Health inspection·June 9, 2022

F 0563 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete During a review of the facility's Policy and Procedure (P&P) titled Visitors, dated 8/31/21, the P&P indicated, Visitor restrictions at the inpatient post-acute settings are as follows: South campus . Visitation is restricted to two (2) per day during visiting hours. [NAME] campus: . Visitation is restricted to two (2) visitors per day during visiting hours. During a review of California Department of Public Health All Facilities Letter (AFL), dated 2/7/22, the AFL indicated, Facilities shall also accommodate visitation in large communal indoor spaces for residents who are not in isolation or quarantine: Indoor spaces used for visitation such as a lobby, cafeteria, activity room physical therapy rooms, etc. should be arranged to accommodate 6-ft distancing between visitor-resident groups. Facilities should assess the maximum number of resident-visitor groups that can be accommodated while maintaining physical distancing between groups in communal indoor spaces designated for visitation; when the maximum is reached, visits will need to be conducted in the resident's room (if appropriate) or outdoors (preferably). During indoor large communal space visits between residents and visitors who are all fully vaccinated, both the resident and visitor must always wear a well-fitting face mask unless eating or drinking while in designated spaces for visitation. These visits may be conducted without physical distancing and include physical contact (e.g., hugs, holding hands). Event ID: Facility ID: 555396 If continuation sheet Page 2 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 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 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 information regarding Advanced Directives (AD - a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury) was provided for one of 37 sampled residents (Resident 146). This failure had the potential to result in Resident 146 being unable to make decisions about her medical care. Findings: During a concurrent interview and record review, on 6/7/22, at 3:56 PM, with Licensed Clinical Social Worker (LCSW), Resident 146's Electronic Health Record (EHR), dated 6/7/22 was reviewed. The EHR indicated, Resident 146 wishes to receive information about advance directive. LCSW stated she provides residents with information regarding ADs. LCSW stated, there was an order dated 5/27/22 to provide information to Resident 146 regarding an AD, and it wasn't done. During an interview with Director of Nursing (DON), on 6/7/22, at 3:59 PM, DON acknowledged the order for Resident 146's AD was not done and stated, this problem would be reviewed. During a review of the facility's Policy and Procedure (P&P) titled Advanced Directives, dated 1/29/20, the P&P indicated, Any patients desiring to formulate an Advance Directive with the capacity to do so will be assisted by being given a choice of an approved Advance Directive form. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 3 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure Physician's Orders (PO) for placement of a Sequential Compression Device (SCD - inflatable sleeve like device that wraps around the legs to improve blood circulation and prevent blood clots) were applied as ordered for four of five sampled residents with POs for the device (Resident 146, Resident 147, Resident 148, and Resident 198). This failure had the potential for blood clot formation which could adversely affect residents' health condition. Residents Affected - Some Findings: 1. During a concurrent observation and interview on 6/6/22, at 10:19 AM, in Resident 146's room, one SCD was observed wrapped around the footboard of the bed. Resident 146 stated, she had been at the facility for approximately one week and had not worn the SCD since admission. Resident 146 stated, I don't know what that [the SCD] is. During an interview on 6/6/22, at 2:57 PM, with Licensed Vocational Nurse (LVN) 11, LVN 11 stated the SCDs should be on at night. During a concurrent interview and record review, on 6/8/22, at 2:42 PM, with Clinical Risk Management Specialist (CRMS), Resident 146's Electronic Health Record (EHR), dated 6/8/22 was reviewed. The EHR indicated, Resident 146 had surgery on 5/18/22, and a PO for SCDs. The EHR indicated, SCDs were applied to Resident 146 on 5/27/22 at 10:33 PM, and on 5/28/22 at 2 AM. CRMS stated, no other documentation for SCD application was noted in the EHR. 2. During a concurrent interview and record review, on 6/8/22, at 2:39 PM, with CRMS, Resident 147's EHR dated 6/8/22 was reviewed. The EHR, dated 6/8/22, indicated, Resident 147 had surgery on 6/1/22 and a physician's order (PO) for SCDs was ordered. The EHR indicated, SCDs were applied to Resident 147 on 6/1/22 at 8:32 PM. CRMS stated no other documentation for SCD application was noted in the EHR. 3. During a concurrent interview and record review, on 6/8/22, at 2:54 PM, with CRMS, Resident 148's Electronic Health Record (EHR), dated 6/8/22 was reviewed. The EHR indicated, Resident 148 had surgery on 6/1/22, and a PO for SCDs. The EHR indicated, SCDs were applied 6/1/22, 6/2/22, 6/4/22, 6/5/22, and 6/6/22. CRMS confirmed no documentation for SCD application for 6/3/22 and 6/7/22 was noted in the EHR. 4. During a concurrent observation and interview on 6/6/22, at 12:02 PM, with Resident 198, in Resident 198's room, a Below the Knee Intermittent Pneumatic Compression Device/Sequential Compression Device (SCD) was noted at the end of Resident 198's bed. Resident 198 stated, she had only had the SCD's applied to her legs three times since she was admitted on [DATE]. Resident 198 stated, she would have liked to wear them. During an interview on 6/8/22, at 3:04 PM, with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, SCD's are applied at night and when requested. During an interview on 6/8/22, at 3:16 PM, with LVN 3, LVN 3 stated, SCD's are applied at night unless a resident refuses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 4 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 198's Physician's Order (PO), dated 5/27/21, the PO indicated, Resident 198 had a constant order for SCD's. During a concurrent interview and record review on 6/9/22, at 9:42 AM, with Clinical Risk Management Specialist (CRMS), Resident 198's Electronic Health Record (EHR), was reviewed. The EHR indicated, SCD's were applied on 5/27/22, 5/29/22, 6/4/22, 6/6/22. CRMS confirmed no documentation for SCD application for 5/28/22, 5/30/22, 5/31/22, 6/1/22, and 6/2/22 were noted in Resident 198's EHR. During a review of The National Library of Medicine's online publication Deep Venous Thrombosis Prophylaxis [The prevention of blood clots], dated 8/25/21, the publication indicated, hospitalized patients are at increased risk of VTE [venous thromboembolism - blood clots that block blood flow and oxygen, which can damage the body's tissue or organs] . Therefore, it is imperative [important] to consider DVT [Deep vein thrombosis- blood clot] prophylaxis [prevention]in every hospitalized patient. The publication indicated patients with increased risk include those with a recent surgery. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 5 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 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 - Some 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 store and label food in a safe and sanitary manner on two observations in the kitchen. These failures had the potential to result in foodborne illnesses. Findings: 1. During a concurrent observation and interview, on 6/6/22, at 10:10 AM, with Food Service Manager (FSM), in the facility's kitchen, an undated box of bananas was noted. FSM confirmed the finding and stated, he writes the date on the top of the box lid and the lid must have been thrown away. During a review of the facility's policy and procedure (P&P) titled, Food Safety Hazard Analysis of Critical Control Points (HACCP) Policy Number Food and Nutrition Services (FNS).606, dated 10/6/21, the P&P indicated, Products are placed in storage using the FIFO (first in, first out) system. 2. During a concurrent observation and interview on 6/6/22, at 10:12 AM, with Food Service Manager (FSM), in the facility's dry storage room, a dented soup can (Campbell's Soup 7 ¼ ounces) was noted on a storage rack. FSM confirmed the finding and stated, normally we have a process when the order comes in, cans are dated and checked for dents. FSM also stated, this can did not get removed from inventory and it must have been missed. During a review of the facility's P&P titled, Dented Cans, Policy Number FNS.310, dated 9/1/21, the P&P indicated, All delivered items are inspected before use. If damage is identified, the item is not used and is placed in the designated area. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 6 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 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 3. During a concurrent observation and interview on 6/6/22 at 11:35 AM, with LVN 11, in the Transitional Care Unit, LVN 11 was noted using a glucometer to check the blood sugar of Resident 197 by placing a drop of Resident 197's blood onto a testing strip on the glucometer. After the test was completed, LVN 11 placed the glucometer back in it's holder in the medication room. LVN 11 stated, All done, and that the glucometer was ready to use for the next resident. LVN 11 did not clean or disinfect the glucometer after she used it for Resident 197. No bleach wipes were noted near the glucometer holder, or among the glucometer testing supplies. Residents Affected - Some During an interview on 6/6/22, at 2:45 PM, with Licensed Vocational Nurse (LVN) 11, LVN 11 stated, she should have disinfected the glucometer with an alcohol wipe after she had used it, and I didn't do that. I should have. During a review of the facility's policy and procedure (P&P) titled, Nova StatStrip Glucose Meter System, dated 8/20/21, the P&P indicated, Cleaning of meter 1. Using a new, fresh germicidal bleach wipe, thoroughly wipe the surface of the meter (top, bottom, left and right sides) a minimum of 3 times horizontally followed by 3 times vertically avoiding the bar code scanner and electrical connector. 2. Gently wipe the surface of the the test strip port making sure that no fluid enters the port. Observe surface contact time. Ensure the meter surface stays wet for 2 minutes and is allowed to air dry for an additional 1 minute. 16. When patient testing is completed, the StatStrip Glucose Hospital Meter System should be cleaned and disinfected after use prior to testing with a new patient. Based on observation, interview, and record review, the facility failed to implement infection control practices when: 1. Personal protective equipment (PPE - refers to gown, gloves, masks and face shield worn to protect the wearer from injury or infection) was not used correctly according to infection control guidelines. 2. Linen was not delivered in a safe and sanitary manner. 3.Licensed Vocational Nurse (LVN) 11 failed to clean and disinfect a glucometer (device used to measure how much sugar is in a drop of blood) after it was used on a resident (Resident 197). These failures had the potential to spread infectious disease to residents, staff and visitors. Findings: 1. During a review of Resident 198's Physician's Orders (PO), dated 6/3/22, the PO indicated, Resident 198 was placed on Contact Isolation (Precautions used to minimize the spread of a contagious disease) due to a diagnosis of Shingles (a viral infection that causes a painful rash on one side of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 7 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 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 the body) PPE: gloves always upon entry to room, gown if direct patient/environment contact. Level of Harm - Minimal harm or potential for actual harm During a concurrent observation and interview on 6/6/22, at 10:13 AM, with LVN 11, in the hallway, Resident 198's door was observed to have a large red stop sign on door. LVN 11 stated, Resident 198 is on contact isolation. Residents Affected - Some During a concurrent observation and interview on 6/6/22, at 10:18 AM, with Certified Nursing Assistant (CNA) 1, CNA 1 was observed entering Resident 198's room without donning (put on an item) a gown or gloves. CNA 1 proceeded to place a pillow under Resident 198's legs, and then reached into her scrub pocket prior to sanitizing her hands with hand gel. CNA 1 stated, she doesn't know if she must follow the sign on the door because she hasn't seen anyone wearing a gown or gloves when entering Resident 198's room. CNA 1 stated, the sign on Resident 198's door indicated that she should have been wearing a gown and gloves. During a concurrent observation and interview on 6/6/22, at 12:14 PM, with LVN 11, LVN 11 was observed entering Resident 198's room to deliver Resident 198's lunch tray. LVN 11 did not don gloves or gown prior to entering Resident 198's room. LVN 11 proceeded to touch Resident 198's bedside table and belongings. LVN 11 confirmed the findings and stated, she should have donned gloves and gown prior to entering Resident 198's room. During an interview on 6/9/22, at 10:48 AM, with Infection Preventionist (IP), IP stated, Residents with a localized shingles rash that is covered should be on contact precautions. IP stated, when a resident is in contact precautions, any staff providing direct care should wear a gown and gloves. IP stated, staff entering a room without providing direct care should wear gloves. IP stated, for residents on Contact precautions, it would be her expectation of staff delivering a food tray to don gloves prior to entering room and staff helping a resident adjust a pillow under resident's legs should don a gown and gloves. During a review of the facility's policy and procedure (P&P) titled, Standard Transmission Based Precautions, dated 12/20, the P&P indicated, All employees shall utilize and employ protective methods to prevent exposure to pathogens throughout performance of their duties. All employees shall prevent the spread of infection within the hospital meeting the following criteria: .C. Adequate precautions for infection transmission by airborne, droplet and contact routes. IV. 1. Contact Precautions: You must at a minimum wear gloves when entering the room. E. [NAME] gown upon entry into the patient's room if anticipating close proximity to the patient. 2. During a concurrent observation and interview on 6/8/22, at 2:39 PM, with Laundry Services (LS), in the hallway, LS was observed bringing a large black cart of clean linen into the facility. The clean linen cart was partially covered with a white sheet. LS confirmed the finding and stated, linen is supposed to be covered with plastic bags but the facility ran out. During a concurrent observation and interview on 6/9/22, at 9:07 AM, with Laundry Manager (LM), LM observed a photograph of the linen cart delivered to the facility on 6/8/22, at 2:39 PM. LM stated, That is not acceptable. It should have been covered with at least an alternative (cover). LM also stated, linen carts are lined with a plastic insert bag prior to filling with clean linen. Plastic insert bags are then tied to ensure all linen is covered. LM stated, there are alternative plastic bags that cover the top of the linen carts if the plastic inserts are not available. Alternative plastic coverings are always available. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 8 of 9 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 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/09/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kaweah Health Skilled Nursing Center 1633 South Court Street Visalia, CA 93277 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P titled, Linen Distribution Process, dated 1/21, the P&P indicated, Linen will be delivered in a safe and sanitary manner.II. The Laundry Worker will transport covered carts to each area.V. Offsite Linen Delivery.C. Filled orders will be placed in Clean disinfected and covered carts tagged with the delivery location. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 9 of 9