a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 35 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE mouse hole, in the insulation around the kitchen swamp cooler, that allowed access from the outside to the inside of the kitchen. During a concurrent observation and interview with the DSS, on 10/9/17, at 5:02 PM, in the facility kitchen, mouse feces were noted on the the bottom shelf of the drying rack for the resident's meal plate covers. The DSS confirmed the findings. During an interview with the DSS, on 10/10/17, at 8:12 AM, she stated the mouse hole was covered, and one mouse had been caught earlier that morning. The DSS stated staff had cleaned the kitchen thoroughly. During a concurrent observation and interview with the DSS, on 10/10/17, at 8:29 AM, in the facility kitchen the following was noted: a. Mouse feces under the rinsing sink. b. Mouse feces under the the counter in the kitchen where the steamer is stored. c. Mouse feces in the storage area of the kitchen. d. Heavy accumulation of thick gray/brownish particles on the filter of the "reach in refrigerator." e. Heavy accumulation of thick gray/brownish particles on a three-blade fan that blows toward the food preparation area of the kitchen. The DSS confirmed the findings and stated "We [kitchen staff] cleaned the whole kitchen last night." During an interview with the Administrator on 10/10/17, at 9:54 AM, he stated there was only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 36 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE one identified entry point from the outside into the kitchen that a mouse or other pest could enter, and it was sealed off last night. The Administrator stated, "I think there might be some other mice leaving more feces despite our cleaning." During a concurrent observation and interview with the Administrator, on 10/10/17, at 10:46 AM, the following was found: a. Rotten wood on the roof was noted (measuring approximately four inches in width and 2 inches in length) allowing, entry access for pests to enter the building outside of the facility "B-wing" area. b. A mouse hole (measuring approximately an inch and a half in diameter ) was underneath the brick portion of the wall next to a water spout on the outside of the kitchen. c. Three entry holes (measuring approximately two inches in diameter) was noted on the outside of the kitchen area roof next to the gas shut off valve was not covered. d. A large hole in the screen of the the kitchen window exhaust fan (measuring approximately two inches in diameter) allowed access for pest from the outside directly into the kitchen dishwashing area. e. Rotten wood on the roof (measuring approximately five inches in length and three inches in width) allowed an entry access point for pest. Located on the outside portion of the facility kitchen. The Administrator confirmed the findings and stated the areas identified are easily accessible areas for pests to enter the building, specifically the kitchen. The Administrator stated the holes FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 37 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE would be covered immediately. During an observation on 10/11/17, at 8 AM, one entry hole from the outside that opened into the kitchen area roof next to the gas shut off valve was noted. During an interview with the Regional Clinical Director, on 10/11/17, at 8:08 AM, she confirmed one entry hole from the outside remained open into the kitchen area next to the gas shut off valve. During an interview with the Registered Dietitian (RD), on 10/11/17, at 11 AM, she stated the cleanliness of the kitchen had periods of, "fluctuation." The RD stated the fluctuations included dirty cabinets, and kitchen areas not cleaned very well. The RD could not speak to how she follows up with any recommendations or concerns with the cleanliness or sanitary condition of the kitchen. During an interview with the DCO, on 10/11/17, at 5 PM, she stated her expectation was for staff to inform maintenance of any issues with pests. Maintenance would then log the concerns in the "maintenance log" and inform pest control to come in. During a review of the facility record titled "MAINTENANCE LOG" last entry dated 10/9/17, it indicated zero entries under the section "Problem" of mice issues in the kitchen. During a review of the facility pest control record titled "[Company name] COMMERCIAL SERVICE AND INSPECTION REPORT", dated 5/26/17 to 9/22/17, indicated the facility did not report any issues or concerns with mice. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 38 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the DSS, on 10/12/17, at 8:20 AM, she stated two mice were caught earlier that morning. One mouse was located in the kitchen store room and the other mouse was by the kitchen steamer. The facility policy and procedure titled "CANNED AND DRY GOODS STORAGE," dated 2011, indicated "...13. The storeroom will be checked routinely for any evidence of pests...16. The Storage area will be cleaned..." The facility job description titled "Dietitian" dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner...Develop, implement, and maintain a procedure for reporting hazardous conditions..." The facility job description titled "Director of Food Services" dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner...Develop, implement, and maintain a procedure for reporting hazardous conditions..." The facility policy and procedure titled "Pest Control" dated 2008, indicated "Our facility shall maintain an effective pest control program...1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents...3. Windows are screened at all times...6. Maintenance services assist, when appropriate and necessary, in providing pest control services." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 39 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility job description titled "Administrator" dated 2003, indicated "Duties and Responsibilities...Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice...Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed...Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services...Ensure that the building and grounds are maintained in good repair...Other(s) that may become necessary/appropriate to assure that the facility is maintained in a clean, safe, and sanitary manner..." The Federal Food and Drug Administration (FDA- a section of health and human services department tasked with the responsibility of the safety and security of most of our nation's food supply and protecting public health by assuring the safety, effectiveness, quality, and security of human products) indicated, "Controlling pests in a food processing facility is essential in order to minimize the transmission of food-borne illnesses caused by microbial contamination. Effective pest control is based on: Preventing entry (exclusion), removing nesting/breeding sites (harborage), and eliminating potential sources of food and water. Pest control requires vigilance inside and outside the plant. This includes: Maintaining the building to prevent entry of pests. Maintaining the grounds to ensure proper sanitation and remove harborage for pests. Following good manufacturing practices to ensure proper in-plant sanitation." (https://www.accessdata.fda.gov/orau/pestcontr olfood/pcf) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 40 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 4. During a concurrent interview with the DCO, on 10/11/17, at 5 PM, and review of the facility policy and procedure titled "SANITATION AND INFECTION CONTROL" dated 2011, the policy indicated "SUBJECT: CLEANING SCHEDULES/PROCEDURES...All [kitchen] staff will be trained to use cleaning schedules/procedures during orientation..." The DCO confirmed there was no documentation on all members of kitchen staff to indicate training was done on orientation per policy. The DCO stated if there was no documentation then it was not done. 5. During a concurrent observation and interview with the DSS, on 10/9/17, at 5:02 PM, in the facility kitchen, mouse feces were noted on the bottom shelf of the drying rack where the dome covers for residents' meals were stored. The dome covers were moved by the kitchen staff to the food serving area, and proceeded to place the dome covers on the dinner meals. At this point, the tray line was stopped by the survey team. The DSS confirmed the dome covers were stored on the drying racks where the mouse feces were found and should not have been used. The DSS stated she would re-wash all the dome covers. During an interview with the Director of Nursing (DON), and the Administrator, on 10/9/17, at 5:18 PM, both the Administrator and the DON confirmed the use of the dome covers was unsanitary. The facility job description titled "Director of Food Services" dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner...Develop, implement, and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 41 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintain a procedure for reporting hazardous conditions..." The facility job description titled "DIETARY SERVICE SUPERVISOR" dated 2011, indicated "4. Supervises the preparation of food...Ensures food is prepared by methods that conserve nutritional value and is palatable and attractive to residents...Maintains all dietary records, i.e., temperature records, tray cards, profile cards, nutritional assessments, MDS, care plans,...9. Ensures sanitation and safety standards are maintained according to State, Federal, and local regulations." The facility job description titled "COOK" dated 2011, indicated "6. Assures all food items are handled properly to meet safety and sanitation standards according to State and Federal regulations." The facility job description titled "Administrator" dated 2003, indicated "...assure that the facility is maintained in a clean, safe, and sanitary manner..." The FDA indicated, "Controlling pests in a food processing facility is essential in order to minimize the transmission of food-borne illnesses caused by microbial contamination." 6. During a concurrent observation and interview with the DSS, on 10/9/17, at 5:21 PM, the outside metal storage shed for dietary supplies was noted. The metal shed was on a wooden floor, which was covered with dirt, and debris. Cobwebs were noted on several cartons. Social Services and Activities had items stored on the left side of the shed, while dietary items were on the right side and rear of the shed. On the shed floor, just to the right of the door was an open carton, approximately one-half full of unwrapped feminine hygiene products. The DSS confirmed the finding and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 42 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE agreed she would not use them. On the shed floor, just to the left of the door was a dusty, uncovered, slow-cooker and two small rectangular insulated soft lunch boxes. The DSS stated the slow cooker had been used to make nachos and the lunch boxes had been donated. Around the inside perimeter of the shed, was a short wooden shelf, approximately four inches high, on the shelf were: six boxes bouffant hats - used by food service workers one carton hot/cold insulated bowls two cartons of kitchen roll towels one open carton of clear lids for cups one carton of dinner napkins one carton bouffant hats one open carton of plastic spoons The DSS confirmed the findings and stated they had just used the last of the disposable Styrofoam containers to serve tonight's dinner. The facility policy and procedure titled "Canned and dry Goods Storage" dated 2011, indicated "Food and supplies should also be stored 6 [six] inches off the floor...Storage area will be cleaned as outlined..." The Food Code, dated 2013, indicated "...single-service and single-use articles shall be stored: (1) in a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor."

F441 SS=F INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.80(a)(1)(2)(4)(e)(f) 11/30/2017 (a) Infection prevention and control program. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 43 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 44 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility’s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. One random Resident (19) used a trash can at the end of his bed to keep the mattress from sliding down. 2. Kitchen supplies stored in an unsanitary manner. 3. Several storage areas had items stored less than six inches above the floor. 4. Several areas throughout the facility had damaged floor tiles. 5. Bleach was stored in an area which had the potential to become hot, causing the bleach to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 45 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE decompose (break down, inactivate). 6. An effective infection reduction and prevention program was not implemented, and maintained. 7. Expired foods were not discarded. 8. Follow facility policy and procedure on hand washing. 9. Glucometer (hand-held machine used to measure amount of sugar, glucose, in drops of blood) was not disinfected after use according to the manufacture instructions. These failures had the potential to result in the transmission of infection and communicable diseases to residents and staff. Findings: During an observation and concurrent interview, on 10/09/17, at 2:29 PM, with Resident 19 in his room, his trash can was observed sitting on top of his comforter between the foot board and mattress, with soiled tissues in the trash can. Resident 19 stated his trash can was being used to keep the mattress from slipping down. During an observation and concurrent interview with Director of Staff Development (DSD) and Resident 19 in Resident 19's room, on 10/09/17, at 4:23 PM, Resident 19 stated the trash can had been at the foot of his bed since he was admitted to the facility. He also stated the mattress was to short for the bed. The DSD confirmed the mattress was to short for the bed, and it was an infection control concern. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 46 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/9/17, at 5:21 PM, the outside metal storage shed for dietary supplies was noted. The metal shed was on a wooden floor, which was covered with dirt, and debris. Cobwebs were noted on several cartons. Social Services and Activities had items stored on the left side of the shed, while dietary items were on the right side and rear of the shed. On the shed floor, just to the right of the door was an open carton, approximately one-half full of unwrapped feminine hygiene products. The DSS confirmed the finding and agreed she would not use them. On the shed floor, just to the left of the door was a dusty, uncovered, slow-cooker and two small rectangular insulated soft lunch boxes. The DSS stated the slow cooker had been used to make nachos and the lunch boxes had been donated. Around the inside perimeter of the shed, was a short wooden shelf, approximately four inches high, on the shelf were: six boxes bouffant hats - used by food service workers one carton hot/cold insulated bowls two cartons of kitchen roll towels one open carton of clear lids for cups one carton of dinner napkins one carton bouffant hats one open carton of plastic spoons The DSS confirmed the findings and stated they had just used the last of the disposable Styrofoam containers to serve tonight's dinner. The facility policy and procedure titled "Canned and dry Goods Storage" dated 2011, indicated "Food and supplies should also be stored 6 [six] inches off the floor...Storage area will be cleaned as outlined..." The Food Code, dated 2013, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 47 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "...single-service and single-use articles shall be stored: (1) in a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor." During the environmental tour observation and interview with the Plant Supervisor (PS), on 10/10/17, at 9:30 AM, in C Wing, the glove storage room had seven cartons of synthetic vinyl examination gloves stored approximately four inches from the floor. The enteral feeding (liquid feeding, typically given through a tube placed into the stomach) closet had four cartons and three trays of enteral feeding stored approximately four inches from the floor. The linen storage closet had clean linen stored approximately four inches from the floor. The PS confirmed the finding. During the environmental tour observation and concurrent interview with the PS, on 10/10/17, at 9:19 AM, the A Wing storage closet contained wheelchairs, walkers, pads and accessories for the wheelchairs. Pads and wheelchair accessories were noted in a utility sink at the back of the closet. The utility sink had a layer of gray particles covering it. The PS stated these were clean items and confirmed the items in the sink should be considered dirty. During the environmental tour observation and concurrent interview with the PS, on 10/10/17, at 9:22 AM, in the A Wing Shower Room, a plastic expandable curtain was noted covering the linen supply. The top of the plastic curtain had a jagged rectangular hole approximately four inches by two inches, exposing the clean linen. The PS confirmed the finding. During the environmental tour observation and concurrent interview with the PS, on 10/10/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 48 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE at 10:30 AM, in Storage Shed 2, were three five gallon containers of 9% laundry bleach and ten - one gallon bottles of bleach. The PS confirmed the findings. During a concurrent review of the "Storage Instructions" printed on the five gallon bleach container and interview with the PS, on 10/10/17, at 10:30 AM, the instructions indicated,"Store in a cool, well ventilated place, away from direct sunlight and heat sources." The PS confirmed the findings and stated during the summer the sheds would be well over 100 degrees. He was unable to state what would occur if the bleach became hot. During a review of the Safety Data Sheet, dated 2/25/14, the 9% Laundry Bleach begins to boil, release chlorine gas (a corrosive vapor) and decompose at 104°F (degrees Fahrenheit). According to Clorox® "Regular-Bleach should be stored between 50°F and 70°F, and away from direct sunlight. This is recommended for both unopened and opened bottles. When properly stored, a bottle of bleach has a one year shelf life. Beyond a year, it should be replaced because the sodium hypochlorite active begins to rapidly break down..." (https://www.clorox.com/dr-laundry/cloroxregular-bleach-should-be-replaced-every-yearand-stored-as-directed-for-optimumperformance). During a review of the monthly infection control reports from 10/20/16 through 9/21/17, the reports indicated the number and type of infections present on admission, the number and type of infections acquired in the facility. The report did not indicate any actions or plans to reduce the number of infections acquired in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 49 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the Administrator and the Director of Nursing (DON), on 10/12/17, at 2:35 PM, the DON confirmed the reports and stated Infection Control does not meet separately and develop a plan to reduce infections. During an observation, on 10/9/17, at 1:52 PM, the refrigerator in the A-B wing nurses station was found with multiple expired food items including: two packages of ready snacks expiration dated 8/30/17, a bottle of juice expiration date 9/24/17, and a package cookies expiration date 2/28/17. Licensed Vocational Nurse (LVN) 5 stated expired food items were brought in from outside by family for residents. LVN 5 gathered all expired food items and placed them in the nearby trash can. During a concurrent observation and interview on 10/11/17, at 4:34 PM, the refrigerator in the A-B wing nurses station was found with undated drink items which included a renal supplement (prescribed nutritional drink), two cranberry juice and one apple juice. LVN 1 confirmed the findings and stated all drinks should have been labeled. The policy and procedure titled "Foods Brought by Family/Visitors" dated 2014, indicated "Containers will be labeled with the resident's name, the item and the "use by" date. The nursing staff is responsible for discarding perishable foods on or before the "use by" date. During an observation of the medication administration on 10/9/17, at 4:08 PM, Registered Nurse (RN) 2, was observed preparing insulin medication for Resident 21 on the medication cart. After the insulin medication was prepared to the ordered dose, RN 2 applied gloves, locked the medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 50 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE cart with her gloved hand, walked to Resident 21's room, knocked on the door with her gloved hand, and injected the prepared insulin into Resident 21's stomach area. RN 2 proceeded to walk out of Resident 21's room and back infront of the medication cart where she was observed removing her gloves. During an interview with the DSD, on 10/10/17, at 3:50 PM, she stated it was the facility's practice to have "No gloves worn in the hallway" and hand washing was to be done after each glove use. The facility policy titled "Handwashing/Hand Hygiene" dated 8/15, indicated "All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors...The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections." During an observation of the medication administration, on 10/10/17, at 11:33 AM, LVN 6 was observed wiping the glucometer with an alcohol pad after checking Resident 6's blood sugar. LVN 6 stated, "We usually use the purple one [Sani Cloth Wipes] but mine is not here." The glucometer manufacture instructions, indicated "Cleaning and Disinfection: With ONLY PDI Super Sani Cloth Wipes, rub the entire outside meter using 3 circular wiping motions with moderate pressure on the front, back, left side, right side, top and bottom of the meter."

F465 SS=F SAFE/FUNCTIONAL/SANITARY/COMFORTA F465 BLE ENVIRON FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 11/03/2017 Facility ID: CA040000032 If continuation sheet 51 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE CFR(s): 483.90(i)(5) (i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. (5) Establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account non-smoking residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide a safe and sanitary environment when: 1. A separation between the wooden trim of the building and the stucco outside the kitchen, at the main entrance and outside Rooms 7 and 9. 2. A jagged hole approximately two inches by four inches in the wooden trim of the building outside Room 9. 3. Food service workers' protective gear, disposable dining ware, paper goods, and disposable food containers for resident use were not stored in a clean area. 4. Patient care items were stored improperly. These failures had the potential to allow mold, dirt, vermin to grow and spread of infectious disease throughout the facility and contaminate patient care equipment. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 52 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 1a. During a concurrent observation and interview with the Plant Supervisor (PS), on 10/10/17, at 10:02 AM, a separation was noted between the stucco and the wooden trim outside the kitchen wing. The open area was approximately one-half inch wide and extended the length of the kitchen. The PS confirmed the finding. 1b. During a concurrent observation and interview with the PS, on 10/10/17, at 10:05 AM, a separation was noted between the stucco and the trim at the main entrance. The PS confirmed. 1c. During a concurrent observation and interview with the PS, on 10/10/17, at 10:10 AM, a separation was noted between the stucco and the wooden trim outside Rooms 7 and 9. The PS stated the separation was at least 3/4 of an inch wide. 2. During a concurrent observation and interview with the PS, on 10/10/17, at 10:10 AM, a jagged hole was noted, in the trim, in the corner, by Room 9. The PS stated the hole was approximately two inches by four inches. 3. During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on 10/9/17, at 5:21 PM, the outside metal storage shed for dietary supplies was noted. The metal shed was on a wooden floor, which was covered with dirt, and debris. Cobwebs were noted on several cartons. Social Services and Activities had items stored on the left side of the shed, while dietary items were on the right side and rear of the shed. On the shed floor, just to the right of the door was an open carton, approximately one-half full of unwrapped feminine hygiene products. The DSS confirmed the finding and agreed she would not use them. On the shed floor, just to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 53 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the left of the door was a dusty, uncovered, slow-cooker and two small rectangular insulated soft lunch boxes. The DSS stated the slow cooker had been used to make nachos and the lunch boxes had been donated. Around the inside perimeter of the shed, was a short wooden shelf, approximately four inches high, the following items were seen on the shelf: six boxes bouffant hats - used by food service workers one carton hot/cold insulated bowls two cartons of kitchen roll towels one open carton of clear lids for cups one carton of dinner napkins one carton bouffant hats one open carton of plastic spoons The DSS confirmed the findings and stated they had just used the last of the disposable Styrofoam containers to serve tonight's dinner. The facility policy and procedure titled "Canned and dry Goods Storage" dated 2011, indicated "Food and supplies should also be stored 6 [six] inches off the floor...Storage area will be cleaned as outlined..." The Food Code, dated 2013, indicated "...single-service and single-use articles shall be stored: (1) in a clean, dry location; (2) Where they are not exposed to splash, dust, or other contamination; and (3) At least 15 cm [centimeters] (6 inches) above the floor." 4. During a concurrent observation and interview with the PS, on 10/10/17, at 10:20 AM, in storage shed 3, two cartons of orange multi-surface cleaner and a carton of manual dishwashing detergent were on a plastic milk carton. Three cartons of Adult disposable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 54 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE briefs were against the rear wall, two of the cartons were on a pallet, while the third was tipping over onto a beige fall mat. On the other side of the mat on a blue stool were three bottles of floor wax. And in front of the floor wax, on the floor, was a carton of sharps containers. The PS confirmed the findings and stated we used to have C-trains. The facility job description titled "Director of Maintenance" dated 2003, indicated in part functions included: "Assist in establishing a preventative maintenance program. Inspect storage rooms...for upkeep and supply control. ...solicit advice from inter-department supervisors ...assist in identifying and correcting problem areas. Promptly report equipment or facility damage to the Administrator. Ensure that containers of hazardous chemicals in the department are properly labeled and stored. Develop, maintain, and implement infection control and universal policies and procedures to assure that a sanitary environment is maintained at all times..."

F469 SS=F MAINTAINS EFFECTIVE PEST CONTROL PROGRAM CFR(s): 483.90(i)(4)

F469 11/03/2017 (i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to implement an effective pest control program when evidence of mice were found inside the facility kitchen. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 55 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This failure resulted in pest infestation and had the potential to negatively affect residents health and safety. Findings: During a concurrent observation and interview with the Dietary Services Supervisor (DSS), on 10/9/17, at 9:35 AM, in the facility kitchen the following was noted: a. Mouse feces in the kitchen store room. b. Mouse feces in the freezer area of the kitchen. In between freezer "1" and "2", and behind freezer "3". c. Mouse feces in the storage rack area of the kitchen. d. Mouse feces in all corners of the "all purpose room". e. A hole, in the insulation around the kitchen swamp cooler, provided direct access for mice to enter into the kitchen storage area. The DSS confirmed the above findings and stated the facility kitchen was not cleaned per her expectations, and the kitchen had a mouse problem. During an interview with Cook 1, on 10/9/17, at 1:46 PM, she stated she had noticed mouse feces in the facility kitchen for about a month. Cook 1 stated she informed the DSS of the mouse feces when she first noticed it. During an interview with the DSS, on 10/9/17, at 1:50 PM, she stated the kitchen had an ongoing mouse problem. The DSS confirmed staff had reported mouse feces to her when fresh droppings were noted after sweeping. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 56 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The DSS stated staff cleaned the kitchen but would notice fresh droppings right after any cleaning was done. The DSS stated, "We know we've got a mouse, it is ongoing. I always see [mouse feces]. We keep our food in tubs because of the mice. Other than put more glue traps out and clean we did nothing else [to correct kitchen mouse issue]." During an interview with the Administrator on 10/9/17, at 2:10 PM, he stated he was aware of the kitchen having rodent issues. The Administrator was not able to state whether pest control was informed of the mouse feces found in the kitchen. The Administrator was not able to identify any other interventions done other than placing glue traps to catch the mice. The Administrator confirmed there was a mouse hole, in the insulation around the kitchen swamp cooler, that allowed access from the outside to the inside of the kitchen. During a concurrent observation and interview with the DSS, on 10/9/17, at 5:02 PM, in the facility kitchen, mouse feces were noted on the the bottom shelf of the drying rack where the dome covers for the residents' meal trays were stored. The DSS confirmed the findings. During an interview with the DSS, on 10/10/17, at 8:12 AM, she stated the mouse hole was covered, and one mouse had been caught earlier that morning. The DSS stated staff had cleaned the kitchen thoroughly. During a concurrent observation and interview with the DSS, on 10/10/17, at 8:29 AM, in the facility kitchen the following was noted: a. Mouse feces under the rinsing sink. b. Mouse feces under the the counter in the kitchen where the steamer is stored. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 57 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE c. Mouse feces in the storage area of the kitchen. The DSS confirmed the findings and stated "We [kitchen staff] cleaned the whole kitchen last night." During an interview with the Administrator on 10/10/17, at 9:54 AM, he stated there was only one identified entry point from the outside into the kitchen that a mouse or other pest could enter, and it was sealed off last night. The Administrator stated, "I think there might be some other mice leaving more feces despite our cleaning." During a concurrent observation and interview with the Administrator, on 10/10/17, at 10:46 AM, the following was found: a. Rotten wood on the roof was noted (measuring approximately four inches in width and 2 inches in length) allowing, entry access for pests to enter the building outside of the facility "B-wing" area. b. A mouse hole (measuring approximately an inch and a half in diameter ) was underneath the brick portion of the wall next to a water spout on the outside of the kitchen. c. Three entry holes (measuring approximately two inches in diameter) was noted on the outside of the kitchen area roof next to the gas shut off valve was not covered. d. A large hole in the screen of the the kitchen window exhaust fan (measuring approximately two inches in diameter) allowed access for pest from the outside directly into the kitchen dishwashing area. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 58 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE e. Rotten wood on the roof (measuring approximately five inches in length and three inches in width) allowed an entry access point for pest. Located on the outside portion of the facility kitchen. The Administrator confirmed the findings and stated the areas identified are easily accessible areas for pests to enter the building, specifically the kitchen. The Administrator stated the holes would be covered immediately. During an observation on 10/11/17, at 8 AM, one entry hole from the outside that opened into the kitchen area roof next to the gas shut off valve was noted. During an interview with the Regional Clinical Director (RCD), on 10/11/17, at 8:08 AM, she confirmed one entry hole from the outside remained open into the kitchen area next to the gas shut off valve. During an interview with the Director of Clinical Operations, on 10/11/17, at 5 PM, she stated her expectation was for staff to inform maintenance of any issues with pests. Maintenance would then log the concerns in the "maintenance log" and inform pest control to come in. During a review of the facility record titled "MAINTENANCE LOG" last entry dated 10/9/17, it indicated zero entries under the section "Problem" of mice issues. During a review of the facility pest control record titled "[Company name] COMMERCIAL SERVICE AND INSPECTION REPORT", dated 5/26/17 to 9/22/17, indicated the facility did not report any issues or concerns with mice. During an interview with the DSS, on 10/12/17, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 59 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE at 8:20 AM, she stated two mice were caught earlier that morning. One mouse was located in the kitchen store room and the other mouse was by the kitchen steamer. The facility policy and procedure titled "CANNED AND DRY GOODS STORAGE" dated 2011, indicated "...13. The storeroom will be checked routinely for any evidence of pests...16. The Storage area will be cleaned..." The facility job description titled "Dietitian" dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner...Develop, implement, and maintain a procedure for reporting hazardous conditions..." The facility job description titled "Director of Food Services" dated 2003, indicated "...Ensure that food service work areas are maintained in a clean and sanitary manner. Ensure that all food storage rooms, preparation areas, etc., are maintained in a clean, safe, and sanitary manner...Develop, implement, and maintain a procedure for reporting hazardous conditions..." The facility policy and procedure titled "Pest Control" dated 2008, indicated "Our facility shall maintain and effective pest control program...1. This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents...3. Windows are screened at all times...6. Maintenance services assist, when appropriate and necessary, in providing pest control services." The facility job description titled "Administrator" FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 60 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 2003, indicated "Duties and Responsibilities...Assist department directors in the development, use, and implementation of departmental policies and procedures and professional standards of practice...Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed...Consult with department directors concerning the operation of their departments to assist in eliminating/correcting problem areas, and/or improvement of services...Ensure that the building and grounds are maintained in good repair...Other(s) that may become necessary/appropriate to assure that the facility is maintained in a clean, safe, and sanitary manner..." The Federal Food and Drug Administration (FDA- a section of health and human services department tasked with the responsibility of the safety and security of most of our nation's food supply and protecting public health by assuring the safety, effectiveness, quality, and security of human products) indicated, "Controlling pests in a food processing facility is essential in order to minimize the transmission of food-borne illnesses caused by microbial contamination. Effective pest control is based on: Preventing entry (exclusion), removing nesting/breeding sites (harborage), and eliminating potential sources of food and water. Pest control requires vigilance inside and outside the plant. This includes: Maintaining the building to prevent entry of pests. Maintaining the grounds to ensure proper sanitation and remove harborage for pests. Following good manufacturing practices to ensure proper in-plant sanitation." (https://www.accessdata.fda.gov/orau/pestcontr olfood/pcf) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 61 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F517 WRITTEN PLANS TO MEET EMERGENCIES/DISASTERS CFR(s): 483.75(m)(1)

F517 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/12/2017 The facility must have detailed written plans and procedures to meet all potential emergencies and disasters, such as fire, severe weather, and missing residents. This REQUIREMENT is not met as evidenced by: Based on observation and interview, the facility failed to ensure emergency crash cart supplies were complete. This failure had the potential to result in the facility to be unprepared in the event of an actual medical emergency. Findings: During an observation on 10/10/17, at 8:44 AM, in the C wing Utility Room, a crash cart was noted. The supplies list found inside the crash cart was compared with the actual supplies present. Multiple items were missing including two suction catheters, two oxygen tubings, one oxygen mask, and one yankauer suction (a suctioning device used to clear mucous in mouth). Licensed Vocational Nurse 3 confirmed the findings and stated, "The crash cart should always be complete with the supplies needed." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 62 of 63 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055448 (X3) DATE SURVEY COMPLETED 10/12/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE DINUBA HEALTHCARE 1730 S College Ave Dinuba, CA 93618 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F518 TRAIN ALL STAFF-EMERGENCY PROCEDURES/DRILLS CFR(s): 483.75(m)(2)

F518 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 10/31/2017 The facility must train all employees in emergency procedures when they begin to work in the facility; periodically review the procedures with existing staff; and carry out unannounced staff drills using those procedures. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure easy access of the emergency crash cart. This had the potential for a delay in basic first aid or basic life support when needed. Findings: During a concurrent observation and interview with the Activities Supervisor (AS), on 5/9/17, at 5:54 PM, he stated the crash cart was kept in the utility room on A Wing. The AS attempted three times to unlock the utility room door. When the AS opened the door, there were two mechanical lifts (used to transfer a resident, with limited mobility, from bed to chair and back) blocking access to the crash cart. The facility policy titled "First Aid Treatment" dated 8/11, indicated "The goal of staff training is to enable employees to provide basic life support...Basic first aid intervention includes (but is not limited to interventions for the following situations: a. Choking, breathing emergencies...e. Shock...g. Allergic reactions and anaphylaxis...The goal of emergency interventions is to stabilize the resident and the situation until further treatment is available." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: MLCW11 Facility ID: CA040000032 If continuation sheet 63 of 63