Health inspection·July 10, 2023

F 0695 Level of Harm - Actual harm Residents Affected - Few During an interview on [DATE], at 9:45 a.m., with Nurse Manager (NM), NM stated, on [DATE], during shift change between 6:30 p.m. to 7:30 p.m., Resident 1 was in her room, lying in bed and noted to be cyanotic (a bluish or purplish discoloration of the skin, lips caused by lack of oxygen) with respiratory distress. NM stated, CPR was initiated, and Resident 1 was transferred to the acute hospital on [DATE], for evaluation and returned on [DATE]. NM stated, NP noted Resident 1's ventilator machine was on a standby mode and was not giving her [Resident 1] the air she needed. During a concurrent interview and record review on [DATE], at 10:21 a.m., with Director of Nurses (DON), Resident 1's OS, dated [DATE], was reviewed. DON stated, Resident 1 had an order for the ventilator machine to be on continuous mode. DON stated, Resident 1's ventilator machine should never have been placed on a standby mode. DON stated, During the investigation we (management) don't know who put the ventilator on a standby mode. DON stated, Resident 1's code status (full support which includes CPR, if the patient has no heartbeat and is not breathing) was a full code (all procedures will be provided to keep a person alive if the heart stopped beating and/or they stopped breathing). During a concurrent observation and interview on [DATE], at 10:52 a.m., with Certified Nursing Assistant (CNA), in Resident 1's room, Resident 1 was lying in bed. A ventilator machine was at Resident 1's bedside with a plastic breathing tube connected from the ventilator machine to Resident 1 ' s neck area. A rhythmic whoosh, pause, whoosh, pause was heard from Resident 1's ventilator machine. CNA stated, Resident 1 was non-verbal and required two staff assistance for turning and repositioning in bed. During an interview on [DATE], at 10:58 a.m., with Respiratory Technician (RT) 1 and RT 2, RT 1 stated, When the power button located in front of the ventilator machines monitor screen is pressed, a 'standby and a power off' question will appear on the monitor screen. When the standby mode is selected, the machine remains on, but it is not giving out any air. RT 1 stated, The standby mode on a ventilator machine is used when there is an order for weaning (process in decreasing the amount of ventilatory support) a resident off the machine and required an RT to be always at bedside with the resident during the weaning process. RT 2 stated, Resident 1 had an order for the ventilator machine to be on continuously and should not have been placed on a standby mode. During a concurrent interview and record review, on [DATE], at 12:33 p.m., with DON, Resident 1's ventilator machine alarm and button internal log (ventilator machine had its own memory log that record each event or incident), dated [DATE], was reviewed. The log indicated the following: [DATE] at 4:59 p.m. the Start/Stop Key Pressed. [DATE] at 4:59 p.m. (1 second later), the Standby mode was selected. [DATE] at 7:13 p.m. the ventilator machine was turned back on. DON stated, the log indicated Resident 1's ventilator machine was on a standby mode for more than two hours (2 hours and 14 minutes). DON confirmed the ventilator machine was on a standby mode ([DATE]), which resulted in respiratory distress for Resident 1. During an interview on [DATE], at 4:26 p.m., with Registered Nurse (RN) 1, RN 1 stated, on [DATE], at 5 p.m. she administered pain medication to Resident 1 in her room. RN 1 stated, at 5:50 p.m., she returned to Resident 1's room to re-assess Resident 1 and noted her (Resident 1) slight grimacing (frowning). RN 1 stated, at 6:15 p.m., she gave report to the oncoming nurse (Licensed Vocational (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 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 0695 Level of Harm - Actual harm Residents Affected - Few Nurse-LVN) inside Resident 1's room. RN 1 stated, she went into Resident 1's room three times (no time given) and did not notice Resident 1's ventilator machine was on a standby mode and Resident 1 was not receiving any air. RN 1 stated, Resident 1 Could not breathe without the ventilator machine. During an interview on [DATE], at 9:33 p.m., with RN 2, RN 2 stated, on [DATE], at approximately 6:20 p.m., Resident 1 was in her room with the NP. RN 2 stated, NP noted Resident 1 to be uncomfortable (uneasy). At approximately 7 p.m., RN 2 returned to Resident 1's room with the NP and found Resident 1 was dusky [grayish] color and had a faint (weak) pulse. RN 2 stated, CPR was immediately started. RN 2 stated, the NP noted Resident 1's ventilator machine was on a standby mode ([DATE]). RN 2 stated, Resident 1 needed the ventilator machine to help with breathing. During an interview on [DATE], at 12:39 p.m., with RT 3, RT 3 stated, When a ventilator machine is placed on a standby mode, the machine is on, but it is not giving breath to the resident, not ventilating, not working. RT 3 stated, Resident 1 was dependent on the ventilator machine, was not ready for any type of weaning, the ventilator machine should never have been placed on a standby mode. During an interview on [DATE], at 2:03 p.m., with NP, NP stated, on [DATE], she assessed Resident 1 two times (no time given). NP stated, Resident 1 looked uncomfortable, and she ordered pain medication to be given and a bladder scan (procedure used to detect how much urine is in the bladder). NP stated, she returned to Resident 1's room and noted Resident 1's skin color was different and noted the ventilator machine was on a standby mode. NP stated, she re-started Resident 1's ventilator machine and initiated the CPR. NP stated, Resident 1 had an order for the ventilator machine to be on continuously, There is no reason for her [Resident 1] to be on standby mode. During an interview on [DATE], at 7:23 a.m., with LVN, LVN stated, on [DATE], at approximately 6:20 p.m., he was in Resident 1's room getting verbal report from RN 1. LVN stated, at 6:50 p.m., he went back in Resident 1's room with RN 3 to perform the bladder scan and he noted the lights on Resident 1's ventilator machine was on but was not making any noise. LVN stated, he did not take a closer look at Resident 1's ventilator machine because he thought it was on. LVN stated, Resident 1 had always been on the ventilator since she was admitted ([DATE]). During an interview on [DATE], at 10:08 p.m., with RN 3, RN 3 stated, on [DATE], at approximately 6:50 p.m., she went to Resident 1's room to help with the bladder scan procedure. RN 3 stated, she did not notice Resident 1's ventilator machine was on a standby mode. RN 3 stated, Resident 1 had an order to be on the ventilator machine continuously. RN 3 stated, She [Resident 1] would not be able to tolerate without it [ventilator machine]. During a review of Resident 1's Nursing Narrative Note (NNN), dated [DATE] at 8:23 p.m., the NNN indicated, Approximately [7:23 p.m.] [sic] NP decided to go back and follow up on [Resident 1] and noticed that [Resident 1] was gray/dusky in color and was unresponsive [not reacting or responding] with faint [weak] pulse. [Resident 1] was in respiratory distress and CPR was initiated. During a review of Resident 1's Critical Care Progress Note (CCPN), dated [DATE] at 7:40 p.m., written by the NP, the CCPN indicated Significant Findings: Respiratory arrest (medical emergency where the ability of a resident to breathe stops). CPR started. send to [acute hospital] for evaluation. During a review of Resident 1's EMS (Emergency Medical Services- is a system that provides emergency medical care) narrative note, date [DATE], at 7:25 p.m., the note indicated, RN at scene states she was doing her normal evening rounds, and when she came to this patient [Resident 1], noticed that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555396 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/10/2023 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 0695 her ventilator was turned off.Continuously monitored patient during transport and arrived [acute hospital]. Level of Harm - Actual harm During a review of the acute hospital Emergency Documentation (ED), dated [DATE], at 10:30 p.m., the ED indicated, ED Course: [AGE] year-old female. presents to our facility status post [after] CPR. Staff found patient somewhat uncomfortable and realized that her ventilator has been turned off. They turned the ventilator back on, checked her pulse which was reported to be thready [weak]. CPR was initiated and maintained for approximately 10 minutes . Critical Care Note: There was an acute [sudden] impairment of an organ system (a group of organs in the body that work together to perform a specific function) with a high probability of imminent or life-threatening deterioration (a critical illness or injury acutely impairs one or more vital organ systems) in the patient's condition. Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled, Orders: Processing & Notation of Non-Medication Orders, dated [DATE], the P&P indicated, Licensed staff ensure Practitioner orders are followed when delivering care to patients. During a review of the facility's P&P titled, Mechanical Ventilation, dated [DATE], the P&P indicated, Respiratory Care practitioners will safely establish and maintain mechanical ventilatory support resulting in respiratory homeostasis [state of balance] . Procedures: XIII. Automatic Stop Order: Not applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555396 If continuation sheet Page 4 of 4