Health inspection·May 15, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. Based on interview and record review, the facility failed to ensure documentation of the Advance Directive (legal document outlining a person's healthcare and end of life wishes should the person become unable to verbalize those wishes) status was accurate for one of four sampled residents (Resident 10). This failure resulted in an inaccurate medical record and had the potential for Resident 10's healthcare wishes not to be honored. Findings: During a concurrent interview and record review on 5/14/25 at 10:48 a.m. with Social Services Director (SSD) 1 and SSD 2, Resident 10's medical record was reviewed. SSD 1 stated the Physician's Order for Life Sustaining Treatment (POLST) dated 1/20/20, indicated No Advance Directive. The Social Services Progress Notes dated 1/24/25 indicated, Advance Directive . a. Yes [has an advance directive] on file. SSD 1 stated she was unable to find a copy of Resident 10's advance directive. During a review of the facilities policy and procedure (P&P) titled, Advance Directive dated 7/31/24, the P&P indicated, Advance Directive Information . c. During the Social Service Assessment process, the Director of Social Services or Designee will also ask the resident if they have a written advance directive. d. If the resident has an Advance Directive, the Facility shall request a copy of the document from the resident or the resident's representative . e. If a copy is provided by the resident or the resident's representative, it will be placed in the medical record. A copy of the facility's documentation policy was requested, none was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. Based on interview and record review, the facility failed to communicate a nurse-to-nurse report when transferring a resident to the hospital for one of two sampled residents (Resident 1). This failure resulted in the hospital not having any of Resident 1's medical or surgical history. Findings: During a concurrent interview and record review on 5/14/25 at 11:12 a.m. with Social Services Director (SSD) 1, Resident 1's Medical Record (MR) was reviewed. SSD 1 stated Resident 1 was transferred to the hospital for labored breathing. The Physician Order dated 4/12/25 at 11 a.m. indicated, send to ED [emergency department] for eval[uation] and treat as needed one time only for labored breathing for 1 Day. The SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form (HTF), dated 4/11/25, indicated, the form was completed and reviewed by Licensed Vocational Nurse (LVN) 4. The HTF indicated, Report Called in By (name/title) was filled in with na [not applicable] and Report Called in to (name/title) was filled in with na. During a concurrent interview and record review on 5/14/25 at 11:46 a.m. with LVN 2, Resident 1's HTF was reviewed. LVN 2 stated the form needs to be completed when transferring a resident to the hospital. A nursing documentation policy and procedure was requested and none was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Based on observation, interview, and record review, the facility failed to ensure one of one sampled resident (Resident 196), was administered oxygen according to physician's order. This failure had the potential to result in Resident 196 to experience hypoxia (low levels of oxygen in the body) or hyperoxia (high level of oxygen in the body). Findings: During a concurrent observation and interview on 5/12/25 at 10:03 a.m. with Resident 196 in her room, Resident 196's oxygen setting on the oxygen concentrator was 5 LPM (liters per minute). Resident 196 stated it was always at 3 LPM. During an interview on 5/12/25 at 12:41 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 196's oxygen setting order was 2 LPM. During a concurrent observation and interview on 5/12/25 at 12:42 p.m. with Certified Nursing Assistant (CNA) 1 in the Yellow Hallway, CNA 1 was wheeling Resident 196 with an oxygen tank behind the wheelchair. CNA 1 stated the oxygen was set at 2 LPM. Resident 196 told CNA 1 her oxygen was supposed to be at 3 LPM. During a review of Resident 196's Order Summary Report (OSR), dated 5/13/25, the OSR indicated, Oxygen 3 LPM Via Nasal Cannula Continuously every day and night shift for COPD (Chronic Obstructive Pulmonary Disease - lung disease where airflow is restricted). During a review of the facility's policy and procedure (P&P) titled, Oxygen Therapy, dated November 2017, the P&P indicated, I. Administration of Oxygen A. Administer oxygen per physician orders. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to accurately assess the skin of one of four sampled residents (Resident 31). This failure resulted in skin breakdown and pain for Resident 31. Residents Affected - Few Findings: During an interview on 5/13/25 at 10:35 a.m. with Family Member (FM) 1, FM 1 stated Resident 31 was dependent on staff for positioning and repositioning in bed. FM 1 stated Resident 31 had arthritis which caused her a lot of pain. FM 1 stated Resident 31 would usually lay on her left side because it was less painful for her. FM 1 stated Resident 31 had sores and redness on her left ear, left outer ankle, left outer foot, and right inner foot. During a review of Resident 31's admission Record (AR) dated 12/22/22, the AR indicated Resident 31's diagnoses included, OTHER ABNORMALITIES OF GAIT [manner of walking] AND MOBILITY . MUSCLE WEAKNESS . DEAF NONSPEAKING . RHEUMATOID ARTHRITIS [body's immune system attacks the lining of the joints causing pain and swelling]. During a concurrent interview and record review on 5/14/25 at 3:45 p.m. with Social Services Director (SSD) 1 and SSD 2, Resident 31's Medical Record (MR) was reviewed. SSD 1 stated she was unable to find any documentation indicating any pressure injuries (PI) or skin issues. During a concurrent observation and interview on 5/14/25 at 3:52 p.m. with Licensed Vocational Nurse (LVN) 1, in Resident 31's room, LVN 1 stated Resident 31 did not have any PIs or skin issues. LVN 1 used a white board to ask Resident 31 for permission to assess her skin and Resident 31 agreed to the assessment. LVN 1 examined Resident 31's left ear which had a permanent inward bend of the helix (curved part of outer ear). Inside the left helix was an open red and draining wound the size of a pencil eraser. LVN 1 touched the area with a tissue and Resident 31, who was non-verbal, pulled away and cried out in pain. LVN 1 then assessed Resident 31's feet. Resident 31 had a red nickel-sized area on her outer left ankle, which was partly covered in a scab, a dime-sized red area on the left outer area of the left foot near the small toe, and a red dime-sized area on the inner right foot near the big toe. Resident 31 wrote on her communication board that she had skin issues on her ear and feet for two months. LVN 1 stated certified nursing assistants (CNA) are supposed to report any resident skin issues noted during baths or showers. LVN 1 stated LVNs assess for any skin changes when weekly head-to-toe physical evaluations are completed. During an interview on 5/14/25 at 4:42 p.m. with Director of Nursing (DON), DON stated LVNs are expected to complete a weekly head-to-toe assessment of each resident and document any unusual findings on the weekly Long Term Care Evaluation. DON stated CNAs should document any unusual findings on the shower sheet (non-permanent part of the resident's MR which is used to communicate concerns from the CNA staff to the nursing staff). During an interview on 5/14/25 at 4:45 p.m. with LVN 2, LVN 2 stated nurses complete a head-to-toe assessment of each resident weekly. During a concurrent interview and record review on 5/15/25 at 10:49 a.m. with Director of Staff Development (DSD), Resident 31's Skin Monitoring: Comprehensive CNA Shower Review [SMCSR] documentation was reviewed, and the following was noted: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 SMCSR dated 3/4/25, Visual Assessment indicated no abnormal skin findings. Level of Harm - Minimal harm or potential for actual harm SMCSR dated 3/7/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/11/25, Visual Assessment indicated no abnormal skin findings. Residents Affected - Few SMCSR dated 3/14/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/18/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/21/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/25/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 3/28/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/1/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/15/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/18/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/22/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 4/25/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 5/2/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 5/9/25, Visual Assessment indicated no abnormal skin findings. SMCSR dated 5/13/25, Visual Assessment indicated no abnormal skin findings. DSD stated her expectation was for CNAs to document any discoloration, open areas on the skin, redness, scratches, scabs, folds, knees, under female resident's breasts, or other pressure points. During a review of Resident 31's Long Term Care Evaluation [weekly comprehensive nursing assessment] dated 3/23/25, 3/30/25, 4/6/25, 4/13/25, 4/20/25, 4/27/25, and 5/4/25 indicated Skin changes since last evaluation . No. The Skin Check dated 3/16/25, 3/23/25, 3/30/25, 4/6/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, and 5/11/25 indicated, 1. Skin Check . 8. No skin issues [was marked]. The Minimum Data Set [MDScomprehensive assessment tool] Section M - Skin Conditions dated 4/25/25, indicated, Risk of Pressure Ulcers/Injuries 1. Yes and Unhealed Pressure Ulcers/Injuries . Does this resident have one or more unhealed pressure ulcers/injuries? 0. No. During a review of the facility's policy and procedure (P&P) titled, Licensed Nurse Weekly Progress Notes dated 10/9/24, the P&P indicated, POLICY: Weekly nurses' progress notes will be written by licensed personnel on each resident, specific to the psychological, emotional, social, spiritual, and recreational needs and consistent with the Plan of Care. PURPOSE: To reflect observations of the resident's response to their environment, physical limitations, independent activities, dependency status, behavioral changes, skin problems, dietary problems and restorative measures to characterize the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 functional status of progression and/or regression. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Pressure Injury Prevention, dated 7/31/24, the P&P indicated, 5. Staff will observe for any signs of potential or active pressure injury daily. 6. A weekly skin check will be completed and documented in the medical record. Residents Affected - Few A nursing documentation P&P was requested, none was provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on interview and record review, the facility failed to follow its policy and procedure (P&P) titled, Comprehensive Person-Centered Care Planning for one of four sampled residents (Resident 10). This failure resulted in Resident 10 falling and sustaining a broken femoral neck (bone that connects upper leg to hip) bone. Findings: During a concurrent interview and record review on 5/14/25 at 10:02 a.m. with Social Services Director (SSD) 1 and SSD 2, Resident 10's Medical Record (MR) was reviewed. SSD 1 stated Resident 10 had an unwitnessed fall on 3/17/25 in her bathroom while attempting to self-toilet. Care Plan Report (CP), dated 2/13/25, indicated, Resident 10 was at risk for falls r/t [related to] impaired mobility and unsteadiness in gait [manner of walking]. The Physician Orders (PO), dated 3/17/25, at 11:15 a.m., indicated, Transfer to acute [hospital] for further evaluation related to Fracture [sic] of the left hip. The Discharge Documentation (DD), dated 3/22/25, indicated, Resident 10 was diagnosed with a Fracture [break] of femoral neck, left [side], requiring surgery to repair. During a review of Resident 10's MR, The CP, dated 2/13/25, indicated, Goal [:] the resident will be free of falls . Intervention [:] Ensure that The [sic] resident is wearing appropriate footwear when ambulating [walking] or mobilizing [moving] in w/c [wheelchair]. The Post Fall Evaluation (PFE), dated 3/17/25, indicated, 9. Reason for fall Resident [10] wearing fuzzy socks with no grip. The Progress Notes (PN), dated 3/17/25, at 1:31 p.m., indicated, Fall Details: Date/Time of Fall: 03/17/2025 7:15 AM Fall was not witnessed. Fall occurred in the bathroom. Resident was attempting to self toilet at the time of the fall. Reason for the fall was evident. Reason for fall: Resident wearing fuzzy socks with no grip. During a review of the facilities P&P titled, Comprehensive Person-Centered Care Planning dated 9/7/23, the P&P indicated, a. The baseline care plan must include the minimum healthcare information necessary to properly care for each resident immediately upon their admission. It should address resident-specific health and safety concerns to prevent decline or injury, and would identify needs for supervision, behavioral interventions, and assistance with activities of daily living, as necessary. B. The Baseline Care Plan Summary will be developed and implemented, using the necessary combination of problem specific care plans, within 48 hours of the resident's admission . 4 . b. Additional changes or updates to the resident's comprehensive care plan will be made on the assessed needs of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure one of one sampled resident (Resident 196), post dialysis (mechanical removal of toxins in the blood when the kidneys no longer function adequately) access care was done timely. This failure had the potential for Resident 196's dialysis access to develop an infection or stenosis (narrowing of a vein or artery) which can cause prolonged bleeding and dialysis access failure. Residents Affected - Few Findings: During a review of Resident 196's Order Summary Report (OSR), dated 5/13/25 the OSR indicated Resident 196 had an order to go to dialysis treatment every Monday, Wednesday, and Friday. During a concurrent observation and interview on 5/13/25 at 11:26 a.m. with Resident 196 in her room, Resident 196's dialysis dressing was on her left upper arm and asked Family Member (FM) 2 to take off the dressing. Resident 196 stated the staff was supposed to remove the dressing after her dialysis treatment on 5/12/25. During an interview on 5/15/25 at 12:14 p.m. with Licensed Vocational Nurse (LVN) 3, LVN 3 stated Resident 196's dialysis access dressing should be removed two hours after Resident 196 returned from her dialysis treatment. During an observation on 5/15/25 at 12:17 p.m. in Resident 196's room, her dialysis access dressing remained on her left upper arm from her dialysis treatment on 5/14/25. During a review of the facility's policy and procedure (P&P) titled, Dialysis Management dated 1/25/24, the P&P indicated, 4. Vascular Access Site.viii. Dressing will be changed in accordance with Attending Physician's Order. Resident 196's post dialysis evaluations for 5/12/25 and 5/14/25 were requested and none were provided. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a medication error rate of less than five percent for two of five sampled residents (Resident 33 and Resident 6). This failure resulted in Resident 33 and Resident 6 receiving medications unsafely and had the potential for adverse outcomes. Residents Affected - Some Findings: During an observation on 5/15/25 at 8:46 a.m. with Licensed Vocational Nurse (LVN) 2 in Resident 33's room. LVN 2 administered Lisinopril (used to treat high blood pressure, heart failure, and to improve survival after a heart attack) 5 milligrams (mg), Carvedilol (used to treat heart failure and high blood pressure) 3.125 mg, and Spironalactone (used to treat high blood pressure, heart failure, and fluid retention) 25 mg, by mouth to Resident 33. LVN 2 did not take Resident 33's heart rate or blood pressure before administering the medications. During an observation on 5/15/25 at 8:55 a.m. with LVN 2 in Resident 6's room, LVN 2 administered Amlodipine (used to treat high blood pressure and certain types of chest pain) 5 mg by mouth to Resident 6. LVN 2 did not take Resident 6's heart rate or blood pressure before administering the medication. During an interview on 5/15/25 at 9:26 a.m. with LVN 2, LVN 2 stated she did not take heart rates or blood pressures before administering medications to Resident 33 or Resident 6. During a review of Resident 33's Medical Record (MR), the Physician Order (PO) dated 10/9/24 at 10:59 a.m. indicated Lisinopril Oral Tablet 5 MG . Give 1 tablet by mouth one time a day for HTN [hypertensionhigh blood pressure] Obtain Bp [blood pressure]. If sbp [systolic blood pressure- top number when reading a blood pressure] below 100 hold [medication] and notify MD [physician]. If sbp above 180 administer [medication] and notify [MD]. Carvedilol Oral Tablet 3.125 MG . Give 1 tablet by mouth two times a day for HTN obtain Bp. If sbp is below 100 OR pulse [heart rate] below 60 Hold [medication] and notify [MD]. If sbp is above 180 administer [medication] and notify MD. Spironolactone Oral Tablet 25 MG . Give 1 tablet by mouth one time a day for HTN obtain bp & pulse. If sbp is below 100 Hold [medication] and notify MD, if sbp above 180 administer [medication] and notify MD. During a review of Resident 6's MR, the PO dated 2/27/25 at 6:15 p.m. indicated, amlodipine Besylate Oral Tablet 5 MG . Give 1 tablet by mouth one time a day for HTN[,] LVN to obtain BP, hold [medication] for SBP < [less than] 100 or pulse < 60 hold [medication] and notify MD. If SBP is greater than 180 administer [medication] and notify MD. During a review of the facility's policy and procedure (P&P) titled, Medication - Administration dated 1/1/12, the P&P indicated, Purpose to ensure the accurate administration of medications for residents in the facility . C. Tests and taking of vital signs, upon which administration of medications or treatments are conditioned, will be performed as required and the results recorded. i. When administration of the drug is dependent upon vital signs or testing, the vital signs/testing will be completed prior to administration of the medication and recorded in the medical record i.e. BP, pulse, finger stick blood glucose monitoring etc. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to ensure food items were used by the discard date, dated when opened, and labeled. This failure had the potential to cause foodborne illness (illness caused by the ingestion of contaminated food or beverages) to the residents. Findings: During a concurrent observation and interview on 5/12/25 at 9:01 a.m. with Certified Dietary Manager (CDM) in the kitchen, there was a large container with brown liquid that was not labeled. CDM stated it was iced tea, and it should be labeled. During a concurrent observation and interview on 5/12/25 at 9:03 a.m. with CDM in the kitchen, there were three pitchers of juice with no labels in the refrigerator. CDM stated there should be a label with the date of when the juice was poured into the pitchers. During a concurrent observation and interview on 5/12/25 at 9:05 a.m. with CDM in the kitchen, there were opened, unlabeled containers of mayonnaise and ranch dressing in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent observation and interview on 5/12/25 at 9:07 a.m. with CDM in the kitchen, there was a container of Worcestershire sauce with no label in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent observation and interview on 5/12/25 at 9:10 a.m. with CDM in the kitchen, there was a half full container of 2% milk and a carton of liquid eggs with no open date labels in the refrigerator. CDM stated the containers should be labeled with a date when opened. During a concurrent observation and interview on 5/12/25 at 9:19 a.m. with CDM in the storage room, there was an opened bag of vanilla wafers on the shelf. CDM stated the bag should be sealed with an open date label. During a concurrent observation and interview on 5/12/25 at 9:20 a.m. with CDM in the storage room, there was a tray of cinnamon rolls with a use by date of 5/10/25. CDM stated the cinnamon rolls should have been thrown away. During a review of the facility's policy and procedure (P&P) titled, Food storage and Handling, dated 2022, the P&P indicated, All items will be correctly labeled and dated. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555354 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Delta Healthcare & Wellness Center, LP 514 North Bridge Street Visalia, CA 93291 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to implement infection control standards for two of eight residents (Resident 7 and Resident 21). This failure had the potential to spread illness to residents, staff, and visitors. Residents Affected - Some Findings: During an observation and interview on 5/13/25 at 9:38 a.m. with Physical Therapist (PT) 1 in hallway, trash cans were not in the rooms and two were noted in the hallway. PT 1 exited Resident 7's isolation room with a soiled isolation gown rolled up in her hands. PT 1 crossed the hallway to dispose of the gown in the hallway trash can. PT 1 stated, There isn't a trash can in the room big enough for soiled personal protective equipment [PPE- gowns, gloves, and masks used to prevent the spread of infection]. During a concurrent observation and interview on 5/13/25 at 9:44 a.m. with Hospice Aide (HA), in Resident 21's room, which had transmission-based precautions (TBP-placed for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others) signage and a PPE cart outside of the room's entrance. HA stated she worked for a hospice agency, and came twice a week to bathe, dress, and make Resident 21's bed. HA was not wearing PPE and entered and exited Resident 21's room multiple times. During an interview on 5/13/25 at 9:49 a.m. with Infection Preventionist (IP), IP stated anyone going into rooms with TBP signage should follow the instructions. IP stated the facility should have notified the Hospice agency about the facility having a norovirus (highly contagious virus in the stomach that causes diarrhea and vomiting) outbreak on 5/12/25 that resulted in multiple rooms being placed on TBP. During an interview on 5/13/25 at 9:52 a.m. with HA, HA stated she put on PPE when she first entered the room, but she did not re-gown or re-glove when she re-entered the room multiple times. During a review of the facility's policy and procedure (P&P) titled, Resident Isolation-Categories of Transmission-Based Precaution, dated 1/1/12, the P&P indicated, To ensure that transmission-based precautions are used when caring for residents with communicable diseases or transmittable infections. Standard precautions are used when caring for residents at all times regardless of their suspected or confirmed infection status. Transmission-based precautions are used accordingly when caring for residents who are documented or are suspected of having communicable diseases or infections that can be transmitted to others. Procedure: . I. Transmission-based precautions are used whenever measures more stringent than standard precautions are needed to prevent or control the spread of infection. III. Contact Precautions A. Contact precautions are implemented for residents known or suspected to be infected or colonized with microorganisms that are transmitted by direct contact with the resident or indirect contact with environmental surfaces or resident-care items in the resident's environment. i. examples of infections requiring Contact Precautions include, but are not limited to: a. Gastrointestinal, respiratory, skin, or wound infections . C. iii. Gloves are removed before leaving the room and hands are washed immediately with an antimicrobial agent or a waterless antiseptic agent. iv. After gloves are removed and hands are washed, the potentially contaminated environmental surfaces or items in the resident's room are not touched. D. Gown ii. The gown is removed and hand hygiene is performed before leaving the resident's environment. iii. After removing the gown, clothing is not allowed to contact potentially contaminated environmental surfaces. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555354 If continuation sheet Page 12 of 12