Health inspection·March 1, 2024

F 0550 stated the dignity bag covered the urine which could be a dignity issue for Resident 26. Level of Harm - Minimal harm or potential for actual harm During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was that residents catheters were in a dignity bag and placed under the resident's wheelchair. The DON stated this was to preserve residents' privacy and dignity. The DON stated it was not appropriate to have Resident 26's drainage bag uncovered. Residents Affected - Few During an interview on 3/01/24 at 3:18 p.m. with the Administrator (ADM), the ADM stated his expectation was for the residents catheters to not be seen and that the tubing was off the floor. The ADM stated if the bag was uncovered, it was not preserving Resident 26's dignity. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 2 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 12 sampled residents (Residents 4, 10, 24 and 26) when: 1. Residents 4, 10, and 24 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. 2. Resident 26 did not have an individualized care plan developed and implemented for the use of a dignity bag (a bag used to cover and hold the [NAME] catheter [an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag] drainage/collection bag so it is not visible). This failure violated Resident 26's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 26. Findings: 1. During a review of Resident 4's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 2/29/24, the AR indicated, Resident 4 was admitted from home on 1/26/24 to the facility, with diagnoses that included Anxiety (A mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), Hypertension (high blood pressure), Atrial fibrillation (Afib, is an irregular and often very rapid heart rate), and Arthritis (inflammation or swelling of joints). During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 1, on 2/29/24, at 10:22 a.m., Resident 4's nursing Care Plan (CP) was reviewed. LVN 1 stated Resident 4 had a risks and benefits form for side rail use and consent (a permission for something to happen or agreement to do something) signed by family consenting to the use of side rails on 1/26/24. LVN 1 reviewed Resident 4's CP and stated there was no CP developed for the use of side rails. LVN 1 stated the use of side rails should have been care planned to include interventions such as bed inspection, frequent visual checks and monitoring of side rails for continued use. LVN 1 stated the CP for side rails should have been developed when the consent was signed by Resident 4's responsible party (RP). During a review of Resident 10's AR, dated 2/29/24, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses which included Senile Degeneration of Brain (memory loss), Dementia (impaired ability to remember, think, or make decisions), Hypertension, Type 2 Diabetes Mellitus (high blood sugar), and Cerebral Infarction (stroke). During an observation on 2/27/24, at 10:42 a.m., in Resident 10's room, Resident 10 was sleeping and laying in bed, on his back, with half-length side rails up on both sides of the bed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 3 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a concurrent interview and record review with LVN 2, on 2/29/24, at 10:01 a.m., Resident 10's nursing CP was reviewed. LVN 2 stated Resident 10 had a risks and benefits form for side rail use completed on 1/19/24 and the consent signed by the RP consenting to the use of side rails on 2/1/24. LVN 2 reviewed Resident 10's CP and stated there was no CP developed for the use of side rails. LVN 2 stated the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. LVN 2 stated the CP for side rails should have been developed when the consent was signed by Resident's RP and after obtaining a physician order. During a review of Resident 24's AR, dated 2/29/24, the AR indicated, Resident 24 was admitted from an acute care hospital on [DATE] to the facility, with diagnoses which included Urinary Tract Infection (UTIbladder infection), Myocardial Infarction (heart attack), Cardiomyopathy (is a disease of the heart muscle that makes it harder for the heart to pump blood to the rest of the body), Pneumonia (lung infection caused by bacteria), and Multiple Sclerosis (commonly known as MS, is a long-lasting disease which can cause problems with vision, balance, muscle control, and other body functions). During a concurrent interview and record review with LVN 2, on 2/27/24, at 2:52 p.m., Resident 24's nursing CP was reviewed. LVN 2 stated Resident 24 had a risks and benefits form for side rail use and consent signed by Resident 24 [self-responsible] consenting to the use of side rails on 11/1/23. LVN 2 reviewed Resident 24's CP and stated there was no CP developed for the use of side rails. LVN 2 stated the use of side rails should have been care planned to include interventions to prevent risks of entrapment, injury, and monitoring for continued use. LVN 2 stated the CP for side rails should have been developed when the consent was signed by Resident 24's and after obtaining a physician order. During an interview with the Director of Nursing (DON), on 3/1/24, at 12:26 p.m., the DON stated upon reviewing the risks and benefits form for side rail use and obtaining the consent from the RP, a physician order should be obtained from the attending physician and a CP should be developed. The DON stated the CP drove resident care to ensure residents care was being met. The DON stated the facility failed to follow the facility's P&P related to care planning process. During a review of the facility's policy and procedure (P&P) titled Care Plans, Comprehensive Person-Center dated 3/22, the P&P indicated, . The comprehensive, person-centered care plan is developed .no more than 21 days after admission . The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment . a. includes measurable objectives and timeframes; b. describe the services that are to be furnished to attain or maintain resident's highest practicable physical, mental, and psychosocial well-being . During a review of the facility's P&P titled Bed Safety and Bed Rails dated 6/23, the P&P indicated, . Resident beds meet the safety specifications established by the administration team . 2. The use of bed rails or side rails is prohibited unless the criteria for use of bed rails have been met, including attempts to use alternative, interdisciplinary evaluation, resident assessment, and informed consent . During a review of the facility's document titled, Job Description: Licensed Vocational Nurse, undated, the document indicated, . Essential Job Functions include, but are not limited to the following . Assessment of Residents . Following all facilities Policies and Procedures . Perform other duties as requested . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 4 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. During a concurrent observation and interview on 2/27/24 at 12:30 p.m. with Resident 26 in the hallway outside Resident 26's room, Resident 26 was observed in a wheelchair with his Foley catheter bag hooked on the side of his wheelchair, uncovered. Resident 26 stated he had been at the facility for a while. Resident 26 did not want to answer further questions. During a review or Resident 26's admission Record (AR), dated 3/1/24, the AR indicated Resident 26 was admitted on [DATE] with diagnoses of follicular lymphoma (Cancer of the lymph nodes [small, bean-shaped organs that filter substances in the body and contain cells that fight infection]), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 26's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 26 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 7 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which suggested Resident 26 was severely cognitively impaired. During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was resident's catheters were in a dignity bag and placed under the resident's wheelchair. The DON stated this was to preserve residents' privacy and dignity. The DON stated it was not appropriate to have Resident 26's urine bag uncovered. The DON stated the facility needed to provide a better care plan for Resident 26. During a review of the facility's policy and procedure (P&P) titled, Comprehensive Care Plan dated 7/2013, indicated, . a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident . During a review of Resident 26's Care Plan (CP), (undated), the CP indicated no care plan in place for a Foley catheter dignity bag for Resident 26. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 5 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to provide fire safety accommodations to ensure the residents remained safe while they smoked for four of four sampled residents (Residents 7, 9, 10 and 24), when Residents 7, 9, 10, and 24 were not provided with noncombustible (non flammable) aprons prior to smoking cigarettes. This failure had the potential to place the residents at risk for smoking related injuries. Findings: During a review of Resident 7's admission Record (AR), dated 3/1/24, the AR indicated Resident 7 was admitted on [DATE] with diagnoses of anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and muscle weakness. During a review of Resident 7's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/19/24, the MDS section C indicated Resident 7 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 15 out of 15 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact) which suggested Resident 7 was cognitively intact. During a review of Resident 7's Care Plan (CP), dated, 2/11/24, the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . educate Resident/Responsible Party (RP) on the facility's tobacco/smoking policy(s) . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 7 was observed sitting in her wheelchair smoking a traditional cigarette. Resident 7 was observed not wearing a noncombustible apron. During a review of Resident 9's AR, dated 3/1/24, the AR indicated Resident 9 was admitted on [DATE] with a diagnosis of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life). During a review of Resident 9's MDS, dated 1/23/24, the MDS section C indicated Resident 9 had a BIMS score of 14 out of 15 which suggested Resident 9 was cognitively intact. During a review of Resident 9's CP, dated 1/24/24, the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . educate Resident/Responsible Party (RP) on the facility's tobacco/smoking policy(s) . During a concurrent observation and interview on 2/29/24 at 10:46 a.m. with Resident 9 in her room, Resident 9 was observed sitting in her wheelchair by her door. Resident 9 stated she smoked, and she had a smoking schedule. Resident 9 stated staff did not tell her about smoking safety. Resident 9 stated she did not wear a smoking apron when she smoked. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 6 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 9 was observed sitting in her walker smoking an electronic cigarette (e-cig) next to residents smoking traditional cigarettes. Resident 9 was observed not wearing a noncombustible apron. During a review of Resident 10's AR, dated 3/1/24, the AR indicated, Resident 10 was admitted on [DATE] with a diagnosis of dementia. During a review of Resident 10's MDS, dated 1/30/24, the MDS Section C indicated Resident 10 had a BIMS score of 9 out of 15, which suggested Resident 10 was moderately impaired. During a review of Resident 10's CP, dated (undated), the CP indicated, . Resident will adhere to the Tobacco/Smoking Policies of the Facility . Resident will not suffer injury from unsafe smoking practices . staff to extinguish cigarettes . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 10 was observed sitting in his wheelchair smoking a traditional cigarette. Resident 10 was observed not wearing a noncombustible apron. During a review of Resident 24's AR, dated 3/1/24, the AR indicated Resident 24 was admitted on [DATE] with a diagnosis of multiple sclerosis (a condition where body attacks itself) During a review of Resident 24's MDS, dated 1/25/24, the MDS indicated, Resident 24 had a BIMS score of 15 out of 15, which suggested Resident 24 was cognitively intact. During a review of Resident 24's CP, dated 12/28/23, the CP indicated, . the resident will not smoke without supervision through the review date . instruct resident about the facility policy on smoking; locations, times, safety concerns . notify charge nurse immediately if it is suspected resident has violated facility smoking policy . the resident requires SUPERVISION while smoking . During an observation on 2/29/24 at 11:07 a.m. outside in the smoking area, Resident 24 was observed sitting in her wheelchair with an assistant smoking a traditional cigarette. Resident 24 was observed not wearing a noncombustible apron. During a concurrent observation and interview on 2/29/24 at 11:12 a.m. with the Activities Assistant (AA) outside the facility in the designated smoking area, the AA was observed giving the residents their smoking articles, no noncombustible aprons were observed in the AA's possession. The AA stated the residents lit their own cigarettes. The AA stated the residents flicked the cigarette ashes on the ground. The AA stated the residents did not like to wear the noncombustible apron. The AA stated she was not sure if the residents were educated on safety while smoking. During a concurrent interview and record review on 3/1/24 at 3:18 p.m. with the Administrator (ADM), the facility's policy and procedure (P&P) titled, Smoking Policy - Residents dated 7/20 was reviewed. The P&P indicated, . this facility shall establish and maintain safe resident smoking practices . resident must apply the noncombustible apron prior to smoking . The ADM stated he was not aware the P&P stated the residents must wear a noncombustible apron. The ADM stated the staff needed to follow the P&P. The ADM stated there could be inconsistencies in resident care and resident safety if the P&Ps were not followed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 7 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: Residents Affected - Many 1. One of one drawer that stored clean utensils had dried food on a spatula. This had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents. 2. Five unlabeled food items and two expired food items were found in the resident nourishment refrigerator and kitchen refrigerators. These failures placed residents at risk for cross contamination and had the potential to cause foodborne illness (illness caused by ingestion of contaminated food or beverages) to 28 of 28 residents who consumed the food . Findings: 1. During a concurrent observation and interview on 2/27/24 at 9:26 a.m. with the Kitchen Supervisor (KS) in the kitchen, the clean utensil drawer was observed to have a spatula with dried, caked on yellow food particles mixed in with clean utensils. The KS observed the dirty spatula and stated the spatula was not clean. The KS stated the spatula should not be in the clean utensil drawer. The KS stated all the utensils in the clean utensil drawer needed to be removed and reprocessed. During an interview on 2/28/24 at 1:37 p.m. with the Registered Dietician (RD), the RD stated dirty cooking utensils should not be in the clean cooking utensil drawer. The RD stated her expectations of the kitchen was that it be clean and sanitized to prevent the risk of cross contamination and residents getting sick from food borne illness. During an interview on 3/01/24 at 11:54 a.m. with the KS, the KS stated the dirty utensils probably got into the clean utensil drawer after the dishes were washed. The KS stated staff might have just grabbed the utensils and put them in the drawer without checking to be sure they were clean. The KS stated it was important to get food particles off the utensils. The KS stated dirty utensils could lead to cross-contamination. The KS stated using dirty utensils could get the residents sick. During an interview on 3/01/24 at 3:18 p.m. with the Administrator (ADM), the ADM stated dirty utensils should not be in the clean utensil drawer. The ADM stated his expectation was for the kitchen to be clean and sanitary. The ADM stated having dirty utensils in the clean utensil drawer could cause cross contamination and food born illness to the residents. During a review of the facility's policy and procedure (P&P) titled, Sanitation and Infection Control . Dishwashing Procedures (Dish machine), dated 2023, indicated, . all the dishes should be inspected after coming out of the dish machine and if the dishes are not clean then they should be washed again in the dish machine . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 8 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a review of the KS job description titled, Orientation, Inservice, & Personnel Management . Director of Food and Nutrition Services Job Description dated 2023, indicated, . ensures sanitation and safety standards are maintained according to State, Federal, and local regulations . During a review of professional reference titled, FDA Food Code 2022, section 4-601.11 Equipment, Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils, dated 2022, indicated, . EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to sight and touch .the FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations . During a review of professional reference titled, FDA Food Code 2022, section 4-903.11 Equipment, Utensils, Linens, and Single-Service and Single-Use Articles, dated 2022, indicated, . cleaned EQUIPMENT and UTENSILS, laundered LINENS, and SINGLE-SERVICE and SINGLE-USE ARTICLES shall be stored . in a clean, dry location . where they are not exposed to splash, dust, or other contamination . During a review of professional reference titled, FDA Food Code 2022, section 4-602.13 Nonfood-Contact Surfaces, dated 2022, indicated, . the presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food. If these areas are not kept clean, they may also provide harborage for insects, rodents, and other pests . 2. During a concurrent observation and interview on 02/27/24 at 9:33 a.m. with [NAME] (CK) 1 in the walk-in refrigerator in the kitchen, a package of raspberries with a white substance on them was observed. CK 1 stated the raspberries looked like they had mold on them. Three bowls of chopped vegetable food items were observed in Refrigerator #1 without labels. CK 1 stated the vegetables were chopped this morning. CK 1 stated she did not put a label on the food items. During a concurrent observation and interview on 2/28/24 at 10:50 a.m. with the RD in the staff lounge, the Resident Nourishment Refrigerator was observed to have an unlabeled food container, shriveled, discolored tomatoes in a container labeled 10/11/23, and an opened jar of food with a received date of 9/29/23, without an opened date label. The Resident Freezer was observed to have cloth ice packs with resident names on them, unwrapped. The RD stated there should not be unlabeled and expired food in the resident refrigerator. The RD stated there should not be medical equipment in the resident freezer. During an interview on 2/28/24 at 11:06 a.m. with the KS, the KS stated the resident food was held only three days in the resident nourishment refrigerator. The KS stated the night shift kitchen staff checked the resident refrigerator. The KS stated the freezer packs were for nurses to use, not the residents. The KS stated the dietary department did not use the Resident Freezer. During an interview on 2/28/24 at 1:37 p.m. with the RD, the RD stated her expectations for storing resident food was it be labeled and dated with an opened date, used by dated and dated when prepared or received. The RD stated there should not be expired food or unlabeled food in the resident refrigerator. The RD stated if residents were served expired food or outdated food, they could become sick. During an interview on 2/29/24 at 8:55 a.m. with LVN 2, LVN 2 stated the dietary department monitored the resident refrigerator. LVN 2 stated we did not let residents keep personal food. LVN 2 stated we would not save the resident's food. LVN 2 stated nursing did not keep track of resident's food. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 9 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many LVN 2 stated storing the ice packs in the resident freezer was not a good idea. LVN 2 stated it could cause cross contamination. LVN 2 stated if ice packs leaked, they could leak out into the resident's food. During an interview on 2/29/24 at 9:33 a.m. with the Director of Nursing (DON), the DON stated the facility had a policy and procedure (P&P) for the resident nourishment refrigerator. The DON stated staff were required to follow those policies. The DON stated it was not appropriate for other departments to put medical equipment in the resident refrigerator. The DON stated the dietary department was responsible for the resident refrigerator. The DON stated nursing staff would get the resident's food from the resident refrigerator. The DON stated if the food was expired, the resident could get sick. The DON stated she would expect the dietary department to follow daily checks of the resident refrigerator. The DON stated if there was expired food in the resident refrigerator it needed to be thrown away immediately. The DON stated expired food should not be in the refrigerator. During an interview on 3/01/24 at 3:18 p.m. with the ADM, the ADM stated his expectation was for the resident refrigerator to be clean and sanitary. The ADM stated no expired food should be in the refrigerators. The ADM stated eating expired food could cause foodborne illness. The ADM stated no medical equipment should be in the resident refrigerator or freezer. The ADM stated there would be a potential for cross-contamination and food borne illness from bacteria. During a review of the facility's P&P titled, Sanitation and Infection Control . Food Brought in From Outside Sources, dated 2023, indicated, . All food brought in should be checked by the charge nurse or the Director of Food and Nutrition Services. It must be placed in a tightly sealed container with the resident's name and date on it . Food that does not have a manufacturer's printed date must be thrown out 3 days from the time it was brought in . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 10 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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** Based on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for four of 12 sampled residents (Residents 1, 12, 17, and 26) when Resident 1, 12, 17 and 26's copy of Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. This failure had the potential for the Resident 1, 12, 17 and 26's decisions regarding treatment options and end of life wishes to not be honored. Findings: During a review of Resident 1's admission Record (AR), dated [DATE], the AR indicated, Resident 1 was admitted on [DATE] with diagnoses of anoxic brain damage (brain damage due to a complete lack of oxygen to the brain), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and cortical blindness (loss of vision due to damage of the visual pathways in the brain). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated [DATE], the MDS, section C indicated Resident 1 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 99 indicating Resident 1 was not interviewable (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact). During a concurrent interview and record review on [DATE] at 8:55 a.m. with Licensed Vocational Nurse (LVN) 2, Resident 1's POLST, dated [DATE] was reviewed. The POLST indicated, no physician phone number documented on the POLST. LVN 2 stated Resident 1's POLST was not complete. LVN 2 stated the purpose of a completed POLST was to know what the residents' wishes were for life sustaining treatment. LVN 2 stated if the POLST was not completed with the Doctor or guardian's phone number, the receiving facility would not be able to contact the guardian or the Doctor. LVN 2 stated if the resident was transferred to another facility, the facility would want to call the Doctor. During a review of Resident 12's AR, dated [DATE], the AR indicated Resident 12 was admitted on [DATE] with diagnoses of fracture of upper and lower end of the fibula (a break in the smaller of two bones in the lower leg), and chronic kidney disease (a condition in which the kidneys are damaged and cannot filter waste from the blood as well as they should). During a review of Resident 12's MDS, dated [DATE], the MDS indicated Resident 12 had a BIMS score of 15 out of 15, which suggested Resident 12 was cognitively intact. During a concurrent interview and record review on [DATE] at 9:03 a.m. with LVN 2, Resident 12's POLST, dated [DATE] was reviewed. LVN 2 stated page 2, which included patient name, patient date of birth , patient gender, (Nurse Practitioner/Physician's Assistant (NP/PA)'s supervising physician information, the POLST preparer's name, and additional contact names. LVN 2 stated page 2 of Resident 12's POLST was not filled out. LVN 2 stated Resident 12's POLST was not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 11 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 During a review of Resident 17's AR, dated, [DATE], the AR indicated Resident 17 was admitted on [DATE] with diagnoses of dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), and fracture of right femur (a break in the thigh bone). Residents Affected - Some During a review of Resident 17's MDS, dated [DATE], the MDS indicated Resident 17 had a BIMS score of 14 out of 15, which suggested Resident 17 was cognitively intact. During a concurrent interview and record review on [DATE] at 8:55 a.m. with LVN 2 Resident 17's POLST, dated [DATE] was reviewed. LVN 2 stated Resident 17's POLST was not completed accurately. LVN 2 stated the purpose of a completed POLST was to know what the resident's wishes were, whether to do Cardiopulmonary Resuscitation (an emergency procedure consisting of chest compressions often combined with mouth-to-mouth breathing in a person who's heart has stopped beating and is no longer breathing) (CPR) or not. LVN 2 stated Resident 17's POLST was not clear, Do Not Attempt Resuscitation/DNR (do not perform CPR, allow a natural death) and Full Treatment (primary goal of prolonging life by all medically effective means) were marked. LVN 2 stated if the POLST was not completed correctly, staff and emergency personnel would not know the resident's wishes for life sustaining treatment. During a review of Resident 26's AR, dated [DATE], the AR indicated Resident 26 was admitted on [DATE] with diagnoses of follicular lymphoma (Cancer of the lymph nodes [small, bean-shaped organs that filter substances in the body and contain cells that fight infection]), acute kidney failure (a condition when the kidneys suddenly are unable to filter waste products from the blood), and Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks). During a review of Resident 26's MDS, dated [DATE], the MDS indicated Resident 26 had a BIMS score of 7 out of 15, which suggested Resident 26 was severely cognitively impaired. During a concurrent interview and record review on [DATE] at 9:06 a.m. with LVN 2, Resident 26's POLST, dated [DATE] was reviewed. LVN stated Resident 26's POLST was not completed. LVN 2 stated the Doctor's printed name and phone number were not completed and page 2, of Resident 26's POLST. LVN 2 stated the purpose of a completed POLST was to know what the resident's wishes were. LVN 2 stated if the POLST was not completed with the Doctor's phone number or if it did not have the guardian's phone number, staff and emergency personnel would not be able to contact the Doctor if the resident was sent to another facility. LVN 2 stated staff would want to call the Doctor. During a concurrent interview and record review on [DATE] at 9:33 a.m. with the Director of Nursing (DON), the DON stated her expectation was for the POLST forms to be completed. The DON stated she mis-read the instruction on completing the POLST page 2 and thought that page 2 did not need to be completed. The DON stated the form disclosed to other facilities what care was necessary for the residents life sustaining treatment. During a concurrent interview and record review on [DATE] at 3:18 p.m. with the Administrator (ADM), Resident 1's POLST, dated [DATE] was reviewed. The ADM stated Resident 1's POLST was contradictory. The ADM stated both boxes were marked Do Not Attempt Resuscitation/CPR and Full Treatment. The ADM stated we would not know to save the Resident or not. The ADM stated if the POLST was incomplete without the physician's phone number, we would not be able to get in touch with the physician. The ADM stated the POLST was for residents' wishes for life sustaining treatment to be known and fulfilled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 12 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 Add the policy of POLST Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 13 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Based on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for two of two sampled residents (Residents 2 and 10) when the facility failed to ensure that hospice personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures and staff were not aware of who was the designated hospice coordinator. This failure had the potential to place Residents 2 and 10 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness. Findings: During a review of Resident 2's admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 3/1/24, the AR indicated, Resident 2 was admitted from an acute care hospital on 4/23/19 to the facility, with diagnoses which included Dementia (a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Hypertension (high blood pressure), Repeated Falls, Atrial fibrillation (Afib, is an irregular and often very rapid heartbeat), Hemorrhage of Cerebrum (stroke, bleeding inside the brain), and Atherosclerotic Heart Disease (hardening of veins causing limited blood flow and could result to stroke). During a review of Resident 2's Order Summary Report (OSR), dated 11/17/23, the OSR indicated, . Admit to [Name of Hospice Agency] Diagnosis: Atherosclerotic Heart Disease . During a review of Resident 10's AR, dated 2/29/24, the AR indicated, Resident 10 was admitted from an acute care hospital on 1/19/24 to the facility, with diagnoses which included Senile Degeneration of Brain (memory loss), Dementia, Hypertension, Type 2 Diabetes Mellitus (high blood sugar), and Cerebral Infarction (stroke). During a review of Resident 10's Order Summary Report (OSR), dated 1/19/24, the OSR indicated, . Admit to [Name of Hospice Agency] Diagnosis: Senile Degeneration of Brain . During an interview on 3/1/24, at 12:35 p.m., with [Hospice Agency] Hospice Social Worker (HSW), HSW stated he was the assigned Hospice Social Worker for Resident 2 and Resident 10 and have been coming to the facility since April 2022. HSW stated he visited Resident 2 and Resident 10 once a week and provided psychosocial and emotional support. HSW stated he did not recall having an orientation on the facility's policy and procedures or meeting the facility's Hospice Coordinator. HSW stated, I thought the facility's Social Services Director (SSD) was the designated Hospice Coordinator. During an interview on 3/1/24, at 12:47 p.m., with Certified Nurse Assistant (CNA) 1 and CNA 2, in the main hallway, CNA 1 and CNA 2 both stated they currently have two residents receiving hospice care [Resident 2 and Resident 10] and the SSD was the facility's designated Hospice Coordinator. During an interview on 3/1/24, at 12:50 p.m., with the Infection Preventionist (IP-professional who ensures healthcare workers and patients are doing all the things they should to prevent (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 14 of 15 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/01/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some infections), in the main hallway across the nurses's station, the IP stated the SSD was the facility's designated Hospice Coordinator. During a concurrent interview and record review, on 3/1/23, at 12:54 p.m., with the Social Services Director (SSD), the facility's Policy and Procedure (P&P) titled Hospice Program, dated 7/2017 was reviewed. The P&P indicated, . 12. Our facility has designated [blank space, no name and no title] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . The SSD stated she coordinated the hospice referral and family meeting for hospice evaluation but she did not know the facility's designated Hospice Coordinator. The SSD stated she was not aware of any orientation conducted on the facility's P&P to hospice staff. The DSD stated the facility failed to follow its own hospice P&P. During a concurrent interview and record review, on 3/1/23, at 2:30 p.m., with the Director of Nursing (DON), the facility's P&P titled Hospice Program, dated 7/2017 was reviewed. The P&P indicated, . 12. Our facility has designated [blank space, no name and no title] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . The DON stated she was the facility's designated Hospice Coordinator and not the SSD. The DON stated she did not have any record or proof that an orientation on the P&P of the facility to hospice staff caring for facility residents was done. The DON stated the facility failed to follow its own hospice policy. The DON stated the lack of orientation to the facility's policy and procedure to hospice personnel could potentially result to not meeting the medical, physical, psychosocial, and spiritual needs of Residents 2 and Resident 10. During a review of the facility's P&P titled, Hospice Program, dated 7/2017, the P&P indicated, . Hospice services are available to residents at the end of life . 12. Our facility has designated [blank space, no name and no title] to coordinate care provided to the resident by our facility staff and the hospice staff .e. Ensuring that our facility staff provides orientation on the P&P of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents . 13. Coordinated care plans for residents receiving hospice services . in order to maintain the resident's highest practicable physical, mental and psychosocial well-being . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 15 of 15