Health inspection·July 22, 2019

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent lunch dining observation and interview with CNA 4, on 7/15/19, at 12:44 p.m., CNA 4 went back to resume feeding Resident 17 and Resident 53 who were waiting for meal assistance. CNA 4 tried to wake up Resident 53 who fell asleep at the table. CNA 4 stated I know it's not right to stop feeding [Resident 17 and Resident 53] especially her [Resident 53], who tends to fall asleep. CNA 4 stated that other staff members in the dining room should have helped but there was no staff around at that time. CNA 4 stated It's a dignity issue. I know it's not right. If we stop helping them eat, they might lose their appetite. There should be continued feeding to assist residents. CNA 4 stated Our goal is to assist and feed all residents during meal times so that they will not feel hungry until dinner time. I just do the best I can to help all the residents. During an interview with CNA 12, on 7/15/19 at 3:19 p.m., She stated It was a dignity issue if you leave a resident who has not completed her meal. CNA 12 stated it was the resident's right for a continuous and uninterrupted meals without delay during assistance with meals. During an interview with Licensed Vocational Nurse (LVN) 6, on 7/15/19 at 3:52 p.m., she stated Residents' (Residents 17, 31, 46, 53, 65, 99 and 108) rights and dignity were violated due to delays in assisting with meals. Residents were waiting for their turn to be fed because CNA's were busy assisting other residents in the room. During an interview with Assistant Director of Nursing (ADON), on 7/17/19, at 9:00 a.m., the ADON stated residents' (Resident's 17,31, 46, 53, 65, 99 and 108) rights and dignity were violated in the dining room due to the delayed assistance with meals. 2. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 5 on 7/15/19 at 12:14 p.m., in the dining room, CNA 5 sat in a folding chair in between the wheelchair of Resident 65 and Resident 108 while providing meal assistance. There were two other residents in the half moon dining table who were getting assistance with their meals by another staff member. During a concurrent observation and interview with CNA 5, on 7/15/19 at 12:45 p.m., in the dining room, CNA 5 stood up and stopped assisting Resident 65 and Resident 108 and went to Resident 46 who was on the other table located on the left side corner of the dining room. CNA 5 stated she went to assist Resident 46 because she was not eating her food and needed assistance. During an observation, on 7/15/19 at 12:47 p.m. in the dining room, Resident 65 and Resident 108 sat in their wheelchairs and stared at other residents on the dining table while their food was before them. Resident 65 and Resident 108 were not being assisted with their meals. During an observation, on 7/15/19, at 12:48 p.m., in the dining room CNA 5 stood up and stopped meal assistance to Resident 46 and moved to Resident 99 whose bib fell and had to be fixed. CNA 5 went back to Resident 65 and Resident 108 to resume their meal feeding. During a concurrent observation and interview with Resident 63, on 7/15/19 at 12:54 p.m. in the dining room, Resident 63 stated I cannot walk today, I have a sore hip. CNA 5 stood up and stopped feeding Resident 46 and proceeded to Resident 63 because she wanted to go back to her room. CNA 5 wheeled Resident 63 back to her room and meal assistance for Resident 46 stopped. During an interview with Licensed Vocational Nurse (LVN) 6, on 7/15/19 at 3:52 p.m., she stated Residents (Resident's 17,31, 46, 53, 65, 99 and 108) right and dignity were violated due to the delays in feeding. Residents were waiting for their turn to be fed because CNA's were busy assisting other (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 2 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0550 residents in the room. Level of Harm - Minimal harm or potential for actual harm During an interview with CNA 5, on 7/16/19, at 12:07 p.m., CNA 5 stated staff in the East Wing dining room usually assisted two residents during meals at the same time. CNA 5 stated that most of the time staff had to can stop assisting one resident to assist another. CNA 5 stated it was not a good practice, not sanitary, interrupted meals and lessened the appetite due to cold food and can cause weight loss. CNA 5 stated the practice violated resident's respect and dignity by not providing continuous meal feeding during dining. Residents Affected - Some During an interview with Assistant Director of Nursing (ADON), on 7/17/19, at 9:00 a.m., the ADON stated residents' (Resident's 17,31, 46, 53, 65, 99 and 108) rights and dignity were violated in the dining room due to the delayed feeding during meals. 3. During a concurrent observation and interview on 7/15/19 at 12:30 p.m., in the hallway of East Wing, Resident 31 and Resident 86 were seated in wheelchairs eating lunch in the hallway in front of dining room and exit door. CNA 6 sat in between wheelchairs of Resident 31 and Resident 86. Each resident had an over-the-bed table positioned in front of them. Lunch trays were placed on the over-the-bed tables. CNA 6 sat next to Resident 31 and Resident 86 and began to assist them with their lunchin the hallway. CNA 6 stated Resident 31 and Resident 86 were fed in the hallway since there were not enough space in the dining room. During an interview with Licensed Vocational Nurse (LVN) 6, on 7/15/19 at 3:52 p.m., she stated Residents' (Resident's 17,31, 46, 53, 65, 99 and 108) rights and dignity were violated due to the delays in assisting with meals and serving meals in the hallway. During an interview with CNA 10, on 7/16/19, at 9:01 a.m., she stated Resident 31 and Resident 86 were assisted with their meal outside the dining room in the hallway because the dining room was too small to accommodate all the residents assigned to East Wing dining room. CNA 10 stated it's undignified for Residents 31 and 86 to be seen eating in the hallway by visitors. During an interview with Assistant Director of Nursing (ADON), on 7/17/19, at 9:00 a.m., the ADON stated residents' (Resident's 17,31, 46, 53, 65, 99 and 108) dining room rights and dignity were violated due to the delayed assistance with meals. During a concurrent observation and interview with CNA 4, 7/19/19, at 12:15 p.m., in the hallway of East Wing, Resident 53 and Resident 66 were seated in wheelchairs eating lunch in the hallway in front of dining room and exit door in the east wing. Resident 53 and Resident 66 had an over-the-bed table positioned in front of them. Lunch trays were placed on the over-the-bed tables. Resident 66 began to eat lunch without supervision while in the hallway. CNA 4 stated Resident 53's and Resident 66's respect and dignity were violated because of having to eat their meals in the hallway and being able to be seen by family and visitors. 4. During an observation on 7/19/19, at 9:31 a.m., in the dining room, CNA 11 was in the standing position and stood over Resident 17 and Resident 53 while assisting with the meal. CNA 11 stood next to Resident 17 and 53. During an interview with CNA 11, on 7/19/19, at 9:33 a.m., she stated she was standing while feeding Resident 17 and Resident 53. CNA 11 stated I forgot, I should have sat on the chair while feeding to maintain eye level to [Resident 17 and Resident 53]. CNA 11 stated I should have provided respect (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 3 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0550 and dignity by sitting next to them [Resident 17 and Resident 53]. Level of Harm - Minimal harm or potential for actual harm The facility policy and procedure titled Assistance with Meals, dated 7/2017, indicated Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy interpretation and Implementation Dining Room Residents: 1. All residents will be encouraged to eat in the dining room. 2. Facility Staff will serve resident trays and will help residents who requires assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing while assisting them with meals; b. Keeping interaction with other staff to a minimum while assisting residents with meals; . Residents Affected - Some The facility policy and procedure titled Quality of Life- Dignity, dated 8/2009, indicated Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy interpretation and Implementation 1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the residents will be assisted in maintaining and enhancing his or her self-esteem and self-worth . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 4 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0583 Keep residents' personal and medical records private and confidential. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure the residents right to privacy during care for two of two sampled residents (Resident 23 and 89) when Licensed Vocational Nurses (LVN 3 and LVN 4) provided care to Resident 23 and 89 without closing privacy curtains during medication administration observation. Residents Affected - Some This deficient practice resulted in Resident 23's and 89's right to privacy during the delivery of care. Findings: During a medication administration observation, on 7/16/19, at 7:45 a.m., LVN 4 entered Resident 89's room and took the resident's apical pulse (heart rate) in view of other staff providing care to other residents, and a visiting family member. LVN 4 did not close the privacy curtain to offer Resident 89 privacy. During an interview with LVN 4, on 7/16/19, at 7:50 a.m., she stated she should have closed the privacy curtain around Resident 89's bed to ensure her privacy was protected from others not involved in her care. During a medication administration observation, on 7/16/19, at 8:35 a.m., LVN 3 entered Resident 23's room and administered an eye drop and inhaler in view of other staff not involved in the resident's care and visitors. LVN 3 did not close the privacy curtain to offer Resident 23 privacy. During an interview with LVN 3, on 7/16/19, at 8:45 a.m., LVN 3 stated she should have closed the privacy curtain around Resident 23's bed to provide the resident privacy during medication administration. During an interview with the Director of Nursing (DON), on 7/18/19, at 10:36 a.m., she stated the residents' rights to privacy should always be maintained while performing care and procedures. The facility policy and procedure titled, Resident Rights dated 8/09, indicated Employees shall treat all residents with kindness, respect and dignity . d. privacy and confidentiality . 3. Our facility will make every effort to assist each resident in exercising his/her rights to assure that the resident is always treated with respect, kindness and dignity . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 5 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. 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 use the least restrictive alternative for the least amount of time and to assess and document ongoing re-evaluation of the need for restraints in accordance with the facility's policy and procedure for one of three sampled residents when Resident 520 was prescribed a tab alarm on admission without using a less restrictive alternative and was not assessed or re-evaluated for 14 days. Residents Affected - Few This deficient practice unnecessarily restrained Resident 520 and kept her from freely moving and reaching for items for fear of setting off the alarm. Findings: During a concurrent observation and interview with Resident 520, on 7/15/19, at 11:31 a.m., in the resident's room, she was sitting up in her wheelchair watching television. Resident 520 had a tab alarm device attached to her wheelchair and the alarm cord clipped to the back of her shirt. Resident 520 stated the facility had alarms attached to her while she was in her wheelchair and when she was in bed. Resident 520 stated she did not like them, did not need them, and they prevented her from reaching for items she wanted. Resident 520 demonstrated the restriction of movement by leaning forward four inches to reach a book on her over bed table. The cord for the tab alarm pulled on her shirt and the resident stopped short of reaching her book. Resident 520 stated if she leaned forward any further the alarm would go off and she didn't want to make the alarm go off. Resident 520 stated the noise made her nervous and she did not like the noise. Resident 520 stated she had a call light and knew how to use it to call for help. During a review of the clinical record for Resident 520, the admission assessment dated [DATE], indicated she was admitted on [DATE] with an active diagnosis of sepsis (bacterial infection in the blood), a urinary tract infection, confusion, and a history of a fall at home. During a review of the clinical record for Resident 520, the Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive, functional, behavioral, and care needs) dated 7/11/19, indicated Resident 520 did not have any significant issues with hearing, vision, speech, or comprehension that would prevent her from understanding instructions or increase her risk for falls. Resident 520's Brief Interview for Mental Status (assessment of cognitive status-memory function) score of 14 out of 15 indicated no cognitive impairment. During a review of the clinical record for Resident 520, the MDS assessment dated [DATE], indicated there was no use of restraints for Resident 529, and she was using a bed alarm and a chair alarm. Resident 520's MDS indicated the plan was for her to be independent on all activities and to be discharged back to the community after occupational and physical therapy. During a review of the clinical record for Resident 520, the Fall Risk Evaluation dated 7/5/19, indicated a risk score of 22 and a resident who scores a 10 or higher is at a high risk [for falls]. During a review of the clinical record for Resident 520, the physician's orders dated 7/5/19, indicated an order for tab alarm when in wheelchair and when in bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 6 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0604 Level of Harm - Minimal harm or potential for actual harm During a review of the clinical record for Resident 520, the consent for devices dated 7/5/19, indicated the reason for use of the tab alarm [for wheelchair and bed], was the probable degree and duration, and the reasonable alternative interventions were discussed with Resident 520's son who signed the consent. The document indicated the consent, use, probable degree and duration, and reasonable alternative interventions were not discussed with Resident 520. Residents Affected - Few During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 7/17/19, at 9:31 a.m., she reviewed Resident 520's clinical chart and verified there was no care plan and no reassessment for the use of the tab alarm or restraints. LVN 1 stated Resident 520 was confused and at risk for falls when she was admitted . She stated the tab alarm was ordered to keep Resident 520 from getting up on her own and falling before staff could attend to her. During a concurrent interview and record review with Director of Nursing (DON), on 7/17/19, at 10:34 a.m., she reviewed Resident 520's clinical chart and verified there was no care plan and no re-assessment for the use of the tab alarm. DON stated the base line care plan indicated Resident 520 had a history of falls and the tab alarm was an intervention for the falls. DON validated there were no interventions or goals for the reduction plan for the tab alarms on the base line care plan. During an interview with Physical Therapist (PT), on 7/18/19, at 9:09 a.m., she stated the tab alarm was a restraint if it was limiting the resident's movement. PT stated the goal of physical therapy was to increase Resident 520's strength to decrease her risk for falling so she could be discharged back to her home. PT stated she was not aware the tab alarm was limiting Resident 520's movement. During an interview with Certified Nursing Assistant (CNA) 3, on 7/18/19, at 9:22 a.m., she stated Resident 520 had asked her if she could remove the alarm tag and she told her No, it was for her safety. CNA 3 stated Resident 520 was able to use her call light and use it when she needed help. She stated Resident 520 had never tried to get up by herself and had not set off her tab alarm that she knew of. CNA 3 stated Resident 520 had transferred herself to the bathroom earlier that day with CNA 3 only standing by for assistance. During a concurrent interview and record review with LVN 6, on 7/18/19, at 10:10 a.m., she reviewed Resident 520's clinical chart and verified there was no care plan and no reassessment for the use of the tab alarm. LVN 6 stated the tab alarm was initiated for Resident 520 on admission because she was confused and was a fall risk. LVN 6 stated least restrictive measures were not attempted prior to implementing the use of the alarms. LVN 6 stated the distance from the resident's room to the nurses' station was far and the resident did not always call for assistance after she was admitted . LVN 6 stated the facility had not tried any less restrictive methods and she would consider the tab alarm a restraint if it prevented the resident from moving. LVN 6 confirmed Resident 520's tab alarm had been triggered by Resident 520 reaching for an item before and not for getting up on her own. She stated she did not know if the tab alarm could be discontinued for Resident 520, the facility would need to discuss that with the family, the resident, and PT would need to evaluate her. During a concurrent interview with Assistant Director of Nursing (ADON), on 7/19/19, at 11:35 a.m., and record review of Resident 520's newly created care plan for tab alarms, dated 7/18/19, ADON validated there was no intervention on the care plan to reassess for the need of tab alarm. ADON stated Resident 520 was reassessed for the tab alarm that morning (14 days after the use of the alarm was initiated) and the resident would be taken off the tab alarm and given a pad char alarm for 72 hours and then reassessed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 7 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent observation and interview with Resident 520, on 7/19/19, 11:35 a.m., she had the tab alarm device attached to her wheelchair and the alarm cord clipped to the back of her shirt. Resident 520 stated her FM had not told her he signed a consent for the tab alarm and the facility had not told her why she was given the alarms. She stated the tab alarm still restricted her movement when she tried to reach for things. Resident 520 stated she needed a little help with transfers still and was able to use the call light for help but was frustrated with the tab alarm still being used on her. The facility's policy and procedure titled Policy and Procedure for the use of Safety Devices, undated, indicated 1. Prior to the application of a safety device (including tab alarm .) that has the potential to impend the activity of the resident, the resident shall be assessed by a Licensed Nurse. 2. When a Licensed Nurse assesses the resident for a safety device, they shall have attempted less restrictive devices prior to the application of a safety device. 3. The IDT shall review the use of all safety devices. 4. If it is determined that the safety device is considered a restraint, the MDS shall be coded accordingly and the physician shall obtain informed consent prior to the device's usage. 5. The care plan will be updated as indicated to reflect any changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 8 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During an interview and record review with MDS 2, on 7/17/19, at 10:31 a.m., MDS 2 reviewed Resident 15's MDS annual assessment section M, current number of stage 2 pressure ulcer; the coding box was coded 2, indicated there were 2 stage 2 pressure ulcers present at the time of assessment. MDS 2 reviewed Resident 15's weekly pressure ulcer record which indicated, one stage 2 pressure ulcer. MDS 2 stated, there was only one pressure ulcer at the time of assessment. MDS 2 stated, The assessment is inaccurate. MDS 2 stated the assessment did not accurately reflect the number of Stage 2 pressure ulcer on Resident 15. Residents Affected - Some Review of facility record titled Resident care plan undated, indicated . date 3/14/19, Resident status: Reopened area Right inner buttock . 3. During a concurrent observation and interview with Resident 61, on 7/15/19, at 10:25 a.m., in Resident's room, Resident 61 was sitting at bedside, she was wearing cam boot (Orthopedic boots protect broken bones and other injuries of the lower leg, ankle, or foot) to right foot. Resident 61 stated she had a fall and had broken her right foot. Resident 61 stated she was not in pain and not taking pain medication. During an interview and record review with MDS 3, on 7/17/19, at 8:51 a.m., MDS 3 reviewed Resident 61's MDS dated [DATE] and stated, The assessment for pain on J section is inaccurate. MDS 3 stated the resident did not received routine and as needed pain medication during the look back period of 5 days. MDS 3 reviewed the Medication administration record (MAR) for June and July 2019, she stated the last as needed pain medication was given 6/11/19 and no record of resident receiving routine pain medication. During an interview and record review with MDS 2 on 7/17/19 at 11:00 a.m., MDS 2 reviewed Resident 61's clinical record titled MAR for the month of 6/19 and 7/19. MDS 2 stated the MAR indicated as needed pain medication was last given 6/11/19. MDS 2 stated there was no order for a routine pain medication. MDS 2 stated, The MDS assessment section J for pain is inaccurate. During a review of the clinical record for Resident 61, the eMAR dated 06/2019, indicated .Hydrocodone 5 mg-acetaminophen 325 mg (unit of measurement) .signed on 6/2/19, 6/4/19, 6/5/19, 6/6/19, 6/7/19, 6/9/19, 6/10/19 and 6/11/19. During an interview with the DON on 7/18/19, at 10:36 a.m., DON stated there are three MDS personnel and they are responsible for their own assessments and that includes the accuracy of the assessments. The facility policy and procedure titled Resident Participation-Assessment/Care Plans dated 9/10, indicated, . 1. The Assessment Coordinator is responsible for ensuring that the Interdisciplinary Assessment Team conduct timely resident assessments and reviews . 7. All persons who have completed any portion of the MDS Resident Assessment Form MUST sign such document attesting to the accuracy of such information. Based on interview and record review, the facility failed to ensure the Minimum Data Set (MDSassessment of healthcare and functional needs) assessment accurately reflected the resident's status for three of three sampled residents (Resident 2, Resident 15, and Resident 61) when: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 9 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0641 1. Rejection of care was incorrectly coded in Section E (behavior) in four of five of Resident 2's MDS assessments. Level of Harm - Minimal harm or potential for actual harm 2. Pressure ulcer was incorrectly coded in Section M (skin condition) of Resident 15's annual assessment. Residents Affected - Some 3. Pain was incorrectly coded in Section J (health condition) of Resident 61's 5-day assessment. These failures resulted in an inaccurate assessments of Resident 2, 15 and 61's MDS assessment, resulted in care plans for refusal of weights to not be addressed and updated in IDT meetings for Resident 2, and had the potential to result in Resident 15 and 61's care needs going unmet. Findings: 1. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 7/17/19, at 3:29 a.m., he reviewed Resident 2's weight log and stated Resident 2 had been refusing her physician ordered weekly weights and had gained a lot of weight in the last year. LVN 2 stated Resident 2's weekly weight log indicated Resident 2 began refusing weekly weights on 1/14/18 and refused all weekly weights from 7/1/18 through 1/17/19. LVN 2 stated the weight log dated 7/1/18 indicated Resident 2 weighed 230 pounds and on 1/17/19 she weighed 284 pounds indicating a 54-pound weight gain within six months. LVN 2 stated Resident 2 was not weighed again until 4/12/19 when she weighed 317 pounds indicating an additional 33-pound weight gain. LVN 2 stated Resident 2 was weighed on 5/28/19 and weighed 322 pounds, indicating an additional 5-pound weight gain for a total of 92 pounds within 11 months. LVN stated Resident 2 refused all weekly weights since 5/28/19. LVN 2 reviewed Resident 2's clinical record and was unable to find a care plan addressing the refusal of weights and ongoing weight gain. During a concurrent observation and interview with Resident 2, on 7/17/19, at 3:44 p.m., Resident 2 was lying in her bed in her room. Resident 2 stated she refused her weights because she had severe pain every time the staff would try to get her out of bed. She stated the, Sling [a cloth support devise used with a mechanical lift to transfer residents that are unable to stand] the staff used to get her out of bed hurts her. Resident 2 stated she knew she had gained a lot of weight in the last year and did not want to know what her weight was. During a review of the clinical record for Resident 2, the Face Sheet (a document with resident demographic and medical diagnosis information) undated, indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included hypertension (high blood pressure), diabetes mellitus (a disease that causes elevated levels of sugar in the blood and urine), Parkinson's Disease (a progressive disease of the nervous system involving shaking, tensing of muscles, and slow movement), anxiety disorder, depression, low back pain, chronic (constant) pain, insomnia (inability or difficulty falling asleep), constipation, fibromyalgia (a disorder characterized by widespread muscle and skeletal pain and fatigue), and obesity. During a review of Resident 2's clinical record, the Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status), dated 7/6/19, indicated her Brief Interview for Mental Status (assessment of cognitive status-memory function) score was 15 out of 15 indicating no cognitive impairment. The MDS indicated Resident 2 had a score of 0 out of 2 for rejection of care, which indicated she did not reject evaluation or care weights that was necessary to achieve the resident's goals for health and well-being. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 10 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review with Social Services Director (SSD), on 7/22/19, at 11:38 a.m., she stated she completed section E in the MDS for the residents of the facility. SSD stated she relied on the system to pull information from care tracker (an electronic documentation system where Certified Nurses Aids (CNA) document activities of daily living for the residents) to fill out the section on rejection of evaluation or care. She stated she had the ability to verify the information by checking care tracker, talking to nurses, and looking at the resident's chart, and would verify the information at times. SSD reviewed Resident 2's MDS section E assessments dated 7/6/19, 3/29/19, 12/28/19, 7/27/18, and 6/26/18 and verified Resident 2 had a score of 0 for rejection of care on MDS's dated 7/6/19, 3/29/19, 12/28/19, and 7/27/18. SSD verified Resident 2 had a score of 1 for rejection of care, which indicated the resident had rejected care one to three of the seven days, on the MDS dated [DATE] but stated she did not know why. SSD reviewed Resident 2's weight log and Medication Administration Record (MAR) (where refusals of weights were tracked) and verified the resident had been continuously refusing weights during the lookback period for all five MDS assessments. SSD stated she was unsure if refusing weekly weights or physician appointments fell under rejection of evaluation or care that was necessary to achieve the resident's goals for health and well-being and stated I don't tend to think of residents weights or physician appointments as part of her goals if she's refusing it. During a concurrent interview and record review with Director of Nursing (DON), on 7/22/19, at 12:33 p.m., the DON stated the Certified Nursing Assistant (CNA)s performed resident weights and would inform the LVN if the resident refused. The DON stated the LVN would document the weight refusal in the Medication Administration Record (MAR). The DON stated the MAR information will transfer over to the MDS section E because it was not part of the CNA documentation. The DON stated the staff member responsible for documenting each section is responsible for the accuracy of that section. DON reviewed Resident 2's MDS section E dated 7/6/19, 3/29/19, 12/28/19, and 7/27/18 and confirmed rejection of care was inaccurately coded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 11 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a baseline resident centered care plans (a plan that provides direction for individualized care of the resident) were developed and implemented to meet the identified needs of two of four sampled residents (Resident 60 and 520) when: 1. Resident 60 did not have a fall risk care plan with interventions to address Resident 60's safety risks to prevent fall. 2. Resident 520's tab alarm care plan did not include interventions and goals. 2b. Resident 520 did not have a tab alarm restraint care plan. These failures affected Resident 60 and 520's quality of care and needs not being addressed and resulted in Resident 60's fall and contributed to Resident 520's unnecessary restraints. Findings: 1. During an interview with Resident 60, on 7/17/19, at 10:19 a.m., Resident 60 stated she had another fall on 7/8/19 when she got up from her wheelchair and tried to transfer herself to her bed and fell down on the floor. During an interview with Certified Nursing Assistant (CNA) 12, on 7/17/19, at 11 a.m., she stated, [Resident 60] had poor safety awareness and needed to be encouraged to use her call light. During a review of the clinical record for Resident 60, the face sheet (a document with personal identifiable and medical information), indicated Resident 60 was admitted to the facility on [DATE] with diagnoses which included; aftercare following joint replacement surgery (a procedure of dysfunctional joint replaced with prosthesis) on right femur fracture due to fall from bed, vitamin D deficiency (cause your bones to become thin and brittle). During a review of the clinical record for Resident 60, the MDS assessment dated [DATE] indicated Resident 60 required support of two staff members for physical assistance during transfers. The Minimum Data Set (MDS) (evaluation of a resident's cognitive, functional, behavioral, and care needs) document indicated Resident 60 was unsteady and was only able to stabilize with staff assistance in balance during transitions (moving and turning around) and moving from seated to standing position. During a review of the clinical records for Resident 60, the Fall Risk Evaluation (a health assessment by licensed nurses to evaluate risk of fall) dated 4/25/19, indicated the fall total score was 22 (a resident who scored 10 or higher was at a high risk for falls). During a review of the clinical records of Resident 60, the Acute Care Physical Therapy Initial Assessment dated 4/22/19, indicated, . History of Present Illness/Hospital Course . Resident 60 . with displaced R [Right] intertrochanteric (thigh bone) fracture after falling out of bed at home. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 5, on 7/17/19, at 10:29 a.m., she stated Resident 60 was assessed as a high risk for fall on admission. LVN 5 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 12 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 reviewed the clinical record and stated she was not able to locate Resident 60's baseline care plan for fall. LVN 5 stated Resident 60's baseline care plan should have been initiated on admission by the licensed nurses to address Resident 60's immediate safety needs and that did not occur. During an interview with the Director of Nursing (DON), on 7/17/19, at 12:16 p.m., she stated, I did not see a care plan for Resident 60 specific for fall risk. The DON stated Resident 60's baseline care plan should have been completed by the licensed nurses on admission to meet the resident's immediate risk and to evaluate the resident's condition but that did not occur. During a concurrent interview with the Director of Staff Development (DSD) and record review, on 7/18/19, at 9:13 a.m., she reviewed Resident 60's care plans and sated a baseline care plan should have been initiated on admission and completed within 48 hours to implement effective care interventions for the identified fall risk. The DSD stated a fall risk care plan was not developed and it should have. 2. During a concurrent observation and interview with Resident 520, on 7/15/19, at 11:31 a.m., in the resident's room, she sat in her wheelchair watching television. Resident 520 had a tab alarm device attached to her wheelchair and the alarm cord clipped to the back of her shirt. Resident 520 stated the facility had alarms attached to her while she was in her wheelchair and when she was in bed. Resident 520 stated she did not like the tab alarm, did not need them, and they prevented her from reaching for items she wanted to reach. Resident 520 demonstrated the restrictions of movement by leaning forward four inches to reach a book on her over bed table. The cord for the tab alarm pulled on her shirt and the resident stopped short of reaching her book. Resident 520 stated if she leaned forward any further, the alarm would go off and she didn't want to make the alarm go off because the noise made her nervous and she did not like the noise. During a record review of Resident 520's MDS assessment, dated 7/11/19, indicated there was no use of restraints for Resident 520. During a concurrent interview and record review with LVN 1, on 7/17/19, at 9:31 a.m., she reviewed Resident 520's clinical record and was unable to find a baseline care plan for the use of the tab alarm and restraints. LVN 1 stated Resident 520 was confused and was identified as a risk for falls when she was admitted on [DATE]. LVN 1 stated the tab alarm was ordered to keep Resident 520 from getting up on her own and falling before staff could attend to her. During a concurrent interview and record review with DON, on 7/17/19, at 10:34 a.m., she reviewed Resident 520's clinical record and stated there was a check mark next to tab alarms on the baseline care plan interventions and no baseline care plan for restraints. The DON stated a Tab alarm was not considered to be a restraint. The DON stated the baseline care plan indicated Resident 520 had a history of falls and the tab alarm was an intervention to prevent falls. The DON stated the care plan did not have interventions or goals listed for the tab alarms. DON stated a resident should have a care plan for the use of a tab alarm and restraints. During an interview with Physical Therapist (PT) 1, on 7/18/19, at 9:09 a.m., she stated the tab alarm was a restraint if it was limiting the resident's movement. During an interview with Certified Nursing Assistant (CNA) 3, on 7//18/19, at 9:22 a.m., CNA 3 stated Resident 520 had never tried to get up by herself and had not set off her tab alarm during any of the days CNA 3 had been on shift. CNA 3 stated she would consider the tab alarm a restraint if the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 13 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 resident was afraid to set off the alarm. CNA 3 stated, [Resident 520] must not move very much because she had never set off the alarm. During a concurrent interview and record review with LVN 6, on 7/18/19, at 10:10 a.m., she reviewed Resident 520's care plans and verified there was no care plan, no reassessment for the use of the tab alarm and no care plan for the use of restraints. LVN 6 stated Resident 520 had set off her tab alarm by reaching for an item before and not for getting up on her own. The facility policy and procedure titled Policy and Procedure for the use of Safety Devices undated, indicated 1. Prior to the application of a safety device (including tab alarm .) that has the potential to impend the activity of the resident, the resident shall be assessed by a Licensed Nurse. 2. When a Licensed Nurse assesses the resident for a safety device, they shall have attempted less restrictive devices prior to the application of a safety device. 3. The IDT shall review the use of all safety devices. 4. If it is determined that the safety device is considered a restraint, the MDS shall be coded accordingly and the physician shall obtain informed consent prior to the device's usage. 5. The care plan will be updated as indicated to reflect any changes. The facility policy and procedure titled BASELINE CARE PLANS undated, indicated, . 1. Baseline care plans will be initiated on admission and completed within 48 hours 2. Baseline care plans shall contain, but not be limited to, initial goals based on admission orders, physician orders, dietary orders, therapy services, social service . applicable. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 14 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to timely revise and implement a person-centered comprehensive care plans for one of three sampled residents (Resident 2) when Resident 2's refusals of physician ordered weights was not reviewed and revised by the interdisciplinary team (IDT - A coordinated group of experts from several different healthcare fields who work together toward an identified resident goal). These failures directly contributed to a severe weight gain of 92 pounds within 11 months and placed Resident 2 at an increased risk for health related complications. Findings: During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 7/17/19, at 3:29 a.m., he reviewed Resident 2's weight log and stated Resident 2 had been refusing her physician ordered weekly weights and had gained a lot of weight in the last year. LVN 2 stated Resident 2's weekly weight log indicated Resident 2 began refusing weekly weights on 1/14/18 and refused all weekly weights from 7/1/18 through 1/17/19. LVN 2 stated the weight log dated 7/1/18 indicated Resident 2 weighed 230 pounds and on 1/17/19 she weighed 284 pounds indicating a 54-pound weight gain within six months. LVN 2 stated Resident 2 was not weighed again until 4/12/19 when she weighed 317 pounds indicating an additional 33-pound weight gain. LVN 2 stated Resident 2 was weighed on 5/28/19 and weighed 322 pounds, indicating an additional 5-pound weight gain for a total of 92 pounds within 11 months. LVN stated Resident 2 refused all weekly weights since 5/28/19. LVN 2 reviewed Resident 2's clinical record and was unable to find a care plan addressing the refusal of weights and ongoing weight gain. During a concurrent observation and interview with Resident 2, on 7/17/19, at 3:44 p.m., Resident 2 was lying in her bed in her room. Resident 2 stated she refused her weights because she had severe pain every time the staff would try to get her out of bed. She stated the, Sling [a cloth support devise used with a mechanical lift to transfer residents that are unable to stand] the staff used to get her out of bed hurts her. Resident 2 stated she knew she had gained a lot of weight in the last year and did not want to know what her weight was. During a review of the clinical record for Resident 2, the Face Sheet (a document with resident demographic and medical diagnosis information) undated, indicated Resident 2 was admitted to the facility on [DATE]. Resident 2's diagnoses included hypertension (high blood pressure), diabetes mellitus (a disease that causes elevated levels of sugar in the blood and urine), Parkinson's Disease (a progressive disease of the nervous system involving shaking, tensing of muscles, and slow movement), anxiety disorder, depression, low back pain, chronic (constant) pain, insomnia (inability or difficulty falling asleep), constipation, fibromyalgia (a disorder characterized by widespread muscle and skeletal pain and fatigue), and obesity. During a review of the clinical record for Resident 2, the Minimum Data Set (MDS) assessment (an evaluation of a resident's cognitive and functional status) dated 7/6/19, indicated Resident 2's Brief Interview for Mental Status (assessment of cognitive status-memory function) score was 15 out of 15, indicating Resident 2 did not have cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 15 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0657 Level of Harm - Minimal harm or potential for actual harm During an interview with Certified Nursing Assistant (CNA) 3, on 7/18/19, at 9:13 a.m., CNA 3 stated she took care of Resident 2 multiple days a week. CNA 3 stated Resident 2 always refused to be weighed because she didn't want to know her weight. CNA 3 stated the Sling used to move her from the bed to the chair hurt her. CNA 3 stated she had reported Resident 2's weight refusals to the licensed nurse on staff at the time of each refusal. Residents Affected - Few During a concurrent interview and record review with LVN 1, on 7/18/19, at 9:34 a.m., LVN 1 stated she took care of Resident 2 multiple days a week. LVN 1 stated Resident 2 had refused weekly weights because she was gaining a lot of weight and didn't want to know what her weight was. LVN 1 stated she was aware Resident 2 had been gaining a significant amount of weight. LVN 1 stated she recognized the importance of knowing Resident 2's accurate weight to ensure the physician has the correct information for appropriate medication dosing. LVN 1 stated Resident 2's significant weight gain could cause medical problems and increase the severity of medical problems like high blood pressure and her Diabetes. LVN 1 stated the complications of Resident 2 gaining 92 pounds within 11 months would increase her pain, decreased mobility, increased depression, decreased activity level, and worsen the symptoms of her Parkinson's Disease and fibromyalgia. LVN 1 reviewed Resident 2's care plans and was unable to find a weight refusal care plan or an ongoing weight gain care plan. LVN 2 stated she was not sure if she was supposed to care plan refusals of physician ordered weights so she did not care plan the weight refusals or ongoing weight gain as a problem for Resident 2. During a concurrent interview and record review with Director of Nursing (DON), on 7/18/19, at 11:49 a.m., the DON stated she expected the licensed nurses to notify the prescribing doctor and create a care plan if a resident was refusing doctors' orders for weekly weights. The DON reviewed the overflow clinical record and found a care plan for refusals of weights dated 1/5/19 (almost one year after her first weight refusal and after six months of continuous refusals to be weighed). The DON stated the care plan dated 1/5/19 was found in the record room, not in the clinical record and the interventions were, 1. [physicians name] is aware via fax, 2. contacted [resident's family member's name] by phone informed resident been refusing weekly weights, she is aware, 3. Copy given to [Registered Dietitian]. The DON stated Resident 2's care plan for refusal of weights did not have measurable, patient centered, interventions. DON stated Resident 2's clinical record had been thinned out and this was an old care plan that was no longer in use. DON stated Resident 2 did not have a current care plan for refusal of weights and ongoing weight gain. During a concurrent interview and record review with DON, on 7/22/19, at 11:02 a.m., DON reviewed Resident 2's IDT notes dated 4/5/19 and stated the IDT did not review Resident 2's care plan on refusals of weights and/or weight gain. The DON stated Resident 2 should have a resident centered care plan to identify the risk of weight refusals and ongoing weight gain. The facility's policy and procedure titled Interdisciplinary Team undated, indicated It is the policy of [Facility Name] that the Interdisciplinary Team is responsible for the development of an individualized, resident centered plan of care for each resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 16 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 Based on observation, interview, and record review, the facility failed to provide care and services in accordance with professional standards of quality for three of five sampled residents (Residents 23, 47, and 89) when: Residents Affected - Some 1. Licensed Vocational Nurse (LVN) 3 and LVN 4 signed the medication administration record (MAR) prior to the administration of medications to Resident 23, 47, and 89. These failures had the potential to place Resident 23, 47, and 89 at risk for medication errors. 2. LVN 3 did not follow the directions of use for Resident 23's medication order for stool softener. This failure had the potential to place Resident 23 at risk for developing bowel complications. Findings: 1. During a medication administration observation with LVN 4, on 7/16/19, at 7:45 a.m., in [NAME] Wing, LVN 4 prepared the scheduled morning medications for Resident 89. LVN 4 was observed clicking the box next to the medication on the Electronic Medication Administration Record (EMAR) (a software designed for medication administration) as she dispensed the medication into the medication cup prior to the administration of medications to Resident 89. During a concurrent observation and interview with LVN 4, on 7/16/19, at 8:10 a.m., in the [NAME] Wing, LVN 4 prepared the scheduled morning medications for Resident 47. LVN 4 was observed clicking the box next to each medication as she dispensed the medication into the medication cup prior to administration of the medications to Resident 47. LVN 4 stated clicking the box on the EMAR next to the medication means the medication was already administered. LVN 4 stated she only edited the EMAR if a resident refused the medication. LVN 4 stated, I should have given the medication first then signed the EMAR. During a concurrent observation and interview with LVN 3, on 7/16/19, at 8:35 a.m., in the [NAME] Wing, LVN 3 prepared the scheduled morning medications for Resident 23. LVN 3 was observed clicking the box on the EMAR next to the medication after she dispensed the medication into the medication cup prior to administration of the medications to Resident 23. LVN 3 stated, I only go back and edit the EMAR when a resident refuses their medication. LVN 3 stated she clicked the box on the EMAR as she dispensed the medication to keep track of the medication. LVN 3 stated, When the box is clicked it means you are signing it. 2. During a concurrent observation and interview with LVN 3, on 7/16/19, at 8:35 a.m., LVN 3 prepared Resident 23's medication [brand name] mixed in four ounces of water and administered it to Resident 23. LVN 3 stated the order was to mix the medication with eight ounces (oz) of water or juice. LVN 3 stated, The resident does not like to drink all of the medication so I mixed it with the small cup of water. LVN 3 stated the cup she used was four oz. During a review of the clinical record for Resident 23, the physician's order dated 7/1/19, indicated, [Name brand medication] 17 gm [gram-unit of measurement] By mouth every day for constipation mix with 8 oz of water or juice (hold for loose stools) . During an interview with the DON, on 7/18/19, at 10:36 a.m., she stated LVN 3 should have signed the EMAR after the medication was administered to Resident 23. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 17 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 FORM CMS-2567 (02/99) Previous Versions Obsolete The facility's policy and procedure titled ADMINISTERING MEDICATIONS POLICY undated, indicated . 3. Medications must be administered in accordance with the orders, including any required frames . 14. The individual administering the medication must initial the resident's E-MAR on the appropriate line after giving each medication . Review of the professional reference titled, Clinical Procedures for safer Patient Care dated 4/4/19 indicated, 6.2 Safe Medication Administration . Medication errors are the number -one error in health care (Center for Disease Control[CDC], 2013) . NEVER document that you have given a medication until you have actually administered it . Event ID: Facility ID: 555513 If continuation sheet Page 18 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. 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 activities of daily living (ADL) were provided to maintain good grooming for one of 57 sampled residents (Resident 42) when Resident 42's finger nails were long and contained a black substance under the nail beds. Residents Affected - Few This failure resulted in Resident 42's nails not being well groomed and the potential for harboring microorganisms (bacteria, virus, or fungus) or infection. Findings: During a concurrent observation and interview with Resident 42, on 7/15/19, at 10:20 a.m., outside of his room, Resident 42 sat in his wheelchair alone putting a puzzle together. Resident 42 had long fingernails approximately 0.5 cm (centimeter - a unit of measurement) with a black substances underneath the nail beds. Resident 42 stated I want my nails to be cut and I was just waiting for the staff to cut and trim my nails. During a concurrent observation and interview with the Certified Nursing Assistant (CNA) 13, on 7/15/19, at 10:25 a.m., she stated Resident 42's fingernails were not clean, there was black dirt under the nail beds, and they were about one cm long. She stated the right thumb had an orange color under the nail bed that looked like a food particle. CNA 13 stated It should have been cleaned and trimmed by the licensed nurses because Resident 42 was a diabetic resident. CNA 13 stated CNAs would clean and trim the residents' fingernails, but if a resident was a diabetic, the licensed nurses were the ones who cut and trim the residents' nails. CNA 13 stated the CNA assigned to Resident 42 should have reported to the licensed nurse that Resident 42 needed his fingernails trimmed. During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 12, on 7/15/19, at 10:30 a.m., LVN 12 assessed Resident 42's fingernails and the nails measured 0.5 cm. She stated the nail beds were soiled with a black substance under the nail beds. LVN 12 stated Resident 42 is a diabetic patient who needs appropriate nail care. LVN 12 stated Resident 42 wants his nails neat and clean at all times. During a review of the clinical record for Resident 42, the face sheet [document which contains resident specific information] undated, indicated Resident 42 was admitted to the facility on [DATE]. Resident 42's diagnoses included Parkinson's disease (a progressive nervous system disorder that affects movement), embolism (obstruction of an artery by a clot of blood) and thrombosis (blood clot) of the lower extremities. During a review of the clinical record for Resident 42, the Minimum Data Set (MDS) assessment (an evaluation of cognitive function, behavioral and care needs) dated 5/28/19, indicated Resident 42 was cognitively intact with a BIMS (Brief Interview for Mental Status) score of 15 of 15. Resident 42's activities of daily living requires extensive assistance for personal hygiene. The facility policy and procedure titled Quality of Life- Dignity, dated 8/09, indicated Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy interpretation and Implementation 1. Residents shall be treated with dignity and respect at all times. 2. Treated with dignity means the residents will be assisted in maintaining and enhancing his or her self-esteem and self-worth. 3. Residents shall be groomed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 19 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0677 as they wish to be groomed (hair styles, nails, facial hair . Level of Harm - Minimal harm or potential for actual harm The facility policy and procedure titled Activities of Daily Living dated 8/2009, indicated, Policy: The ability to meet the demands of daily living is assessed by a registered nurse. A program of assistance and instruction in ADL skills is implemented. Procedure 1. Hygiene a. Resident self-image is maintained . Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 20 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance based on the admission/fall risk assessment and care plan to prevent falls for one of four sampled residents (Resident 97) when Resident 97 with known history of falls, assessed as high risk for falls on 6/27/19 and required supervision while ambulating, was ambulating in his room unsupervised, fell and sustained injuries to his head and shoulder. This failure resulted in Resident 97's fall on 6/28/19, a head injury, a fracture (broken bone) of the left clavicle (collarbone), pain and suffering as a result of the injuries. Findings: During a concurrent interview with the Assistant Director of Nursing (ADON) and clinical record review for Resident 97, on 7/15/19, at 11:38 a.m., the ADON reviewed Resident 97's clinical record and stated Resident 97 was admitted to the facility on [DATE] with a known history of falls. The ADON stated Resident 97 was admitted to the facility after a recent diagnosis of a stroke for rehabilitation therapy services to assist with strengthening, balance, and independence with performing activities of daily living (ADLs). The ADON stated Resident 97 had dementia (a chronic or persistent disorder of the mental processes caused by brain disease or injury and marked by memory disorders, personality changes, and impaired reasoning), was confused and forgetful. She stated Resident 97 was able to walk on his own with a walker (walking device with four wheels used for balance) but required staff supervision. The ADON stated Resident 97 fell on 6/28/17 in the evening shift (4:30 p.m.,) in his room the day after his admission. She stated Resident 97 was sent to the hospital after the fall and the emergency room doctor diagnosed him with a left clavicle fracture and a hematoma (clotted blood collecting in the tissue) on the back of his head as a result of the fall. During an interview with Licensed Vocational Nurse (LVN) 5, on 7/16/19, at 8:46 a.m., she stated Resident 97 fell on 6/28/19. LVN 5 stated she was at the end of the hallway when she heard Resident 97 yelling. When she turned around she saw Resident 97 fall to the floor and hit his head. LVN 5 stated Resident 97 tends to walk by himself a lot and forgets to call for help due to his confusion. She stated Resident 97 was assessed as a high risk for fall on 6/27/19 and needed one-person physical assistance with dressing, toileting and ambulation. LVN 5 stated Resident 97 had weakness to the left side of his body as a result of his stroke and was unsteady on his feet. LVN 5 stated Resident 97 should have been supervised by a staff member at all times but especially during ambulation with his walker. LVN 5 reviewed Resident 97's care plans and was unable to find stated a fall high risk care plan prior to the fall. LVN 5 stated a fall risk care plan should have been completed on the day Resident 97 was assessed as a high risk for fall with resident-centered approaches to address specific interventions for fall preventions such as, ensuring staff provided supervision during ambulation. LVN 5 stated a fall risk care plan was not developed prior to the fall on 6/28/19 and if a fall risk care plan would have been developed Certified Nursing Assistants (CNAs) would have been aware of the need for one-person supervision during ambulation and the fall could have been prevented. During an interview with the Activities Aide (AA) and concurrent record review for Resident 97, at 7/16/19, on 8:50 a.m., the AA stated Resident 97 was admitted to the facility after he had a stroke at his assisted living facility. AA stated Resident 97 was admitted with a known history of a fall. The AA reviewed Resident 97's Physical Therapist (PT) notes dated 6/20/19 and stated PT informed her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 21 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 - Actual harm Residents Affected - Few that a therapy evaluation was conducted on 6/20/19 and Resident 97 required the assistance of one staff person to be by his side during transfers and ambulation because Resident 97 was unsteady on his feet which placed him at a high risk for falls. During a concurrent observation and interview with Resident 97, on 7/16/19, at 3:06 p.m., in the East Wing hallway, he sat in his wheelchair with a sling present on his left shoulder. When asked about the fall incident, he stated, I used my walker and I wanted to go out the door and halfway through the door I fell. It happened so quick. I did not see anybody. During a review of Resident 97's face sheet (a document with demographic, personal and medical information) undated, indicated Resident 97 was admitted to the facility on [DATE]. Resident 97's diagnoses included cerebral infarction (the arteries not supplying blood and oxygen to the brain also called a stroke), altered mental status, hemiplegia (paralysis that affects one side of the body), hemiparesis (weakness one half of the body), and a displaced fracture shaft (long narrow section) of the left clavicle. During a review of the clinical record for Resident 97, the Minimum Data Set (MDS) (assessment of healthcare and functional needs and abilities) assessment section GG (functional abilities and Goalsadmission), dated 6/27/19, indicated, [Resident 97 required] supervision or touching assistance .Helper provides verbal cues and/or touching/staying and/or contact guard assistance as resident [97] completes [waking] activity . During a review of the clinical record for Resident 97, the MDS assessment, dated 7/4/19, indicated Resident 97's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) scored 7 of 15 possible points which indicated the resident was severely impaired in decision making and never or rarely made decisions on his own. During a review of the acute care hospital (ACH) clinical record for Resident 97, the Discharge Summary Report dated 6/27/19, indicated . admit date : [DATE] . admission diagnosis of Transient Ischemic Attack (TIA- brief interruption of blood supply to the brain) . Patient was admitted with left sided weakness . PT [Physical Therapy] Notes. Requires 1 person assist at all times when OOB [out of bed] due to high risk of falls given observation of movement patterns, difficulty with obstacle avoidance, poor safety awareness, and balance deficits .Disposition SNF [skilled nursing facility] with Rehabilitation. During a review of the ACH clinical record for Resident 97, the After Visit Summary dated 6/28/19, indicated a diagnoses of fall, hematoma [a solid swelling of clotted blood within the tissues] of left parietal [behind the ear] scalp and traumatic closed fracture of the left distal [away from the center] clavicle with minimal displacement. Reason for visit: fall. The ACH Imaging Results indicated, X Ray, Impression: Acute non displaced fracture [bone cracks either part or all of the way through, but maintains its proper alignment] involving the distal left clavicle. Reason: Pain. [Head] CT (Computerized Tomography- a computerized form of imaging). Reason: Pain from trauma, fell on buttocks and hematoma to occipital [back of the head] part of head. CT results were not included in the copy of the record provided. During a review of the clinical record for Resident 97, the fall risk evaluation dated 6/27/19, indicated a fall total score was 22 (a scored 10 or higher was at high risk for falls). Resident 97's clinical record did not contain a fall risk care plan for 6/27/19 after the evaluation identified Resident 97 as a high risk for fall. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 22 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 - Actual harm Residents Affected - Few During a review of the clinical record for Resident 97, the daily skilled nurses' notes dated 6/28/19, at 4:50 p.m., indicated, Resident was noted by writer to fall and hit his [Resident 97] head in his room near entry way. [Resident 97] fell from standing to supinated [flat on back] on the floor. On assessment, [Resident 97] was noted with diminished ROM [range of motion] to LUE [left upper extremities] and laceration to back of head with moderate bleeding . When asked how he [Resident 97] fell, resident stated that he was startled when he heard his roommate exiting the bathroom . During an interview with Physical Therapist (PT) 1, on 7/16/19, at 3:09 p.m., she stated Resident 97 was screened and evaluated by the PT department on admission 6/27/18. PT 1 stated Resident 97 was evaluated as high fall risk and needed a one-person standby assistance with his ambulation. She stated Resident 97 was able to ambulate, perform sit to stand, transfers from bed to chair and stand and pivot with a one person contact guard assistance. During a review of the clinical record for Resident 97, the Plan of Treatment for Rehabilitation dated 6/28/19, indicated Resident 97 was on fall precautions due to decreased strength, endurance, mobility, and impaired safety awareness. Resident 97 required a standby assist (staff needed to be next to resident for safety in case of loss of balance) with sit to stand during transfers. He could ambulate with a four wheeled walker with contact guard assist (needs one or two hands of staff member on resident to help with steadiness and balance). During a concurrent interview and record review with the Director of Nursing (DON), on 7/17/19, at 11:49 a.m., the DON reviewed Resident 97's clinical record and stated Resident 97 was assessed as a high fall risk resident on admission 6/27/19 and the licensed nurses did not initiate a fall risk care plan on 6/27/19 that indicate specific care interventions to address the safety prevention of falls. The DON stated Resident 97's fall care plans should have been reviewed and discussed in the Interdisciplinary Team (a group of nurses, therapist, social worker and dietary meet to discuss residents' care planning) meeting to communicate resident's needs and safety, but that did not occur. The DON stated Resident 97 was screened and evaluated by PT and Resident 97's plan of treatment should have been followed by the licensed nurses and CNAs to prevent Resident 97's fall. The DON stated, Somebody [licensed nurses and CNAs] needs to be there to assist him [Resident 97] with ambulation and transfers. During an interview with Certified Nursing Assistant (CNA) 7, on 7/17/19, at 3:30 p.m., CNA 7 stated she was at the nurses' station when she heard a bang on the floor. She saw Resident 97 laying on his back on the floor and half of his body was inside his room with his head sticking out of the doorway into the hallway. CNA 7 assisted Resident 97 to sit up and noticed a moderate amount of bleeding on his head. CNA 7 stated, We [staff] did not see him fall. CNA 7 stated his front wheel walker was facing toward the bed. She stated Resident 97 needed staff next to him during ambulation but when Resident fell no one was with him. CNA 7 stated Resident 97 was not compliant with call light use because he would forget. CNA 7 stated, There should have been someone [staff] checking on him at all times. During a concurrent interview and record review with the Director of Staff Development (DSD), on 7/18/19, at 9:13 a.m., she reviewed Resident 97's clinical record and was unable to locate the ADL Transfer Report (a guide report for CNAs regarding residents' functional abilities, specific to transfers - one person or two person assist, use of side rails, tab alarm, wheelchair pad, floor mat) on 6/27/19 (date of Resident 27's admission) and 6/28/19 (date of Resident 27's fall). The DSD stated, I don't have it [ADL Transfer Report] on the day he [Resident 97] fell. The DSD stated CNAs were made aware of each residents' functional abilities through the ADL Transfer Report which should have been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 23 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 located at the nurses' station. Level of Harm - Actual harm During a concurrent interview and record review with the DSD, on 7/18/19, at 9:15 a.m., she reviewed the PT evaluation and stated PT had evaluated Resident 97's functional abilities and should have communicated that evaluation to the licensed nurses through the plan of treatment for rehabilitation. The DSD stated, I am not sure if the licensed nurses had communicated the transfer abilities of Resident 97 to the assigned CNA. Residents Affected - Few During a concurrent interview and record review with the DSD, on 7/18/19, at 9:18 a.m., the DSD reviewed Resident 97's care plans and stated, We see him [Resident 97] around with his front wheel walker. He [Resident 97] likes to be independent. The DSD stated Resident 97's care plan should have reflected his ADL interventions for transfers and ambulation to prevent him from falling. During a concurrent interview and record review with the DSD, on 7/18/19, at 11:16 a.m., she reviewed Resident 97's clinical record and stated there was no documentation of licensed nurses' progress notes to show there was communication of the ADL transfer abilities of Resident 97 to the assigned CNAs on 6/27/19 and 6/28/19. The facility policy and procedure titled, Comprehensive Assessment and the Care Delivery Process dated 12/16, indicated, . b. define conditions and problems that are causing, could cause, other problems. (1) identify potential causes or contributing factors of problems and symptoms, including . (d) Functional . c. defines current treatments and services; link with problems/diagnoses. (1) Identify the current interventions and treatments; and (2) Link these to problems and diagnoses they are supposed to be treating . 4. Decision making leading to a person-centered plan of care includes: a. Selecting and implementing interventions . The facility policy and procedure titled, Fall Precautions Policy undated, indicated . 14. Follow safe techniques. 15. Evaluate for possible therapeutic interventions. 16. Ensure assistive devices and/or equipment is used appropriately. 17. Assess for confusion and frequently orient resident to surroundings. 18. If resident has confusion provide visual checks every two hours, or more frequently as determined by care team. Review of a professional reference titled, Nursing Care Plans (NCP): Ultimate Guide and Database dated 1/19, (found at https://nurseslabs.com/nursing-care-plans/#Step-4-Setting-Priorities), indicated, . A Nursing care plan (NCP) is a formal process that includes correctly identifying existing needs, as well recognizing potential needs or risks . Without the nursing care planning process, quality and consistency in patient care would be lost . Provides direction for individualized care of the client . the nurse and the client begin planning which nursing diagnosis requires attention first . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 24 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide sufficient staffing to provide care and services to ensure residents received the needed care to attain and maintain their highest practicable physical, mental and psychosocial well-being for the eight of 16 sampled residents (Resident's 17, 31, 46, 53, 65, 86, 99, and 108) when three Certified Nursing Assistants (CNA) were unable to provide residents with full attention, continuous and uninterrupted feeding assistance during meal service. These failures had the potential to result in Resident's 17, 31, 46, 53, 65, 86, 99, and 108 not meeting their daily nutritional needs and could lead to unplanned weight loss. Findings: During a lunch meal dining observation, on 7/15/19, at 11:42 p.m., in the East wing dining room, 14 residents were seated to eat their meal inside the dining area and two residents out in the hallway. Three CNAs working in the morning shift (7am to 3:30 pm) attempted to provide meal assistance to eight residents requiring feeding, in addition to helping other residents by toileting, picking up utensils from the floor and readjusting clothing protectors during meal, readjusting tight fitting clothing, transporting residents back to their room and attempting to re-direct a confused resident propelled her wheelchair in and out of the dining room. All of these dining activities were being attended by three CNA's. During a lunch meal dining observation, on 7/15/19, at 12:20 p.m., in East wing dining room, CNA 4 sat in between Resident 17 and Resident 53 while two other residents in the half moon dining table were waiting for feeding assistance. During a lunch meal dining observation, on 7/15/19, at 12:30 p.m., CNA 4 stopped feeding Resident 17 and Resident 53. CAN 4 stood up when she saw Resident 5 who sat on the far corner of the dining room stand up from her chair and tried to pick up the utensil that fell on the floor while eating. CNA 4 took the utensil off the floor and gave it back to Resident 5 without washing the utensil that was on the floor. Resident 5 continued to use the utensil that was on the floor to finish eating her meal. During a lunch meal dining observation, on 7/15/19, at 12:31 p.m., Resident 17 sat on her wheelchair and stared at other residents at her dining table who were receiving assistance eating. Resident 53 began to close her eyes and started to fall asleep. Resident 17 and Resident 53 were waiting for feeding assistance at their dining table with their meals served and staff were occupied with other residents and were unavailable to provide residents 17 and 53 assisted with their meals. During a review of the clinical record for Resident 17, the face sheet indicated Resident 17 was admitted to the facility on [DATE] which included diagnoses of dementia (gradual loss of memory and decision making capacity), anxiety and moderate depression (a mood disorder that causes a persistent feeling of sadness and loss of interest and can interfere with daily functioning) disorder. Review of Resident 17's clinical record, the MDS dated [DATE], indicated Resident 17 had severe cognitive impairment with a BIMS score of 0 (0-7: severe impairment). Resident 17's activities of daily living need limited assistance on walking in the room, in the corridor and while eating with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 25 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0725 one-person physical assist. Resident 17 used walker and wheelchair for mobility. Level of Harm - Minimal harm or potential for actual harm Review of Resident 53's clinical record, the face sheet indicated Resident 53 was admitted to the facility on [DATE]. Resident 53's diagnoses included dementia, and depression with anxiety disorder. Residents Affected - Some During a dining observation, on 7/15/19, at 12:32 p.m., Resident 63 stated It's too tight, somebody needs to fix it [Resident 63 pointing to her brassiere]. CNA 4 proceeded to Resident 63 to unfasten her brassiere. During a concurrent lunch meal dining observation and interview with CNA 4, on 7/15/19, at 12:44 p.m., CNA 4 began feeding Resident 17 and Resident 53 who were just waiting for assistance. Resident 53 was sleeping and CNA 4 began to woke up Resident 53 who fall asleep while waiting for help. CNA 4 stated I know it's not right to stop feeding [Resident 17 and Resident 53] especially her [Resident 53], she tends to fall asleep. Other staff should have helped but there was no staff around at that time. It's not our right to leave a resident while they're eating. I know it's not right. If we stop helping them eat, they might lose their appetite, the food will get cold and they will stop eating. We should not stop and continued feeding the residents. CNA 4 stated Our goal is to assist and feed them during meals so that they will not feel hungry until dinner time. I just do the best I can to help all the residents in here but we can't do it all. During an interview with CNA 12, on 7/15/19 at 3:19 p.m., she stated CNAs should have provided uninterrupted meal assistance to residents. CNA 12 stated It's not a good practice if you leave a resident and go help another resident who has not completed her meal. CNA 12 stated it was the resident's right for a continuous meal without delay during meal and dining assistance. During an interview with Licensed Vocational Nurse (LVN) 6, on 7/15/19 at 3:52 p.m., she stated they were short-staff and were unable to provide assistance to all eight Residents (Resident's 17,31, 46, 53, 65, 99, and 108) in the East Wing dining room at the same time. LVN 6 stated I came to help [Resident 46]. I saw her food was untouched and I tried to feed her, but there was a door alarm in the East wing which I needed to check. We can't do it all. We need more help. LVN 6 stated residents were not provided with full attention during meal service and residents were waiting for their turn to be fed too long because CNA's were busy assisting other residents in the room. LVN 6 stated there should be extra staff to help in assisting other residents during meals in the East Wing. During a concurrent observation and interview, with CNA 5, on 7/15/19 at 12:45 p.m., in the dining room, CNA 5 stood up and stopped feeding Resident 65 and Resident 108 and walked to Resident 46 who was on the other table located on the left side corner of the dining room. CNA 5 stated Resident 46 was just staring at her food and had not eaten. CNA 5 stated Resident 46 needed meal assistance to eat. During a lunch meal dining observation, on 7/15/19, at 12:48 p.m., CNA 5 stood up and stopped providing meal assistance to Resident 46 and moved to Resident 99 whose clothing protector fell on the floor. CNA 5 readjusted the clothing protector and returned to Resident 65 and Resident 108 to resume their meal feeding. During a lunch meal dining observation, on 7/15/19, at 12:51 p.m., in the dining room, Resident 46 was not eating and staring at her food. CNA 4 sat and started to feed Resident 46. During a concurrent observation and interview with Resident 63, on 7/15/19 at 12:54 p.m. in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 26 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dining room, Resident 63 asked for help to be taken back to her room. CNA 5 stood up and stopped feeding Resident 46 and proceeded to Resident 63. Resident 63 stated I cannot walk today. I have a sore hip. CNA 5 wheeled Resident 63 back to her room. During a concurrent observation and interview with CNA 5, on 7/15/19 at 12:57 p.m. in the dining room, CNA 5 stated Resident 99 needs to be fed. Resident 99 was waiting for help with her meal. CNA 5 began feeding Resident 99. During a concurrent observation and interview with CNA 6, on 7/15/19, at 12:30 p.m., in the hallway of East Wing, Resident 31 and Resident 86 were seated in wheelchairs eating lunch in the hallway in front of dining room and exit door in the east wing. CNA 6 sat in between Resident 31 and Resident 86 and began to feed the residents out in the hallway while visitors and other residents passed by. CNA 6 stood up and stopped feeding Resident 31 and Resident 86 and walked inside the dining room to assist Resident 63 back to her room to fix her tight brassiere. CNA 6 stated she needed to stop feeding Resident 31 and Resident 86 because Resident 63 needed help to go back to her room. CNA 6 stated There's no other staff to help her [Resident 63]. The other two CNAs in the dining room are busy helping other residents. CNA 6 stated, I don't know how much staff is needed here to make sure all the residents get the help they need but some days they need more help. We [CNA's] need extra staff to assist all their [residents] needs during dining . During an interview with CNA 5, on 7/16/19, at 12:07 p.m., CNA 5 stated a staff can feed 2 residents at the same time and can stop feeding and assist another resident in the dining room. CNA 5 stated, It was not a good practice . CNA 5 stated interrupting meals lessen resident's appetite due to cold food and can cause weight loss. CNA 5 stated it violated resident's respect and dignity by not providing a continuous meal feeding during dining. During an interview with Assistant Director of Nursing (ADON), on 7/17/19, at 9:00 a.m., the ADON stated the residents (Resident's 17, 31, 46, 53, 65, 99,108) needing assistance did not happen every day. She stated, Some days, residents fed themselves or need to use bathroom in the middle of dining. Others [Residents] just needed more attention during meal assistance, other days not. It happens on the decline in health conditions specially for dementia (cognitive impairment) residents. We could try two meals schedule for breakfast, lunch and dinner to accommodate residents and their needs. During an interview with the Administrator (ADM), on 7/17/19, at 3:19 p.m., she stated, The East Wing dining had the most CNA's in this facility. The ADM stated CNA's should have called and used their walkie-talkie (hand-held portable, two-way radio transceiver) and ask for help and assistance if they were in need of extra staff. ADM stated the two meal service option would not be a good idea because it will jeopardize the whole system from the kitchen schedule to meal time, and staffing. The facility policy and procedure titled Assistance with Meals, dated 7/2017, indicated Policy Statement Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. Policy interpretation and Implementation Dining Room Residents: 1. All residents will be encouraged to eat in the dining room. 2. Facility Staff will serve resident trays and will help residents who requires assistance with eating. 3. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: a. not standing while assisting them with meals; b. Keeping interaction with other staff to a minimum while assisting residents with meals .Residents Requiring full assistance .2. Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity .b. Keeping interactions with other staff to a minimum while assisting residents with meals . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 27 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0725 Level of Harm - Minimal harm or potential for actual harm The facility policy and procedure titled Quality of Life- Dignity, dated 8/2009, indicated . Policy Statement Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. Policy interpretation and Implementation 1. Residents shall be treated with dignity and respect at all times.2. Treated with dignity means the residents will be assisted in maintaining and enhancing his or her self-esteem and self-worth . Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 28 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure two of four medication carts were locked and medications were securely stored when: 1. Licensed Vocational Nurse (LVN) 3 left the medication cart unlocked and unattended. 2. LVN 11 left the medication unlocked and left Resident 91's medications on top of the medication cart, unattended and accessible to residents, staff and visitors passing by in the East Wing hallway. These failures placed residents at risk of actual or potential for harm. Findings: 1. During a medication pass observation and interview with LVN 3, on 7/16/19, at 8:35 a.m., LVN 3 left the medication cart unlocked and out of sight in front of room [ROOM NUMBER] while she was inside the restroom of room [ROOM NUMBER] washing her hand with door closed. LN 3 stated she was unable to see the unlocked medication cart behind the closed restroom door. LVN 3 stated the medication cart should have been locked. During interview with LVN 8, on 7/17/19, at 3:41 p.m., LVN 8 stated the medication cart should be kept locked when the nurse turned their back from the medication cart. LVN 8 stated, The practice is to locked the medication cart whenever you turned your back from it. LVN 8 stated residents might get into the medication cart and pull out medications and ingest the medications without the nurse noticing. During an interview with LVN 9, on 7/17/19, at 4 p.m., LVN 9 stated, The medication cart must be kept locked when charge nurse turned their back from the med cart. LVN 9 stated the medication cart should never be left unlocked and unattended. During an interview with the Director of Nursing (DON), on 7/18/19, at 10:36 a.m., the DON stated the medication cart should never have been left unlocked and unattended to prevent unauthorized access to the medications. 2. During a concurrent observation and interview with LVN 11, on 7/18/1,9 at 5:29 p.m., in the East Wing hallway, a small white medicine cup filled with four pills and a transdermal patch (a medicated adhesive patch that is placed on the skin to deliver a specific dose of medication through the skin and into the bloodstream) were observed to be on top of the medication cart unattended. Resident 98 was observed sitting in her wheelchair about five feet away from the medication cart. LVN 11 was observed walking out of room [ROOM NUMBER]. LVN 11 approached the medication cart and saw the cup of medications and patch left on top of the medicating cart. LVN 11 stated the medications belonged to Resident 91. He stated the cup contained Metoprolol (medication to treat chest pain and high blood pressure) 50 milligrams (mg-a unit of measurement), Ranitidine (medication to reduce the amount of acid the stomach) 150 mg, Calcium D3 (to treat low blood calcium levels) 400 mg, multivitamin (a dietary supplement), and Rivastigmine (to treat mild to moderate dementia) transdermal patch 9.5 mg. LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 29 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete 11 stated he should not have left the medications unattended because it wasn't safe. LVN 11 stated, Anyone can walk up [to the cart] and take it [medications]. LVN 11 confirmed the medication cart was left unlocked and unattended. LVN 11 stated the facility policy and procedure was to store and secure the medications in the medication and lock the cart and he did not follow the policy. The facility policy and procedure titled Administering Medications Policy undated, indicated 12. During administration of medications, the medication cart will be kept closed and locked when out of sight . No medications are kept on top of the card [cart]. Event ID: Facility ID: 555513 If continuation sheet Page 30 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure 13 of 13 sampled residents (Resident 29, 33, 37, 43, 47, 63, 66, 69, 71, 89, 94, 112, and 118) received the menu as planned during a dining observation when: 1. One of one Dietary Aides (DA 1) did not adjust the pureed recipe menu for pasta to account for the number of servings she was pureeing (a paste or thick liquid suspension usually made from cooked food ground finely). 2. The therapeutic diet menu portion sizes for small portion, mechanical (ground) diets was not followed for 13 of 13 sampled residents (Resident 29, 33, 37, 43, 47, 63, 66, 69, 71, 89, 94, 112, and 118) These failures had the potential to result in residents on pureed diets to choke on their food and for residents on small portion diets to be overwhelmed by the amount of food they were served and placed resident at risk of unplanned weight loss. Findings: 1. During a concurrent observation in the kitchen and interview with DA 1, on 7/15/19, at 10:19 a.m., DA 1 stated she used the standard recipe for pureed meats for pureed pasta. DA 1 stated she was making 12 servings of pureed pasta for lunch service. DA 1 measured out, and added 12 servings of pasta, one quarter cup of thickener, and three and a half cups of half and half to the blender and pureed the pasta. DA 1 stated it was a little thin (puree constancy) and she might need to add more thickener ([NAME]). During a concurrent interview with DA 1 and Dietary Manager (DM), and record review of the facility's standard recipe for pureed meats, dated 12/11/13, on 7/15/19, at 10:29 a.m., the recipe indicated For each five servings add: one quarter cup thickener, three and a half cups half and half. DA 1 stated she should have used one half cup of thickener and seven cups of half and half for her 12 servings. DA 1 stated the incorrect amount of thickener was used in the pureed food, residents on pureed diets could choke. DM stated the dietary staff was expected to adjust the recipe according to how many servings they are making. The DM stated DA 1 should have used more than one half cup of thickener and seven cups of half and half for 12 servings of pureed pasta. 2. During a review of the facility's therapeutic menu dated 7/16/19 titled Tuesday #10, undated, the menu indicated the regular portion sizes for the lunch meal were, Broccoli stir fry, three ounces [oz]; chow mien noodles, #10 scoop [equal to three o]; stir fry vegetables, one half cup; and snickerdoodle cookies, two. For small portion sizes, the menu indicated: broccoli stir fry, two oz; chow mien noodles, #16 scoop [equal to two oz]; stir fry vegetables, one half cup [the regular portion size]; and snickerdoodle cookies, one. During an observation of lunch meal food service in the kitchen, on 7/16/19, at 11:46 a.m., [NAME] 1 served the lunch trays for residents on small portion, mechanical diets, [NAME] 1 served three ounces of chow mien (the regular portion size), two ounces of chow mien (the small portion size), one quarter cup of stir fry vegetables (less than the indicated small portion size of one half cup), and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 31 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0803 two cookies (the regular portion size). Level of Harm - Minimal harm or potential for actual harm During an observation of lunch meal service in the dining room kitchen, on 7/16/19, at 12:15 p.m., DA 2 served the lunch trays for residents on small portion, mechanical diets, DA 2 served two oz of chow mien (the small portion size), two oz of chow mien (the small portion size), one quarter cup of stir fry vegetables (less than the indicated small portion size of one half cup), and two cookies (the regular portion size). Residents Affected - Some During a concurrent interview with [NAME] 1 and DM, and record review of the facility's therapeutic menu for 7/16/19 titled Tuesday #10, undated, on 7/16/19, at 12:20 p.m., [NAME] 1 stated she tried to follow the therapeutic menu guide for all diets and portion sizes. [NAME] 1 stated she gave all residents on small portion, mechanical diets three oz of broccoli stir fry, two oz of chow mien, one quarter cup stir fry vegetables, and they each received two cookies. [NAME] 1 reviewed the therapeutic menu for small portions and mechanical diets and stated she should have given residents on small portion, mechanical diets three oz of broccoli stir fry, one half cup of stir fry vegetables, and one cookie. DM reviewed the therapeutic menu for small portions and mechanical diets and verified [NAME] 1 had not served residents on small portion, mechanical diets the correct portions. During a concurrent interview with DA 2 and record review of the facility's therapeutic menu, titled Tuesday #10, undated, on 7/16/19, at 12:25 p.m., DA 2 stated she used a one quarter cup scoop (equal to two oz) to serve broccoli stir fry, chow mien, and stir fry vegetables for all residents on a small portion mechanical diet portions and all residents not on a carbohydrate restricted diet received two cookies. DA 2 reviewed the therapeutic menu for small portions and mechanical diets and stated the residents on small portion mechanical diets should have received one half cup portion of vegetables and only one cookie. During a review of the facility's diet roster titled Master Resident, dated 7/16/19, indicated 13 residents (Resident 29, 33, 37, 43, 47, 63, 66, 69, 71, 89, 94, 112, and 118) in the facility had a physician ordered small portion, mechanical diets. During a concurrent observation and interview with Resident 69, on 7/16/19 at 12:29 p.m., she had only taken a few bites of her lunch. Resident 69 stated she had too much food on her plate and she couldn't eat it all. During a review of the clinical record for Resident 69, the Brief Interview for Mental Status (BIMS) (assessment of cognitive status-memory function), dated 5/30/19, indicated Resident 69 had a BIMS score of 14 out of 15 possible points which indicated Resident 69 had no cognitive impairment. Resident 69's physician orders dated 7/2019, indicated Resident 69 had a current order for house fine chopped diet, small portions. During an interview with Registered Dietitian (RD), on 7/16/19, at 2:59 p.m., he stated most of the resident on the small portion diets had poor appetites and were overwhelmed by the amount of food on a regular portion diet. RD stated the intent of putting those residents on small portioned diets was to encourage them to eat without overwhelming them. He stated the expectations was for dietary staff to follow the small portion sizes indicated on the therapeutic menus for residents on small portion diets. The facility's policy and procedure titled Food Preparation, Subject: Portion Control, dated 2018, listed the conversions between cups, scoop sizes, and ounces. It indicated Small portions may be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 32 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete given to resident/patients per physician order. Unless otherwise stated on the menu, food items should be reduced by ¼ cup increments for entrees, starch, and vegetables. The facility's policy and procedure titled Portion Control, undated, indicated 2. The menu should list the specific portion size for each food item. Menus should be posted at the tray line for staff to refer to for proper portioning of servings for each diet .4. Serving too large of portions .gives the residents more food than they need or are allowed to have .5. Dietary staff will be in serviced by the dietary manager on portion sizes at regular intervals. Meal observations for quality control of portion sizes should be conducted by the dietary manager or dietetics professional on a routine basis. Event ID: Facility ID: 555513 If continuation sheet Page 33 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 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 food in accordance with professional standards for food service safety in the kitchen when: Residents Affected - Some 1. One dented can of puree pumpkin was stored with the undented canned food and was available for use in residents food. 2. One can of tomato base bullion with an expiration date of 2/20/19 (five months prior) was stored on a kitchen shelf and available for use in residents food. 3. Six open bags of bread were stored in the kitchen and available for use in residents food were not labeled with opened dates. 4. One unlabeled and undated, plastic container of a white powdered substance (food and liquid thickener) was stored in the kitchen and available for use in residents' pureed food. These findings had the potential to result in contaminated, expired, and non-palatable foods being served to the residents of the facility which could further result in food borne illnesses, decreased food consumption, and potential weight loss. Findings: 1. During a concurrent observation in the kitchen pantry and interview with Dietary Manager (DM), on 7/15/19, at 10:13 a.m., one, six pound, ten ounce dented can of puree pumpkin was stored on a shelf with the undented cans of food. DM stated the can should have been stored on a separate shelf with the other dented cans to be returned to the food distribution company. He stated dented cans could contain bacteria that could cause harm to residents. The facility's policy and procedure titled Dietary Policy; Food storage and labeling guidelines dated 2018, indicated, This policy has been written in effort to ensure safety and quality of the food we serve to our residents .Food will be stored and stocked on designated food shelves or racks .Food will be refused for any of the following reasons; a. Dented and damaged cans. 2. During a concurrent observation in the kitchen and interview with DM, on 7/15/19, at 9:54 a.m., one can of tomato base bullion was stored on the kitchen shelf with an expiration date of 2/20/19. DM stated the tomato base bullion should have been thrown away on or before the expiration date. He stated it was the responsibility of the facility's cooks to check all food expiration dates daily. DM stated he did not know if the tomato base bullion had been used in resident's food since the expiration. The facility's policy and procedure titled Dietary Policy; Food storage and labeling guidelines, dated 2018, indicated, This policy has been written in effort to ensure safety and quality of the food we serve to our residents .Therefor dietary supervisor will do frequent inspections to ensure the guidelines stated on this policy are being met .1. All foods will be consumed within the Expiration Date or Best by Date. No foods will be used after expiration dates or past their recommenced used dates. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 34 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 3. During a concurrent observation in the kitchen and interview with DM, on 7/15/19, at 9:39 a.m., two opened loafs of wheat bread, one opened bag of large flat bread, one opened bag of small flat bread, one opened loaf of raisin cinnamon bread, one opened bag of oil top hamburger buns, and one opened bag of regular hamburger buns were stored without an opened date written on them. DM stated all opened food items should have the date they were opened written on the item. He stated the dietary staff were supposed to write the date they opened the bread bags. The facility's policy and procedure titled Dietary Policy; Food storage and labeling guidelines, dated 2018, indicated, This policy has been written in effort to ensure safety and quality of the food we serve to our residents .Food Storage Methods .d. All food must be dated and labeled .e. Designated labels and Permanent markers .will be used to date foods .17. Fresh Bakery/Bread will be stored in the original package and used within 7 days 4. During a concurrent observation in the kitchen and interview with DM, on 7/15/19, at 9:50 a.m., one, one gallon, plastic container of a white powdered substance was stored, unlabeled and undated on the kitchen counter. DM stated it was thickener for pureed foods. DM was unable to state how he knew it was thickener for pureed foods and stated it should be labeled and dated. The facility's policy and procedure titled Dietary Policy; Food storage and labeling guidelines, dated 2018, indicated, This policy has been written in effort to ensure safety and quality of the food we serve to our residents .All food will be kept in its original package that clearly identifies the product .Food Storage Methods .d. All food must be dated and labeled .e. Designated labels and Permanent markers .will be used to date foods. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 35 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. During a concurrent interview and record review with LVN 4, on 7/17/19, at 9:07 a.m., she reviewed Resident 83's clinical record and was unable to find a POLST form. LVN 4 stated the POLST should have been kept in Resident 83's medical record to facilitate communication in an event of a life threatening medical emergency. During a review of the clinical record for Resident 83, the profile face sheet, indicated Resident 83 was admitted to the facility on [DATE] with diagnoses which included emphysema (a chronic respiratory disease where there is over-inflation of the air sacs (alveoli) in the lungs, causing breathlessness), dementia (gradual loss of memory and decision making capacity), and altered mental status. During an interview with MR 1, on 7/17/19 at 9:37 a.m., MR 1 stated reviewed the clinical record and was unable to find the POLST form and stated there should be a POLST form in Resident 83's clinical record. During an interview with AC, on 7/17/19 at 9:42 a.m., AC stated the POLST advance directive form should have been offered on resident's admission date and discussed in care plan conference with resident and family representative. AC stated Resident 83's POLST had been refused to signed by responsible party. AC stated, It [POLST] is an optional document and not required in order to receive care whether the POLST was declined or signed. The AC stated if there was no POLST form in resident's clinical record the facility staff assumed Resident 83's advance directive was a full code [provide full life saving measures in case of an emergency]. The AC reviewed Resident 83's clinical record and was unable to find documentation indicating Resident 83's legal representative had been offered to complete a POLST advance directive and refused. During an interview with DON, on 7/17/19, at 11:38 a.m., she stated the POLST form or any form of documentation in resident's clinical record was a physicians' order and used to communicate with licensed nurses to ensure residents received appropriate care in an event of an emergency situation. During an interview with AC, on 7/18/19, at 7:48 a.m., she stated she cannot locate any documentation in care conference meeting notes or nurses' progress notes on Resident 83's family representative refusal to sing the POLST form. The facility policy and procedure titled: POLICY AND PROCEDURE FOR ADVANCED DIRECTIVES dated 10/18 indicated, . 1. Upon admission, the resident will be provided with written information concerning the right to refuse or accept medical treatment and to formulate an advance directive [POLST] if he or she chooses to do so 4. Prior to or upon admission of a resident, the admissions coordinator or designee will . about the existence of any written advance directives . 5. Information about whether or to the resident has executed an advance directive shall be kept in the medical record. Based on interview and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for two of six sampled residents (Resident 61 and Resident 83) when a copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was not readily available as part of Resident 61 and Resident 83's current medical records. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 36 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some This failure had the potential risk for Resident 61 and Resident 83's decisions regarding their healthcare and treatment options not being honored. Findings: 1. During a concurrent interview with medical records (MR) 1 and record review, on 7/15/19, at 11:23 a.m., MR 1 reviewed Resident 61's clinical record and was unable to find the POLST form. MR 1 stated Resident 61's clinical record should had had a POLST form. MR 1 stated the POLST form should have been completed on admission. MR 1 stated if POLST form was not completed on admission it should had been done on the initial care conference meeting with the resident and the family member. The MR 1 stated the admission coordinator and nurses were responsible for completing the POLST form. During an interview with Licensed Vocational Nurse (LVN) 3, on 7/17/19, at 3:07 a.m., LVN 3 stated The POLST form is very important because in emergency situations LVN 3 stated the decisions documented on the POLST form would direct the nurse on what life saving measures to take when a resident's heart was to stop. LVN 3 stated if the POLST form was not completed or missing from the residents clinical record the wishes of the resident would not be respected. LVN stated, We could get in a lot of trouble. LVN 3 stated, We don't have time to look in the chart [clinical record] and read the progress notes if we have an emergency. LVN 3 stated the admission coordinator was the person responsible for completing the form with the family or responsible party on admission. During an interview with LVN 8, on 7/17/19, at 3:41 p.m., LVN 8 stated, The POLST form is a way to know what to do to a resident in emergency situations. LVN 8 stated if the POLST form was not completed the resident would be treated as a full code [provide full life sustaining measures]. During an interview with Social Service Designee (SSD) 2, on 07/18/19, at 08:45 a.m., she stated the POLST form should be completed on admission and discussed during the initial care conference meeting with the family and resident. SSD 2 stated, The POLST form is very important because if something happens [life threatening emergency] it is their wishes that we should follow. During an interview with the admission Coordinator (AC), on 7/18/19, at 9 a.m., The AC stated POLST form should have been completed on admission by the AC or the charge nurse and that did not occur. The AC stated she did not have documentation the POLST form was discussed with the resident or the resident representative. During a review of the clinical record for Resident 61, the PROFILE FACE SHEET (a document that contains resident medical history, level of functioning, resident preferences and wishes) undated, indicated, . Current [second] admit date [DATE] . Original [first] admit date [DATE] . During an interview with the Director of Nursing (DON), on 7/18/19, at 10:45 a.m., she stated the AC was responsible to complete POLST forms on admission and the charge nurses should have followed up to ensure the POLST form was in Resident 61's medical records and easily accessible. The DON stated the POLST form was an important document to guide the staff on life threatening emergency wishes of resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 37 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 maintain an infection prevention and control program when: Residents Affected - Some 1. Five Certified Nursing assistant (CNA's 4, 5, 6, 10, and 11) and one Licensed Vocational Nurse (LVN) 6 did not perform hand hygiene before, between and after physical contact with 11 of 22 sampled residents (Resident 5, 17, 31, 46, 53, 63, 65, 72, 86, 99, and 108) during lunch meal service in the dining room. 2. License Vocational nurse (LVN) 4 did not disinfect her stethoscope (medical instrument for listening to heart or breathing sounds) after each resident use. These deficient practices had the potential to result in cross contamination and placed residents at risk for infection. Findings: 1. During a Lunch meal dining observation on 7/15/19, at 12:30 p.m., in the East wing, CNA 4 was providing feeding assistance to Resident 17 and Resident 53. CNA 4 stopped feeding Resident 17, and 53 when she saw Resident 5 who was sitting at a corner of the dining room, stand up from her chair and tried to pick up the utensil that fell on the floor. CNA 4 took the utensil from the floor and gave it back to Resident 5 without washing the utensil. CNA 4 then returned to feeding Residents 17 and 53 without performing hand washing. During a Lunch meal dining observation on 7/15/19, at 12:32 p.m., Resident 63 stated It's too tight, somebody needs to fix it [Resident 63 pointing to her bra]. CNA 4 stopped feeding Resident 17, and 53 and walked to Resident 63. CNA 4 unfasten Resident 63's brassiere and went back to feeding Resident 17 and 63 without performing hand hygiene. During a concurrent lunch meal dining observation and interview with CNA 4, on 7/15/19, at 12:38 p.m., CNA 4 stated she should have washed her hands before and after she had contact with Resident 5, Resident 63 and before feeding Resident 17 and Resident 53 to prevent cross contamination. CNA 4 stated she should have given Resident 5 a clean utensil because the utensil that was on the floor could cause Resident 5 to get infections. During a concurrent lunch meal observation and interview CNA 6, on 7/15/19, at 12:40 p.m., in East Wing hallway, Resident 31 and Resident 86 were seated in wheelchairs eating lunch out in the hallway. CNA 6 sat in between Resident 31 and Resident 86. CNA 6 began to fed Resident 31 and Resident 86. CNA 6 stood up and stopped feeding Resident 31 and 86. CNA 6 walked inside the dining room to provide Resident 63 assistance. CNA 6 placed her hand on Resident 63 lower back and right arm. CNA 6 walked Resident 63 back to her room to fix her brassiere. CNA 6 returned and resumed feeding Resident 31 and Resident 86 without performing hand hygiene. CNA 6 stated she should have washed her hands prior to resuming feeding Resident 31 and Resident 46 to prevent infection. During a lunch meal observation, on 7/15/19, at 12:41 p.m., in East wing dining room, Resident 46 sat in her wheelchair with two other residents in the dining table who were eating without assistance. Resident 46 was not eating her meal and LVN 6 sat next to Resident 46 and began to feed her lunch. LVN 6 heard a door alarm sounding in the East Wing. LVN 6 stood up and stopped assisting Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 38 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 Residents Affected - Some 46. LVN 6 left the room to attend to the door alarm. At 12:44 p.m., LVN 6 returned to Resident 46 and resumed feeding her lunch without performing hand hygiene. LVN 6 stated she should have washed her hands after she had contact with other residents and prior to feeding Resident 46 to prevent cross contamination. During a concurrent lunch meal observation and interview with CNA 5, on 7/15/19 at 12:45 p.m., in East wing dining room, CNA 5 was providing feeding assistance to Resident 65 and Resident 108 and saw Resident 99's clothing protector fall onto the floor. CNA 5 stood up and stopped feeding Resident 65 and Resident 108 and took the clothing protector off the floor and placed it on Resident 99 then walked back to feeding Resident 65 and 108. CNA 5 stated she should have washed her hands and she should have given Resident 99 a clean clothing protector. CNA 5 stated It was not a good practice, not sanitary and could cause cross-contamination. During a concurrent observation and interview with CNA10, on 7/16/19, at 9:01 a.m., CNA 10 was serving breakfast meals to residents in the East wing, then took the folding chair, sat beside Resident 99 and began feeding Resident 99 without performing hand washing. CNA 10 stood up, stopped feeding Resident 99 and walked out of the dining room to get cereal from the facility kitchen for Resident 72. CNA 10 returned and resumed feeding Resident 99 without performing hand washing. CNA 10 finished feeding Resident 99 and sat next to Resident 72 and began feeding Resident 72 without performing hand hygiene. CNA 10 stated she should have washed her hands before and after having contact with residents to prevent infection. During a concurrent observation and interview with CNA 11, on 7/18/19, at 8:24 a.m., CNA 11 was assisting Resident 63 to the bathroom and then wheeled Resident 63 back into the dining room. CNA 11 began to fed Resident 65 and Resident 17 without performing hand washing. CNA 11 stated I did not wash my hands because the room with a sink was locked. I am waiting for maintenance to unlock the door. CNA 11 stated I should have washed my hands prior to feeding Resident 17 and Resident 65 and every time I touch other residents to prevent infections. The facility policy and procedure titled, Infection Control Guidelines for all Nursing Procedures dated 8/12, indicated . Purpose: To provide guidelines for general infection control while caring for residents. General Guidelines . 3. Employees must wash their hands for 10 to 20 seconds using antimicrobial or nonantimicrobial soap and water under the following conditions: a. Before and after direct contact with residents; . f. before eating and using a restroom. 2. During a medication pass observation with LVN 4, on 7/16/19, at 7:45 a.m., in [NAME] wing, LVN 4 was observed taking Resident 89's apical pulse (listening for heart rate over the chest area) using her stethoscope. LVN 4 did not disinfect her stethoscope after listening to Resident 89 apical pulse. During a medication pass observation with LVN 4, on 7/16/19, at 8:10 a.m., LVN 4 placed the same stethoscope on Resident 47's arm and checked resident 47's blood pressure using the stethoscope that was not disinfected. During an interview with LVN 4, on 7/16/19, at 8:25 a.m., LVN 4 stated she did not realize she had used the stethoscope on Resident 47 without disinfecting it after using the stethoscope to check Resident 89's apical pulse and before using it to check Resident 47's blood pressure. LVN 4 stated, The practice is to disinfect equipment [stethoscope] after each resident use to prevent the spread of infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 39 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 Residents Affected - Some During an interview with LVN 8, on 7/17/19, at 3:41 p.m., LVN 8 stated the facility practice when using stethoscope was to disinfect the stethoscope after each resident use. LVN 8 stated, The stethoscope touched residents and had to be sanitize after each resident use. During an interview with the Director of Nursing (DON), on 7/18/19, at 10:36 a.m., the DON stated all equipment should be disinfected after each resident use. DON stated, the nurse should have disinfected the stethoscope after she took the Resident 89's apical pulse. The facility policy and procedure titled, Infection Control Guidelines for all Nursing Procedures dated 8/12, indicated . Purpose: To provide guidelines for general infection control while caring for residents. General Guidelines . equipment must be disinfected before and after direct contact with residents . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 40 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide at least one room set aside to use as a resident dining room and for activities, that is a good size, with good lighting, air flow and furniture. Based on observation, interview, and record review, the facility failed to provide sufficient space in the East Wing dining room (the smaller of two facility dining rooms) to safely and comfortably accommodate 16 of 16 (Residents 5, 17, 26, 30, 31, 46, 53, 63, 65, 66, 72, 78, 81, 86, 99, and 108) sampled residents who ambulate (walk), use walkers and wheelchairs (mobility devices). During meal times (breakfast, lunch and dinner); tables, chairs and mobility devices blocked the entrances and exits of the dining room and did not provide comfortable spacing between residents. Facility staff did not develop and implement a plan to maintain safe passage in and out of the dining room. These failures placed residents in the Alzheimer's (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities safely) unit who used the East Wing dining room at risk for potential harm and injury due to crowded or blocked entrances and/or exits. Findings: During a lunch meal observation, on 7/15/19, at 11:35 a.m., in the East Wing dining room, there were 14 Residents (5, 17, 26, 30, 46, 53, 63, 65, 66, 72, 78, 81, 99, and 108) seated for lunch. Residents 31 and 86 were being assisted with their meal by Certified Nursing Assistant (CNA) 6 outside of the dining room in the hallway, blocking the exit door (for evacuation out of the building) for all the residents in the dining room. Residents 17, 53, 65, and Resident 108 sat in their wheelchairs in front of the large half-moon dining table (a table designed for residents to sit around the half circle and a CNA to sit on the opposite side to assist with the meal) near the doorway entrance to the dining room. The half-moon table was positioned up against the south wall of the dining room with two of the residents facing the wall and two residents at each end of the table. CNA 4 sat in between Residents 17 and 53 while she assisted them with their meal. CNA 5 sat in between Residents 65 and 108. Four residents and two staff sat in front of the large half-moon dining table. Resident 65 sat in her wheelchair partially blocking the South end of the dining room entrance door (the only dining room entrance and exit door). In the middle of the room was a square table which accommodated Residents 66, 81, and 99. Resident 66 and 53 were seated back to back in their wheelchairs. The passageway between residents at the half-moon table and the middle table was narrow and not sufficient space for wheelchairs to pass through. Residents 66, 81, and 99 were seated in standard size manual wheelchairs (the basic chair, two small front wheels and two large back wheels) and Resident 63 was seated on a large heavy duty manual wheelchair (greater weight and size capacity than a standard wheelchair). Three residents (Residents 5, 26, and 78) sat at the corner table in the northeast side of the room next to the middle dining table. Resident 26 and Resident 81's wheelchairs were back to back blocking the passageway between the two tables. Resident 78 was cornered at the back end of the wall without his walker and no open path to the dining room exit door. Resident 78 had placed his walker outside of the dining room because there was no room to store the walker in the dining room. Residents 30, 46, and 72 were seated in their wheelchairs at the table located on the northwest corner of the dining room next to the doorway. The table was pushed up against the west wall to accommodate the three residents. During a concurrent dining room observation and interview with CNA 6, on 7/15/19, at 11:42 a.m., Resident 63 told CNA 6 she wanted to go back to her room. CNA 6 assisted Resident 63 by maneuvering Resident 63's wheelchair between residents. CNA 6 moved Resident 30's wheelchair backwards away from the table, interrupting Resident 30's meal to make room for Resident 63's wheelchair to get to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 41 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some exit door. Resident 30 told CNA 6, Hey don't move my wheelchair. CNA 6 stated, the dining room space was too small for residents in wheelchairs and commented that perhaps the dining room was made for ambulatory residents. During an interview with Licensed Vocational Nurse (LVN) 6, on 7/15/19, at 3:52 p.m., she stated she was aware of the dining room overcrowding and stated the East Wing dining room was too small and not enough space to accommodate 16 residents who use wheelchairs and walkers. During a concurrent breakfast dining observation and interview with Resident 78, on 7/16/19, at 8:05 a.m., Resident 78 walked towards the East Wing dining room and placed his walker in front of the exit door. Resident 78 stated That's the way I do it; I do what I am told to do. During an interview with CNA 10, on 7/16/19, at 8:58 a.m., Resident 5 walked to the East Wing dining room (assigned to seat at the northeast table) while CNA 9 moved Resident 63's wheelchair (away from the middle table) out of Resident 5's way. CNA 10 stated it was a safety issue because Resident 5 and Resident 78 used walkers and did not have sufficient space to use the walkers. CNA 10 stated, the residents couldn't get to their assigned seats with the walkers due to the residents sitting in their wheelchairs blocking the path. During a concurrent breakfast dining observation and interview with CNA 6, on 7/16/19, at 9:01 a.m., in the hallway in front of the dining room, Resident 31 was observed in a wheelchair with a breakfast tray on top of the bedside table. CNA 6 stated Resident 31 was being assisted with his meal in the hallway (in front of exit door) because the (East Wing) dining room was too small to accommodate all the residents. CNA 6 stated six months ago that she had notified the ADON about the insufficient space in the East Wing dining room to accommodate all of the residents. During an interview with CNA 5, on 7/16/19, at 12:07 p.m., she stated Resident 31 and Resident 86 were eating in the East Wing dining room hallway. CNA 5 stated, there was no available seating in the dining room to accommodate Resident 31 and Resident 86. During a concurrent observation and interview with Resident 5, on 7/17/19, at 8:15 a.m., in the East Wing dining room, Resident 5 walked out of the dining room with her walker. Resident 5 stated, Too crowded [dining room], I feel it's not safe to pass through. During a concurrent observation and interview with Resident 63, on 7/17/19, at 8:23 a.m., in the East Wing dining room, Resident 63 sat in a large wheelchair while eating her breakfast. Resident 63 stated If I move, I am afraid I might hit the other [residents] wheelchair. During a concurrent breakfast dining observation and interview with the ADON, on 7/17/19, at 9:00 a.m., in the East Wing dining room, Resident 78 was observed attempting to leave the East Wing dining room after breakfast. Resident 78 was observed leaning side to side and walking sideways as he walked between the wheelchairs of Residents 30 and 99. The ADON stated there was a potential for accidents during emergency situations. The ADON stated Resident 78 needed to leave his walker outside of the dining room, and that it was unsafe for him to use his walker in the occupied dining room. The ADON stated about 6 months ago a CNA had reported to her the dining room space was too crowded. During a concurrent breakfast observation and interview with CNA 11, on 7/18/19, at 8:25 a.m., in the East Wing dining room, Resident 63 requested assistance to go to the bathroom. CNA 11 pushed Resident 63's wheelchair and bumped into Resident 65's wheelchair on the way out of the dining room (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 42 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some because the path was not sufficient to move freely. CNA 11 stated the dining room did not have enough space to freely maneuver residents' wheelchairs to exit the dining room. During a breakfast dining observation, on 7/19/19, at 7:30 a.m., in the East wing dining room, 13 residents were observed (ten residents sat in their wheelchairs, two residents were using walkers and one resident was ambulatory) having breakfast. Two residents were eating in their rooms. CNAs were observed moving residents in their wheelchairs to allow other residents to enter the dining room. There was a bedside table and a walker positioned in front of the exit (building evacuation) door. Resident 81 was sitting next to the entrance door to the dining room. Her wheelchair was positioned against the door preventing it from closing. Residents 17, 46 and 108's wheelchairs were positioned between the table and the wall. During a concurrent breakfast dining observation, and an interview with the ADON on 7/19/19, at 7:50 a.m., in the dining room, CNA 11 was bringing Resident 108 into the dining room. She bumped and moved the middle table as she pushed Resident 108 in the dining room. CNA 11 was observed bumping Resident 11's wheelchair with Resident 81's wheelchair as he was brought into the dining room. The ADON stated, It's still too crowded, we are going to have to take them to the Quiet Room [multipurpose room with a table and chairs] in the East Wing [outside of the Alzheimer's unit]. Residents 53 and 65 were taken to the Quiet Room for breakfast. During a concurrent interview and record review with the Dietary Manager (DM), on 7/19/19, at 9:12 a.m., he stated sometimes they assist the residents with their meals in the hallway because the East Wing dining room gets crowded. The DM stated the residents get overwhelmed because the dining room gets so crowded. Some residents eat in their room. The DM reviewed the East Wing Dining Room Seating Chart and stated, I didn't know it was so crowded. During an interview with the Maintenance Director on 7/19/19 at 9:25 a.m., in the East Wing dining room, he stated the dining room measured 286.76 square feet. During a phone interview with the Office of Statewide Health Planning and Development (OSHPD) Compliance Officer on 7/19/19 at 11:02 a.m., he stated the facility must maintain a free access to get to the door in an event of an emergency. He stated the facility needed to move the half-moon table or move the other square tables for easy maneuvering of residents and staff inside the dining room in the East Wing. During an observation, on 7/19/19, at 12:16 p.m., in the East Wing dining room, Resident 66, was sitting on her wheelchair and eating her lunch meal on a bedside table in the hallway between the dining room exit door and the evacuation exit door blocking the egress. During an observation on 7/19/19, at 12:16 p.m., in the East Wing common area, Resident 53 was sitting in her wheelchair eating her lunch meal in front of the exit door of the South side of the East Wing. During a dinner dining observation, on 7/19/19, at 4:45 p.m., in the East wing dining room, three CNAs brought residents in their wheelchairs in to the dining room for dinner. CNAs moved wheelchairs and dining tables to make room for other residents to enter and bumped residents' wheelchairs. During an observation, on 7/19/19, at 4:50 p.m., in the office, a facility document was posted on the door. The document indicated, Attention: Family Members and Visitors. Because of limited space in (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 43 of 44 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 555513 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/22/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Palm Village Retirement Comm. 703 W Herbert Ave Reedley, CA 93654 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 0920 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the dining room, you must wait in the hallway until meal is done. This will allow our residents to eat without distraction, alleviate overcrowding and allow our staff to serve the residents . During an interview with the ADON, on 7/20/19, at 7:30 a.m., in East wing dining room, she stated, The dining room is still crowded on the left side. The ADON told two CNAs to move two residents (Residents 65 and 53) into the quiet room. The ADON took Resident 78's walker and placed it outside of the dining room in the hallway. Resident 78 asked the ADON, Where are you taking my walker. The ADON replied, I am just placing it outside and it will be given to you when you are done eating. During an interview with the DON on 7/21/19 at 5:10 p.m., in the conference room, the DON was informed by the surveyor of the dinner observations in the East Wing dining room regarding the moving of tables, residents, bumping of wheelchairs and the blocking of exits. The DON was made aware of the seating of residents in the front first and moving those residents to seat residents in the back. The DON stated the residents in the back should be seated first and the residents in the front should be seated last. She stated, staff should be trained to exit the room by assisting the residents in the front first and then the residents in the back to keep it orderly during an emergency evacuation. The facility policy and procedure titled, . Center Dining undated, indicated . Policy: .will have sufficient space to accommodate all activities; these spaces shall be adaptable to a variety of uses and residents' needs . and mobility . Procedures: 2. Ensures clear egress and paths of movements .4. Residents' walkers will not block the egress or exits . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555513 If continuation sheet Page 44 of 44