Inspection·June 10, 2021

F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure the SNFABN form (Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage, a form that provides information to the beneficiary so that she/he can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) was completed for one of three sampled residents (Resident 9). This failure resulted in Resident 9 not being informed of the three options available. Residents Affected - Few Findings: During a concurrent interview and record review, on 6/9/21, at 2:06 PM, with Medical Records Director (MRD), SNFABN, dated 3/24/21, was reviewed. The SNFABN indicated, Options: Check only one box. We can't choose a box for you. Option 1, Option 2, and Option 3 checkboxes were left blank. MRD stated, the resident or representative who fills out the SNFABN picks option 1, option 2, or option 3. MRD stated, an option was not picked for Resident 9 and MRD was unaware it was left blank. MRD stated, I missed it. During a review of the facility's Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (FISNFABN), dated 2018, the FISNFABN indicated, Page 4. 3. Option boxes. There are 3 options listed on the SNFABN with corresponding check boxes. The beneficiary must check only one option box. If the beneficiary is physically unable to make a selection, the SNF [Skilled Nursing Facility] may enter the beneficiary's selection at his/her request and indicate on the notice that this was done for the beneficiary. Otherwise, SNFs are not permitted to select or pre-select an option for the beneficiary as this invalidates the notice. During a review of the facility's policy and procedure (P&P) titled, Charting and Documentation, dated July 2017, the P&P indicated, 3. Documentation in the medical record will be objective, complete, and accurate. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 2 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based on interview and record review, the facility failed to develop a care plan for two of 26 sampled residents (Resident 43 and Resident 28). This failure had the potential for unmet care needs and adverse outcomes for Resident 43 and Resident 28. Findings: During a review of Resident 43's physician orders (PO), dated 11/4/20, the PO indicated, Resident 43 may have 12 ounces (unit of measurement) can of beer as needed daily. During a concurrent interview and record review on 6/10/21, at 8:55 AM, with Licensed Vocational Nurse (LVN) 4, Resident 43's care plan (CP) was reviewed. LVN 4 was unable to locate a CP for beer as ordered by the physician. LVN 4 verified, that there was not a CP for beer and stated there should be a CP. During a review of Resident 28's admission Record (AR), dated 4/1/21, the AR indicated, Resident 28 had a diagnosis of chronic atrial fibrillation (A-fib is an irregular and often rapid heart rate that can increase your risk of strokes, heart failure and other heart-related complications). Resident 28's PO, dated 4/1/21, the PO indicated, Apixban (medication used to treat and prevent blood clots and to prevent stroke in people with atrial fibrillation) tablets 5 mg (milligram- unit of measure) Give 1 tablet by mouth two times a day related to CHRONIC ATRIAL FIBRILLATION . During a concurrent interview and record review on 6/8/21, at 4:13 PM, with Director of Nursing (DON), DON reviewed, Resident 28's clinical record and was unable provide a CP for A-fib or Apixban. DON stated, A-fib and Apixban should have been care planned. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/16, the P&P 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. 7. The comprehensive, person-centered care plan will: . g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; . o. Reflect currently recognized standards of practice for problem areas and conditions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 3 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Based on observation, interview, and record review, the facility failed to revise one of 26 sampled residents (Resident 30) care plan timely. This failure had the potential for Resident 30's needs to go unmet. Residents Affected - Few Findings: During a review of Resident 30's Minimum Data Set (MDS- an assessment of resident's needs), dated 4/9/21, at 11:17 AM, the MDS indicated, Resident 30 had an indwelling foley catheter (IFC- thin tube that is inserted into the bladder that drains urine). During an observation on 6/8/21, at 10:41 AM, in Resident 30's room, Resident 30 was observed without a IFC. During a review of Progress Notes (PN), dated 4/9/21, at 9:01 PM, the PN indicated that Resident 30 pulled the IFC out and refused to have it (IFC) reinserted. During a review of Resident 30's Care Plan (CP), initiated on 3/27/21, the CP indicated, Resident 30 had an IFC. During a concurrent interview and record review on 6/10/21, at 10:01 AM, with Licensed Vocational Nurse (LVN) 4, Resident 30's CP was reviewed. The CP indicated, Resident 30 had an IFC. LVN 4 stated, the CP for the IFC should have been removed since the resident no longer had an IFC. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered, revised 12/16, the P&P indicated, 13. Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 4 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) for three of 26 sampled residents (Resident 50, Resident 27, and Resident 74) when: Residents Affected - Some 1. Resident 50 was permitted to have cigarettes and lighter in his room and to smoke without supervision. 2. Resident 27 was permitted to have a cigarette lighter in her room and to smoke without supervision. 3. Resident 74 was permitted to have cigarettes and lighter. These failures had the potential to result in an avoidable smoking accident. Findings: 1. During a concurrent observation and interview on 6/8/21, at 10:15 AM, with Resident 50, in Resident 50's room, there was a cigarette on Resident 50's night stand. Resident 50 stated, he keeps cigarettes in his room and he has a cigarette lighter in his pocket. Resident 50 stated, no one is with him when he smokes. During a concurrent observation and interview on 6/9/21, at 8:39 AM, with Resident 50, in Resident 50's room, the resident pulled a cigarette lighter out of his pocket and demonstrated how he lights the lighter. Resident 50 stated, he can go out anytime he wants to smoke, he does not need anyone with him. During a concurrent observation and interview on 6/9/21, at 9:40 AM, with Administrator in Training (AIT) and Regional Administrator (RA), in the hallway, looking out to the smoking area, Resident 50 was observed smoking a cigarette. There were no staff present in the smoking area. AIT stated, it was Resident 50, and RA was observing him through a window in the administrator's office. The administration office does not have direct access to the smoking area. RA stated, he watches the smokers from the window in his office when no one is available to be outside to observe the smokers. During an interview on 6/9/21, at 10 AM, with the Director of Nursing (DON), DON stated, she could not locate a policy for smoking observation. DON stated, they do not have guidance for staff who monitor smoking. During a concurrent interview and record review on 6/9/21, at 4 PM, with Licensed Vocational Nurse (LVN) 2, Resident 50's SMOKING OBSERVATION/ASSESSMENT (SOA), dated 4/28/21, was reviewed. The SOA indicated, b. Team Decision: 2. May smoke with supervision. LVN 2 stated, Resident 50's smoking assessment indicated Resident 50 needed supervision when smoking. During an observation on 6/9/21, at 4:05 PM, in Resident 50's room, with LVN 2, LVN 2 verified there was a cigarette on Resident 50's night stand. 2. During a concurrent observation and interview on 6/7/21, at 11:30 AM, with Resident 27, in Resident 27's room, a cigarette lighter was observed on the Resident 27's bedside table. Resident 27 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 5 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 stated, staff lets her keep it and she smokes whenever she wants. Level of Harm - Minimal harm or potential for actual harm During an observation on 6/9/21, at 9:08 AM, in Resident 27's room, a cigarette lighter was observed on Resident 27's bedside table. Residents Affected - Some During an interview on 6/9/21, at 10:57 AM, with Resident 27, Resident 27 stated, the staff took her cigarette lighter from her today. Resident 27 stated, she always has it on her bedside table or keeps it in her bra. During a review of Resident 27's SOA, dated 4/22/21, the SOA indicated, Resident 27 may smoke with supervision, staff to watch without intruding. During a review of Resident 27's Care Plan (CP), dated 4/22/21, the CP indicated, Resident 27 may smoke with supervision outside. 3. During an observation and interview on 6/7/21, at 11:52 AM, in Resident 74's room, with Resident 74. Resident 74 stated, he had been in the facility for about three weeks. Resident 74 stated, he was a smoker, he kept his cigarettes and lighter and could smoke anytime he wanted. Resident 74 tapped his front shirt pocket and stated, I have my cigarettes and lighter. Red and white box of cigarettes were noted in his front pocket, when asked about the location of his lighter he stated the lighter was in the box in his pocket. During a review of Resident 74's CP titled [Resident 74] has the potential for injury related to smoking, initiated on 5/10/21, the CP indicated, Cigarettes and lighter will be stored in nurses' station. During an interview on 6/9/21, at 10:19 AM with LVN 2, LVN 2 stated, only some of the residents who smoke have their cigarettes and lighter stored at the nurses' station, some residents have their cigarettes and lighter according to their care plans. During a concurrent interview on 6/9/21, at 10:30 AM, with Resident 74 and Certified Nursing Assistant (CNA) 2, Resident 74 stated, They took my lighter today! I have smoked 70 years and never needed to ask anyone for a lighter. CNA 2 stated, I think he use to have it but he now gets it from nurses' station. Resident 74 stated, that it is his property and they cannot just take it, once he gets it back, he will not give it back. CNA 2 stated, They [smoking residents] are supposed to return it [their cigarettes and lighters] to the nurse. I am not sure if they do or not. During an interview on 6/10/21, at 10:29 AM, with AIT, AIT was made aware of the above findings, stated, We are going to change the way we do our admissions process so we will explain our smoking policy upon admission that way the resident will not be upset when the smoking materials (cigarettes and lighters) are taken away and stored in nurses' station. He confirmed, Resident 74 was very upset at having his cigarettes and lighter taken away and had the P&P been explained to him upon admission, he would not have been so upset yesterday when his lighter was taken away. During a review of the facility's policy and procedure (P&P) titled, Smoking Policy-Residents, revised 7/17, the P&P indicated, This facility shall establish and maintain safe resident smoking practices. 1. Upon admission residents shall be informed of the facility smoking policy, including designated smoking areas, and the extent to which the facility can accommodate their smoking or non-smoking preferences. 9. Any resident with restricted smoking privileges requiring monitoring shall have the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 6 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 direct supervision of a staff member.at all times while smoking. 10. Residents who have independent smoking privileges are permitted to keep cigarettes, e-cigarettes, pipes, tobacco, and other smoking articles in their possession. All other forms of lighters, including matches, are prohibited. 11. Residents without independent smoking privileges may not have or keep any smoking articles, including cigarettes, tobacco, etc. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 7 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Based on observation, interview, and record review, the facility failed to ensure one of 26 sampled residents (Resident 38) continuous tube feeding (a liquid food mixture given through a tube into the stomach to provide nutrients to people who cannot eat or drink safely) container and tubing were changed according to manufacturer's guidelines. This failure had the potential to result in Resident 38's tube feeding becoming contaminated with harmful bacterial growth. Findings: During an observation on 6/7/21, at 10:17 AM, in Resident 38's room, Resident 38 was observed receiving continuous tube feeding. The label on the Jevity 1.5 CAL (tube feeding formula) feeding container had documentation administration began on 6/7/21 at 4:40 AM. The Covidien (manufacturer name) feeding set (tubing) had documentation administration began on 6/7/21 at 4:40 AM. During a concurrent observation and interview on 6/8/21, at 8:31 AM, with Licensed Vocational Nurse (LVN) 3, in Resident 38's room, Resident 38 continued to receive continuous feeding of Jevity 1.5 CAL formula that was started on 6/7/21 at 4:40 AM. LVN 3 stated, the continuous feeding container and tubing should be changed every 24 hours. LVN 3 stated, Night shift should have changed, [formula and tubing] that is (sic) why I am changing right now. During a review of Abbott Laboratories, Inc. manufacturing guidelines for Jevity 1.5 CAL, dated 3/13/2020, the Abbott Laboratories, Inc. manufacturing guidelines indicated, All medical foods, regardless of type of administration system, requires careful handling because they can support microbial [bacteria] growth. Follow these instructions for clean technique and proper set up to reduce the potential for microbial contamination.Follow directions for use provided by manufacturer of feeding sets. During a review of Covidien Operator Manual, dated, 11/2017, the Covidien Operator Manual indicated, The feeding set should be replaced after 24 hours from initiation [start] of feeding. This ensures that the system is operating within specified parameters and prevents bacterial growth that could be hazardous to the patient. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 8 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 - Few 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. Based on observation, interview, and record review, the facility failed to ensure medications and biologicals were labeled appropriately and expired medications were removed from active supply. These failures had the potential for the residents to receive ineffective medications. Findings: During an interview on 6/7/21, at 3:07 PM, with Vocational Nurse (LVN) 5, LVN 5 stated, We audit the medications routinely, to ensure open dates are written on all open bottles and pull any medications close to the expiration date. During a concurrent observation and interview on 6/7/21, at 3:26 PM, at a medication cart, with LVN 1. LVN 1 confirmed, one bottle of Melatonin (supplement used to treat insomnia and to help improving sleep) 5 milligrams (mg- unit of measure) and one bottle of alkums antacids (medication used to treat acid indigestion and heartburn) were open and undated. LVN 1 stated, they should have an open date written on them. During a concurrent observation and interview on 6/8/21, at 11:04 AM, in the south station medication room, with LVN 1. LVN 1 confirmed, two bottles of niacin (vitamin B-3 used by your body to turn food into energy) 500 mg 100 tablets (tabs) with expiration date of 3/21. LVN 1 stated, the medications should have been removed before the expiration date. During an interview on 6/8/21, at 11:24 AM, with Director of Nursing (DON), DON stated, I do require open dates on all medications and biologicals. DON stated, she audits the medication room and medication carts. She stated, she usually pulls the medications one month before they are set to expire. DON stated, she audited the medication room last night and she must have missed a few. During a review of the facility policy and procedure (P&P) titled, Storage of Medications, revised 11/2020, the P&P indicated, The facility stores all drugs and biologicals in a safe, secure, and orderly manner. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 9 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Based on interview and record review, the facility failed to ensure a distinct population was included in the facility assessment. This failure had the potential to lead to unmet care needs for the facility's smoking residents. Findings: During a concurrent interview and record review on 6/10/21, at 10:29 AM, with Administrator in Training (AIT), AIT confirmed the facility had a smoking population. AIT reviewed the Facility Assessment, dated 11/21/19. AIT confirmed, the smoking population was not addressed in the Facility Assessment, he stated it should have been. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 10 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 interview and record review, the facility failed to ensure one of three housekeepers (HK) 1 cleaned high touch surfaces according to the facility's COVID-19 (A highly contagious respiratory illness in humans that is spread from person to person when an infected person coughs, sneezes, or talks. It may also be spread by touching a surface with the virus on it and then touching one's nose, mouth, or eyes) mitigation plan. This failure had the potential to facilitate the spread of COVID-19 to residents, staff, and visitors. Residents Affected - Some Findings: During an interview on 6/9/21, at 2:16 PM, with HK 1, HK 1 stated, handrails in hallways are cleaned every other day, and high touch surfaces are cleaned once a day. During an interview on 6/10/21, at 10:30 AM, with Infection Preventionist (IP), IP stated, Yes housekeeping should be following the facility's COVID-19 mitigation plan by cleaning handrails in hallways and high touch surface areas twice daily. IP stated she does not have a process to ensure the cleaning of high touch surfaces are being done according to the facility's mitigation plan. During a review of the facility's COVID-19 mitigation plan, (undated), the COVID-19 mitigation plan indicated, High touch areas will be wiped down with bleach wipes at least twice a day or more frequently as needed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 11 of 12 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555663 B. Wing A. Building (X3) DATE SURVEY COMPLETED 06/10/2021 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lindsay Gardens Nursing & Rehabilitation 1011 W. Tulare Road Lindsay, CA 93247 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to ensure a policy and procedure(P&P) was developed and implemented to ensure the residents had a safe smoking environment. This failure had the potential to result to an unsafe smoking area and possible exposure to second hand smoke for non-smoking residents. Residents Affected - Some Findings: During an observation on 6/9/21, at 8:32 AM, two residents were observed smoking approximately eight feet from the smoking patio door. During a concurrent observation and interview on 6/9/21, at 8:46 AM, with Administrator in Training (AIT) on the smoking patio. AIT confirmed, two residents were smoking within eight foot of the smoking patio entrance door. He stated, he does not know how far the smoking area should be away from the smoking patio entrance. Requested a P&P for safe smoking area. During an interview on 6/9/21, at 3:36 PM, with AIT, AIT stated, the facility does not have a P&P for smoking area safety. The AIT was asked if eight feet was a safe enough distance to protect non-smoking residents from second hand smoke? He stated, it could be further away. During a concurrent interview and record review on 6/10/21, at 10:29 AM, with AIT, AIT confirmed, no other P&P addressed smoking other than Smoking Policy-Residents. AIT reviewed the P&P and confirmed the P&P does not include requirements for safe smoking area: the amount of distant the smoking area should be from door to ensure non-smoking resident are safe from secondhand smoke, the type of ashtray that should be used, the requirement for a fire extinguisher and smoking blanket, or the requirement for weather protection for smoking residents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555663 If continuation sheet Page 12 of 12