Health inspection·May 8, 2023

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few dignity. LVN 5 stated, residents in room [ROOM NUMBER] and 9 used the sink room to shave. LVN 5 stated, Resident 12's Geri Chair did not fit in the sink room door. LVN 5 stated, the CNA should have shaved Resident 12 in his room with curtains closed or during his showers to provide privacy. During an interview on 5/3/23, at 2:40 p.m., with the Director of Staff Development (DSD), the DSD stated, the sink room in the hallway was used to shaved residents to provide privacy. The DSD stated, CNA 5 should have shaved Resident 12 in his room and not in the hallway to maintain Resident 12's dignity. The DSD stated, dignity was an important right as a human being and does not matter if the person was alert or not. The DSD stated she would be embarrassed if she was exposed to others and while receiving care. During an interview on 5/3/23, at 3:52 p.m., with the Director of Nurses (DON), the DON stated, the expectations was for the CNAs to provide all residents with privacy during care and not use the hallway as a shaving area. The DON stated, shaving Resident 12 in the in the hallway in front of everybody was a dignity and privacy issue and was unacceptable. The DON stated, Resident 12 had the potential to be embarrassed. The DON stated, Resident 12 should have been shaved in his room with the curtains closed. During a review of the facility's policy and procedure (P&P), titled Promoting/Maintaining Resident Dignity, undated, the P&P indicated, .It is the practice of this facility to protect and promote resident rights and treat each resident with respect and dignity . 1. All staff members are involved in providing care to residents to promote and maintain resident dignity and respect resident rights . 4. The resident's former lifestyle and personal choices will be considered when providing care . 9. Groom and dress residents according to resident preference . 12. Maintain resident privacy . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 2 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. Based on interview and record review, the facility failed to provide written notification to the Long-Term Care Ombudsman (LTCO- a person who routinely visits the facility and advocates for the residents) when one of two sampled residents (Resident 47) was transferred to the acute care hospital. This failure had the potential to result in Resident 47 not having an advocate who could inform them of their admission, transfer, and discharge rights and options. Findings: During a concurrent interview and record review, on 5/8/23, at 10:46 a.m., with the Director of Medical Records (DMR), Resident 47's Transfer Form (TF), dated 2/28/23 was reviewed. The DMR stated, he was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DMR stated, during the time when Resident 47 was transferred to the acute care hospital the facility did not have a Director of Social Services (DSS). The DMR stated, it was the responsibility of the DSS to notify the LTCO when Resident 47 was transferred to the acute care hospital. During an interview on 5/8/23, at 10:57 a.m., with the DSS, the DSS stated, the facility process when a resident transferred to the acute care hospital was for the DSS to complete the Transfer/Discharge notification form, provide the form to the LTCO and kept a copy of the form in resident's clinical record. During an interview on 5/8/23, at 11:17 a.m., with the LTCO, the LTCO stated, he was not notified by the facility when Resident 47 was transferred to the acute care hospital. The LTCO stated, the facility should have provided him a written notification when Resident 47 was transferred to the acute care hospital. During a concurrent interview and record review, on 5/8/23, at 12:03 p.m., with the DSS, Resident 47's TF, dated 2/28/23 was reviewed. The DSS stated, she was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DSS stated, the LTCO should have been notified when Resident 47 was transferred to the acute care hospital to be able to advocate for Resident 47. During a concurrent interview and record review, on 5/8/23, at 2:25 p.m., with the Director of Nursing (DON), Resident 47's TF, dated 2/28/23 was reviewed. The DON stated, she was unable to find documentation of LTCO notification when Resident 47 was transferred to the acute care hospital. The DON stated, the expectations was for the DSS to notify the LTCO when a resident was transferred to the acute care hospital and placed the LTCO notification in residents clinical record. The DON stated it was important to notify the LTCO when Resident 47 was transferred to the acute care hospital for the LTCO to provide the support and advocate for Resident 47 while in the acute care hospital. During a review of the facility's policy and procedure (P&P) titled, Transfer and Discharge, (undated), the P&P indicated, . Transfer refers to the movement of a resident from a bed in one certified facility to a bed in another certified facility when the resident expects to return to the original facility . The facility will maintain evidence that the notice was sent to the Ombudsman . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 3 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0623 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Professional reference titled, CMS Issues Clarification of Notice Requirements to Long-Term Care Ombudsman when Resident is transferred or discharged from Long-Term Care Facility dated 7/24/17, (found at https://www.hallrender.com/2017/07/24/cms-issues-clarification-of notice requirements) indicated . On May 12, 2017, the Survey and Certification Group at Centers for Medicare and Medicaid Services (CMS) issued a memorandum, Implementation Issues, Long-Term Care Regulatory Changes . Clarification of Notice before Transfer or Discharge Requirements clarifying the requirements of the Final Rule regarding the timing for providing notice to the State Long-Term Care Ombudsman in the event a resident is transferred or discharged from the long term care facility. Facilities must immediately review and revise their discharge and transfer notice practices, policies and procedures . Emergency Transfers, when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable . Copies of notices for emergency transfers must also still be sent to the Ombudsman . Event ID: Facility ID: 555918 If continuation sheet Page 4 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 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 one of four sampled residents (Resident 23) when Resident 23 who was nonverbal and was coded as comatose (a state of deep unconsciousness for a prolonged period, the person's eyes will be closed and unresponsive to their environment) in the MDS assessment. Residents Affected - Few These failures resulted in an inaccurate assessment of Resident 23's mental status and had the potential for Resident 23's needs to go unmet. Findings: During an observation on 5/1/23, at 10:30 a.m., Resident 23 was lying in bed with eyes open. Resident 23 did not respond when spoken to. During an observation on 5/1/23, at 12:48, in Resident 23's room, a nursing staff was feeding Resident 23 with a puree diet (food with a pudding-like consistency). During a review of Resident 23's MDS, dated 3/21/23, the MDS section B, (a section in the MDS which assessed hearing, speech, and vision), indicated Resident 23 was . Comatose . no discernable consciousness . During an observation on 5/3/23, at 9:41 a.m., Resident 23's eyes were open and was able to track (followed movement in front of eyes). During an interview on 5/3/23, at 9:56 a.m., with Licensed Vocational Nurse (LVN) 2, LVN 2 stated, Resident 23 since admission was nonverbal, but was alert and eat with assistance. During an interview on 5/3/23, at 11:00 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated, Resident 23 was not comatose, and respond to voice, movement, and pain. CNA 1 stated, Resident 23 was able to eat meals with assistance. During a concurrent interview and record review on 5/8/23, at 11:31 a.m., with the Minimal Data Set Nurse (MDSN), Resident 23's MDS section B, dated 3/21/23, was reviewed. The MDSN stated, Resident 23 was non-verbal and awake at times. The MDSN stated, the MDS indicated, Resident 23 was comatose. The MDSN stated, a comatose person could eat a pureed diet by mouth. The MDSN stated, the MDS was not accurate, and it was important to have an accurate MDS to properly care for and meet resident's needs. During a concurrent interview and record review on 5/8/23, at 11:40 a.m., with the MDSN, Resident 23's MDSs, dated 9/19/22, 12/19/22, and 3/21/23, were reviewed. The MDSN stated, all three MDSs indicated Resident 23 was comatose. The MDSN stated, the three MDSs were inaccurate. CMS (Centers for Medicare and Medicaid Services) Professional reference titled, Resident Assessment Instrument dated 10/18 (found at www.cms.gov) indicated, .The purpose of this manual is to offer clear guidance about how to use the Resident Assessment Instrument (RAI) correctly and effectively to help provide appropriate care. Providing care to residents with post-hospital and long-term care needs is complex and challenging work. Clinical competence, observational, interviewing, and critical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 5 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete thinking skills, and assessment expertise from all disciplined are required to develop individualized care plans . The RAI helps nursing home staff to look at residents holistically as individuals for whom quality of life and quality of care are mutually significant and necessary .B0100: Comatose . A pathological state in which neither arousal (wakefulness, alertness) nor awareness exists. The person is unresponsive and cannot be aroused; he/she does not open his/her eyes, does not speak, and does not move his/her extremities on command or in response to noxious stimuli (e.g., pain) . Coding Instructions . Code 0, no: if a diagnosis of coma or persistent vegetative state is not present during the 7-day look-back period. Continue to B0200 Hearing . Code 1, yes: if the record indicates that a physician, nurse practitioner or clinical nurse specialist has documented a diagnosis of coma or persistent vegetative state that is applicable during the 7-day look-back period. Skip to Section G0110, Activities of Daily Living (ADL) Assistance . Only code if a diagnosis of coma or persistent vegetative state has been assigned. For example, some residents in advanced stages of progressive neurologic disorders . may have severe cognitive impairment, be non-communicative and sleep a great deal of time; however, they are usually not comatose or in a persistent vegetative state, as defined here . Event ID: Facility ID: 555918 If continuation sheet Page 6 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 observation, interview and record review, the facility failed to ensure a person-centered comprehensive care plan was implemented timely for one of 23 sampled residents (Resident 30) when Resident 30 had a diagnosis of contractures (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and had a physician order for a left hand splint (a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain) with no implementation of a comprehensive care plan. This failure had the potential to result in Resident 30's care needs going unmet. Findings: During a review of Resident 30's face sheet, titled admission Record (document containing resident personal information), undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (unknown cause) neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness), contracture, muscle weakness, and abnormalities of gait (walking) and mobility. During a review of Resident 30's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/17/23, the MDS indicated Resident 30's Brief Interview for Mental Status (BIMSscreening tool used in nursing home to assess cognition) assessment score was 11 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 30 had a moderate cognitive deficit. During an observation on 5/1/23, at 10:45 a.m., in Resident 30's room, Resident 30 was lying in bed, and eating a pudding using her right hand. A hand splint was on her nightstand and a sign on the wall which indicated, Please put my resting hand splint [a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain] on in the morning. Wear schedule up to 8 hours, discontinue splint if she shows any signs of skin breakdown, irritation, or pain and notify OT [Occupational Therapist]. Resident 30 stated, they never put the splint on me. Resident 30 pulled her blanket back and exposed her left hand which was significantly contracted. Resident 30 stated, she had a stroke and was unable to move her fingers. During an observation on 5/2/23, at 11:24 a.m., in Resident 30's room, Resident 30's hand splint was on top of the nightstand. Resident 30 was lying in bed and pulled up her left hand to show she did not have her hand splint on. Resident 30's left hand the thumb was fully contracted into the palm of her hand, the index and second finger were stiff with moderate contractures, the ring finger and pinkie had significant contractures and was unable to straighten any of her fingers. During a concurrent interview and record review on 5/3/23, at 2:15 p.m., with LVN 5, Resident 30's Order Summary Report, (ORS) dated 5/2023 was reviewed. the ORS indicated, .Resident to wear left resting hand splint for 8 hours per day, while awake, as contracture management. Please check for skin impairment and inform COTA (Certified Occupational Therapy Assistant) if changes occur . LVN 5 stated, the ORS was not followed, and nursing staff should have applied Resident 30's hand splint and assessed the skin underneath the splint for skin breakdown. Resident 30's Care Plan, (CP) was reviewed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 7 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 LVN 5 stated, she was unable to find the Care Plan for Resident 30's left hand splint. LVN 5 stated, the CP for Resident 30's left hand splint should have been implemented to address Resident 30's left hand contractures. During a concurrent interview and record review on 5/8/23, at 1:35 p.m., with the DON, Resident 30's physician orders were reviewed. The DON stated, the physician's orders indicated Resident 30's left hand splint to be worn for 8 hours every day. The DON stated, the licensed nurse's responsibility was to ensure Resident 30's hand splint was applied according to physician's order and to assessed for skin breakdown underneath the splint. Resident 30's CP was reviewed. The DON stated, she was unable to find a CP for Resident 30's left hand splint. The DON stated, Resident 30's CP for left hand splint should have been implemented to address Resident 30's left hand contracture. The DON stated, the CP was important to provide individualized care to each resident. During a review of the facility's policy and procedure (P&P), dated 2022, the P&P indicated, . Comprehensive care plans . It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident . That includes measurable objectives and time frames to meet a residents medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment . The care planning process will include an assessment of the resident's strengths and needs . The comprehensive care plan will describe, at a minimum . The services that are to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being . Any services that would otherwise be furnished, but are not provided due to the resident's exercise of his or her right to refuse treatment . Any specialized services or specialized rehabilitation services the nursing facility will provide . Qualified staff responsible for carrying out interventions specified in the care plan will be notified of their roles and responsibilities for carrying out the interventions, initially and when changes are made . The Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 8 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to meet professional standards of quality for two of three sampled residents (Resident 18 and Resident 30) when: Residents Affected - Few 1. Licensed Vocational Nurse (LVN 1) used an unapproved medication administration technique while using an insulin flex pen (a device used to inject insulin [hormone- regulatory substance made by the body to control blood sugar production]) during a medication pass observation. This failure placed Resident 18 at risk for dosing errors and had the potential for adverse side effects such as hypoglycemia (low blood sugar) or hyperglycemia (high blood sugar). 2. License Nurse (LN) failed to perform a change of condition assessment and documentation for Resident 30's complained of burning with urination. This failure had the potential for Resident 30's change of condition not being addressed by the nursing staff which could lead to delayed in treatment and services. Findings: During a medication pass observation on 5/2/23, at 9:27 a.m., in Resident 18's room, LVN 1 administered Glargine (long acting insulin) 15 units (unit of measurement) SQ (subcutaneous - injection given in the fatty tissue, just under the skin) to Resident 18's right side abdomen using an insulin flex pen. LVN 1 did not prime (remove bubbles from the needle) the insulin pen before administering the insulin to Resident 18. During a review of the clinical record for Resident 18, the Face Sheet (a document with demographic, personal and medical information) undated, indicated Resident 18 had a diagnoses which included Type 2 Diabetes (a long-term metabolic disorder that is characterized by high blood sugar levels). The Physician Orders dated 5/23, indicated, Insulin Glargine inject 15 unit .two times a day related to Type 2 diabetes . During a concurrent interview and record review on 5/2/23, at 11:49 a.m., with LVN 1, the manufacturer's guidelines titled, Instructions for Use [Brand name] KwikPen undated indicated, .Read the instructions for use before you start .Prime before each injection .Priming means removing the air from the Needle and Cartridge that may collect during normal use. It is important to prime your Pen before each injection so that it will wok correctly. If you do not prime before each injection, you may get too much or too little insulin .To prime your Pen, turn the Dose Knob to select 2 units. Hold your Pen with the Needle pointing up. Tap the Cartridge Holder gently to collect air bubbles at the top . Continue holding your Pen with Needle pointing up. Push the Dose Knob in until it stops, and 0 is seen in the Dose window . LVN 1 stated, she was not aware of the need to prime the insulin pen prior to administration. LVN 1 stated she was not trained on how to prime the insulin pen upon hire. LVN 1 stated, per the manufacturer guideline the insulin pen should have been primed prior to administering to Resident 18 to ensure Resident 18 received the correct dose. During a telephone interview on 5/2/23, at 12:09 p.m., with the Pharmacist Consultant (PC), PC stated the main purpose of priming the insulin pen was to ensure air bubbles were removed and the residents received the accurate dose. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 9 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 - Few During a concurrent interview and record review on 5/2/23, at 12:48 p.m., with Director of Staff Development (DSD), LVN 1's employee file was reviewed. DSD stated, there was no in-service training or skills check check to ensure LVN 1's competency for insulin pen use. DSD stated, the purpose of priming the insulin pen was to make sure the insulin was administered with the correct dose. During a concurrent interview and record review on 5/2/23, at 3:20 p.m., with Director of Nursing (DON), the facility policy titled, Medication Administration Subcutaneous Insulin dated 1/22 was reviewed. The Medication Administration Subcutaneous Insulin indicated, To administer subcutaneous insulin as ordered and in a safe, accurate and effective manner .Performing the safety test ensures that you get an accurate dose by .removing air bubbles .Check if insulin comes out of the needle tip .If no insulin comes out, the needle may be blocked. Change the needle and try again . DON stated, it was facility policy and the manufacturers guideline to prime the insulin pen prior to administration to ensure the correct dose was administered. DON stated, the facility did not have in-service training or skills check off for insulin pen administration. During a review of the facility Licensed Vocational Nurse job description undated was reviewed. The job description indicated, .Ability to administer medications and treatment timely and according to facility policy . 2. During a review of Resident 30's face sheet titled, admission Record, undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (sudden onset and cause unknown) neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness), contracture (permanent tightening of the muscles, tendons, skin, and nearby tissues that causes deformity of the joints), muscle weakness, abnormalities of gait (walking) and mobility. During a review of Resident 30's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/17/23, the MDS indicated Resident 30's Brief Interview for Mental Status (BIMSscreening tool used in nursing home to assess cognition) assessment score was 11 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 30 had a moderate cognitive deficit. During an interview on 5/3/23, at 9:31 a.m., with Resident 30, Resident 30 stated she had a urinary tract infection (UTI- infection in any part of the urinary system, the kidneys, bladder, or urethra) and had been on an antibiotic (drug used to treat infection caused by bacteria). Resident 30 stated, it was burning and felt hot when I peed. During a record review of Resident 30's urinalysis (UA) titled Lab Results Report, dated 4/17/23, the UA indicated, .Urine Clarity . Turbid [cloudy discolored urine] . Leukoesterase Urine [white blood cells in the urine which can be associated with infection] . 2+ . During a concurrent interview and record review on 5/8/23, at 10:23 a.m., with LVN 2, Resident 30's clinical record titled Progress Notes was reviewed. LVN 2 stated, Resident 30 had a UTI recently and had complained of burning during urination. LVN 2 stated, she was unable to find a documentation of an assessment performed by the license nurse of Resident 30's onset of burning during urination, which was a change in condition. LVN 2 stated, if there is no documentation [of the assessment], it didn't happen. LVN 2 reviewed Resident 30's clinical record titled Alert Note, dated 4/17/23, the alert note indicated, .MD in house seen patient gave new order for UA [Urinalysis (test of the urine to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 10 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 - Few check for infection)] and send results when received also gave new order for [brand name of medication used to treat discomfort of UTI] 100mg PO [by mouth] TID [three times per day] X 3 days . LVN 2 stated, Resident 30's physician was at the facility on 4/17/23 and ordered a UA. LVN 2 stated, even though Resident 30's physician came to the facility; the LN was still responsible to perform an assessment and document the change in condition. LVN 2 stated, the change of condition assessment and documentation were very important for the nursing staff to know when Resident 30's symptoms started, what was the symptoms, and if the symptoms had improved to verify Resident 30's infection had been properly treated. During a concurrent interview, and record review on 5/8/23, at 11:05 a.m., with the DON, Resident 30's clinical record was reviewed. The DON stated, she was unable to find the LN assessment for the change in condition. The DON stated the expectations was for the LN to perform Resident 30's assessment for change in condition which included the onset of burning in urination, urine characteristics, current vital signs, and document the findings as soon as possible. The DON stated even though the physician was in the facility, the LN was still responsible to perform their own assessment. The DON stated, the change of condition assessment was not documented, then it was not done. The DON stated, the LN did not perform the job duties and responsibilities of accurate assessment and documentation for change of condition. During a review of the facility's document titled Job Description Manual . Licensed Vocational Nurse, undated, the job description indicated, .Charge Nurse . Conduct the daily nursing functions in accordance with Company, State, Federal and local rules, regulations and guidelines . Charts progress notes in an informative, factual manner that reflects the care administered as well as the resident's response to care . Follows established procedure for charting and reporting all reports . documents in progress notes any exceptions to residents condition . Accurately completes and is familiar with the forms used throughout the residents chart . Ensures that the progress notes are reflective of the care plan and that the approaches on the care plan are being followed . During a review of the facility's P&P titled, Nursing Services and Sufficient Staff, dated 2022, the P&P indicated, .It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident . The facility must ensure that licensed nurses have the specific competencies and skill sets . Providing care includes . assessing, evaluating, planning and implementing care plans and responding to resident's needs . The Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 11 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 30) received appropriate equipment to prevent further decline in mobility and range of motion when Resident 30 had a diagnosis of contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) and nursing staff failed to apply Resident 30's left hand splint (a device used to support the hand and wrist in best position while resting and to help reduce swelling and pain) according to physician's order. This failure resulted in the potential risk for Resident 30's left hand contracture to worsen, which could lead to further declined in mobility and range of motion, and increased dependence for activities of daily living. Findings: During a review of Resident 30's face sheet titled, admission Record,(AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes) undated, the face sheet indicated Resident 30 was admitted to the facility on [DATE], with diagnoses which included, Hereditary and idiopathic (sudden onset and cause unknown) neuropathy (nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness), contracture, muscle weakness, abnormalities of gait (walking) and mobility. During a review of Resident 30's Minimum Data Set (MDS-a resident assessment tool used to identify resident cognitive [pertaining to reasoning memory and judgement] and physical functional level) assessment, dated 2/17/23, the MDS indicated Resident 30's Brief Interview for Mental Status (BIMSscreening tool used in nursing home to assess cognition) assessment score was 11 out of 15 (0-15 scale [0-6 severe cognitive deficit, 7-12 moderate cognitive deficit, 13-15 no cognitive deficit]) which indicated Resident 30 had a moderate cognitive deficit. During an observation on 5/1/23, at 10:45 a.m., in Resident 30's room, Resident 30 was lying in bed, and eating a pudding using her right hand. A hand splint was on her nightstand and a sign on the wall which indicated, Please put my resting hand splint on in the morning. Wear schedule up to 8 hours, discontinue splint if she shows any signs of skin breakdown, irritation, or pain and notify OT [Occupational Therapist]. Resident 30 stated, they never put the splint on me. Resident 30 pulled her blanket back and exposed her left hand which was significantly contracted. Resident 30 stated, she had a stroke and was unable to move her fingers. During an observation on 5/2/23, at 11:24 a.m., in Resident 30's room, Resident 30's hand splint was on top of the nightstand. Resident 30 was lying in bed and pulled up her left hand to show she did not have her hand splint on. Resident 30's left hand the thumb was fully contracted into the palm of her hand, the index and second finger were stiff with moderate contractures, the ring finger and pinkie had significant contractures and was unable to straighten any of her fingers. During a concurrent observation and interview on 5/3/23, at 9:29 a.m., Resident 30 did not have the hand splint on. Resident 30 stated, some CNAs [Certified Nursing Assistants] don't want to put it on because some CNA 's can't figure it out. Resident 30 stated, the CNAs remember to put her splint (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 12 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few on about twice per week. Resident 30 stated, she wanted to wear the splint because she did not want her hand contractures to get worse. During a concurrent observation and interview on 5/3/23, at 11:20 a.m., with CNA 5, CNA 5 stated, she was the CNA assigned to Resident 30 and was not aware Resident 30 had a splint to her left hand. CNA 5 walked inside Resident 30's room, looked at the sign above the nightstand and stated, which indicated Please put my resting hand splint on in the morning. Wear schedule up to 8 hours, discontinue splint if she shows any signs of skin breakdown, irritation, or pain and notify OT CNA 5 stated, I have never seen that sign before. CNA 5 looked through the nightstand drawers and took the hand splint out of the second drawer. CNA 5 attempted to put the splint on Resident 30's left hand but was unable to figure out how to put it on correctly. CNA 5 stated, I have never put that [hand splint] on her before. During an interview on 5/3/23, at 11:35 a.m., with Licensed Vocational Nurse (LVN) 5, LVN 5 stated resident 30 was supposed to wear the splint 5 days per week. LVN 5 stated there was a note on Resident 30's wall from therapy to remind the staff to apply the splint on Resident 30's left hand in the morning. During a concurrent interview and record review on 5/3/23, at 2:15 p.m., with LVN 5, Resident 30's physician orders titled Order Summary Report, dated 5/2023 were reviewed. Resident 30's physician orders indicated, .Resident to wear left resting hand splint for 8 hours per day, while awake, as contracture management. please check for skin impairment and inform COTA [Certified Occupational Therapy Assistant] if changes occur . LVN 5 stated, the physician order for Resident 30's hand splint to be worn for 8 hours daily was started on 2/28/23 and nursing staff did not apply the hand splint to Resident 30's left hand according to physician's order. During a concurrent interview and record review on 5/3/23, at 2:20 p.m., with the Director of Nursing (DON), Resident 30's Medication Administration Record (MAR) and Treatment Administration Record (TAR) was reviewed. The DON was not able to find documentation of Resident 30's hand splint application and monitoring. The DON stated, Resident 30's hand splint application and monitoring should be documented in the MAR and TAR. During a concurrent interview and record review on 5/4/23, at 10:06 a.m., with the Director of Rehabilitation Services (DOR), the DOR stated Resident 30 was supposed to wear a left-hand splint three to five times per week to prevent Resident 30's hand contracture from worsening which could lead to decreased mobility. Resident 30's physician orders were reviewed. The DOR stated, the physician's orders indicated Resident 30's left hand splint to be worn for 8 hours every day and was not followed. During a concurrent interview and record review on 5/8/23, at 1:35 p.m., with the DON, Resident 30's physician orders were reviewed. The DON stated, the physician's orders indicated Resident 30's left hand splint to be worn for 8 hours every day. The DON stated, the licensed nurse's responsibility was to ensure Resident 30's hand splint was applied according to physician's order and to assessed for skin breakdown underneath the splint. The DON stated Resident 30 had a history of a stroke (interruption of blood flow to the brain causing damage to brain tissue) and had contractures to the left hand and fingers. The DON stated, the physician's order for Resident 30's hand splint was not followed. The DON stated, it was important to follow the physician's orders for Resident 30's hand splint to prevent Resident 30's hand contractures from worsening which could lead to decreased in range of motion. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 13 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0688 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of the facility's policy and procedure (P&P) titled Provision of Physician Ordered Services, dated 10/2022, the P&P indicated, .The purpose of this policy is to provide a reliable process for the proper and consistent provision of physician ordered services according to professional standards of quality . Professional Standards of Quality means that care and services are provided according to accepted standards of clinical practice. Standards may apply to care provided by a particular clinical discipline of in a specific clinical situation or setting . The Lippincott Manual of Nursing Practice 10th Edition, dated 2014, page 16-17 indicated, Standards of practice General Principles . 1. The practice of professional nursing has standards of practice setting minimum levels of acceptable performance for which its practitioners are accountable .b. These standards provide patients with a means of measuring the quality of care they receive .5. A deviation from the protocol should be documented in the patient's chart with clear, concise statements of the nurse's decisions, actions, and reasons for the care provided, including any apparent deviation . Legal claims most commonly made against professional nurses include the following departures from appropriate care: failure to assess the patient properly or in a timely fashion, follow physician orders, follow appropriate nursing measures, communicate information about the patient, adhere to facility policy or procedure, document appropriate information in the medical record . Failure to formulate or follow the nursing care plan . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 14 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 drugs and biologicals (a substance such as vaccines or drugs derived from a living organism used for treatment) were labeled in accordance with accepted professional standards of practice for five of 23 sampled residents (Resident 1, Resident 5, Resident 15, Resident 18 and Resident 21) when: 1. Resident 5's linaclotide (a medication used to treat irritable bowel syndrome [an intestinal disorder causing pain in the belly, gas, diarrhea, and constipation] with constipation) with an expired date of 1/23/23 was stored in Medication Cart 1 ready for residents used. 2. Resident 15's insulin glargine open date and use by date was incomplete and did not indicate the year. Resident 15's medication Phenylephrine-Cocoa Butter (a medication used to temporarily relieve swelling burning, pain and itching caused by hemorrhoids [a swollen vein or group of veins in the region of the anus]) with an expired date of 4/23/23 was stored in Medication Cart 1 ready for residents used. These failure had the potential for Resident 5 and Resident 15 to receive expired medications which could lead to compromised therapeutic effectiveness and adverse reactions from expired medications. 3. Resident 1's and Resident 18's opened insulin glargine (a medication used to control the amount of glucose in the blood of persons with diabetes [a disease characterized by elevated blood sugar]) with no use by date (the last date recommended for the use of the product while at peak quality) was stored in Medication Cart 2 ready for residents use. This failure placed Resident 1 and Resident 18 at risk to receive insulin which had lost potency and not at its maximum efficacy which could lead to ineffective control of blood sugar. 4. Resident 21's fluticasone propionate/salmeterol (a medication used to treat difficulty breathing, wheezing, shortness of breath, coughing, and chest tightness caused by asthma (a disease that affects the lungs) with an expired date of 4/27/23 was stored in Medication cart 2 ready for residents use. This failure had the potential for Resident 21 to receive expired medications which could lead to compromised therapeutic effectiveness and adverse reactions from expired medications. Findings: 1. During a concurrent observation and interview on 5/2/23, at 10:02 a.m., with Licensed Vocational Nurse (LVN) 6, in the hallway, Resident 5's linaclotide with an expiration date of 1/23/23 was stored in Medication cart 1 ready for residents use. LVN 6 stated, Resident 5's linaclotide was expired on 1/23/23 and should have been removed from the medication and disposed. LVN 6 stated, the process at the facility was to discard expired medications to prevent the administration of expired and ineffective medications. During a review of Resident 5's admission Record (AR- is a document that gives a patient's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 15 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes) dated 5/2/23, the AR indicated Resident 5 had a of diagnoses of constipation. During a review of Resident 5's Order Summary Report (OSR- Physician orders) dated 5/2/23, the OSR indicated Resident 5 had no active physician's order for linaclotide. 2. During a concurrent observation and interview on 5/2/23, at 10:08 a.m., with Licensed Vocational Nurse (LVN) 6, in the hallway, Resident 15's Phenylephrine-Cocoa Butter with an expiration date of 4/23/23 was stored in Medication cart 1 ready for residents use. LVN 6 stated, Resident 15's medication Phenylephrine-Cocoa Butter was expired should have been removed from the medication cart and disposed. Resident 15's insulin glargine stored in Medication cart 1 had an open date of 4/24 and a use by date of 5/22 without an indicated year. LVN 6 stated, the process at the facility was to date the medications with the month, day and year once open. LVN 6 stated, Resident 15's insulin glargine did not indicate a year on the open and use by date. LVN 6 stated, it was important to document the month, day and year to know when to dispose the medication and to prevent the administration of expired and less effective medication. During a review of Resident 15's AR, dated 5/2/23, the AR indicated Resident 15 had a diagnoses which includes Type 2 Diabetes Mellitus (a disease characterized by an elevated blood sugar level) and constipation. During a review of Resident 15's OSR dated 5/2/23, the OSR indicated Resident 15 had medication physician orders for .100 UNIT/ML (Insulin Glargine) Inject 25 unit subcutaneously at bedtime related to TYPE 2 DIABETES MELLITUS . and . (Phenylephrine-Cocoa Butter) Insert 1 suppository rectally as needed for Hemorrhoids . 3. During a concurrent observation and interview on 5/2/23, at 10:37 a.m., with LVN 1, in the hallway, Resident 1's insulin glargine had an open date of 4/27/23 and without a use by date and Resident 18's insulin glargine had an open date of 4/27/23 and without a use by date was stored in Medication cart 2 ready for residents used. LVN 1 stated Resident 1's and Resident 18's insulin glargine should have a use by date. LVN 1 stated, the process at the facility was to document an open date and a used by date once the medications was opened. LVN 1 stated, it was the responsibility of the license nurse who opened the insulin to document the open and use by date. During a review of Resident 1's AR, dated 5/2/23, the AR indicated, Resident 1 had a diagnosis of Type 2 Diabetes Mellitus. During a review of Resident 1's OSR, dated 5/2/23, the OSR indicated, Resident 1 had a medication order for .100/UNIT/ML [milliliter] (Insulin Glargine) Inject 18 unit subcutaneously [applied under the skin] one time a day related to TYPE 2 DIABETES MELLITUS . During a review of Resident 18's AR dated 5/2/23, the AR indicated, Resident 18 had a diagnosis of Type 2 Diabetes Mellitus. During a review of Resident 18's OSR, dated 5/2/23, the OSR Indicated Resident 18 had a medication order for .100/UNIT/ML (Insulin Glargine) Inject 15 unit subcutaneously two times a day related to TYPE 2 DIABETES MELLITUS . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 16 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 4. During a concurrent observation and interview on 5/2/23, at 10:45 a.m., with LVN 1, in the hallway, Resident 21's fluticasone propionate/salmeterol had an open date of 3/28/23, without a use by date and was stored in Medication cart 2 ready for residents use. LVN 1 stated, Resident 21's fluticasone propionate/salmeterol should be disposed after 30 days from the time it was opened. LVN 1 stated, the fluticasone propionate/salmeterol use by date was 4/27/23 and should have been disposed to prevent license nurse from administering expired and ineffective medications to Resident 21. During a review of Resident 21's AR, dated 5/2/23, the AR indicated, Resident 21 had a diagnoses of Respiratory Failure (a serious condition that makes it difficult to breathe on your own) and Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing) During a review of Resident 21's OSR, dated 5/2/23, the OSR indicated Resident 21 had a medication order for .100-50 [Microgram]/DOSE (fluticasone-Salmeterol) 1 inhalation inhale orally two times a day related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE . During an interview on 5/4/23, at 11:12 a.m., with the Director of Nursing (DON), the DON stated, the process for labeling medications at the facility was for the LNs' to document the open date and use by date, so the LNs' would know when to dispose the medications. The DON stated the process at the facility was to destroy expired medications. The DON stated expired medications should not be in the Medication carts. The DON stated it was important to disposed expired medications to prevent LNs' from administering expired medications to residents. The DON stated expired medications administered to residents had the potential to lose its therapeutic efficacy which could lead to lack of treatment of symptoms for which the drug was prescribed. During a review of Medication Storage, dated 1/2021, the Medication Storage indicated, .Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration . Insulin products . Note the date on the label for insulin vials and pens when first used . Outdated, contaminated, discontinued or deteriorated medications . are immediately removed from stock, disposed of according to procedures for medication disposal . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 17 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on observation, interview and record review, the facility failed to ensure food service staff were able to carry out the functions of the food and nutrition service safely and effectively when Kitchen staff (CKA 1, CKA 2, and KA 1) did not air dry bowls and cups prior to storage, did not label opened food products with use by date, did not place a drip pan on thawed uncooked frozen meat inside the refrigerator, and did not perform appropriate glove use in the kitchen. Failure to have staff with the appropriate competencies and skill sets to carry out the functions of food and nutrition services can result in foodborne illnesses from cross contamination or the growth of microorganisms for the 44 residents eating food prepared in the facility. (Cross Reference F812) Findings: During a concurrent observation on 5/1/23, at 9:15 a.m., inside the kitchen, with Cook/Kitchen Aide (CKA), CKA 1 placed a tray of wet bowls inside the cabinet. CKA 1 lifted the bowls and water dripped from the bowls, and stated, the bowls were wet. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the kitchen with Kitchen Aide (KA) 1, opened and unsealed box of cereal was stored in the dry food storage room without an open date and a use by date. KA 1 stated, the opened cereal should have been sealed to prevent insects and bugs from entering the cereal container and have a use by date. During a concurrent observation and interview on 5/1/23, at 10:05 a.m., in the kitchen with CKA 1, uncooked frozen chicken thighs inside a cardboard box were thawed on the bottom of the refrigerator without a drip pan underneath. CKA 1 stated, there was no room in the freezer, so she placed the uncooked frozen chicken thighs inside the refrigerator. CKA 1 stated, the uncooked chicken thighs should have been placed in a pan, but she had no time to placed them in the pan. During a concurrent interview and record review on 5/1/23, at 10:10 a.m., inside the kitchen, with CKA 1, CKA 1 stacked wet cups inside cabinet. CKA 1 stated, the cups were wet. During a concurrent interview and record review on 5/1/23, at 3:07 p.m., with the Resgistered Dietitian (RD), the RD reviewed Nutrition Services Monthly Sanitation Report (NSMSR), dated 4/28/23, the RD stated, the NSMSR of the kitchen did not include checking for dishware stored wet. During an interview on 5/1/23, at 3:21 p.m., the RD stated, the opened cereal should have been sealed to prevent bugs from entering the cereal container and have a use by date. The RD stated, the opened and unsealed cereal placed residents at high risk for cross contamination which could lead to foodborne illness. The RD stated, food items should not be placed inside a cardboard box and stored in the refrigerator to prevent cross contamination which could lead to foodborne illness. During a concurrent observation and interview on 5/2/23, at 10:57 a.m., CKA 1 handled the recipe binder with a gloved hand and immediately handled food serving scoop without removing his gloves, performing hand hygiene, and putting on new gloves. CKA 1 stated, after handling the recipe binder she should have removed her gloves, performed hand hygiene, put on new gloves before handling the food serving scoop to prevent cross contamination. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 18 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0802 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many During a concurrent observation and interview on 5/2/23, at 11:23 a.m., with CK 2, in the kitchen, CKA 2 was making pudding without the use of gloves. CKA 2 stated, she should have worn gloves when preparing food. During a concurrent interview and record review on 5/3/23, at 10:44 a.m., with the Administrator (ADM), CKA 1, CKA 2, and KA 1 Employee File (EF) was reviewed. the ADM stated, CKA 1, CKA 2, and KA 1 did not have competencies for food safety handling. The ADM stated, . if that's what needs to be corrected, then that's what needs to be corrected . During a concurrent interview and record review on 5/4/23, at 1:45 p.m., with the Certfiied Dietary Manager (CDM), CKA 1's EF was reviewed. The CDM stated, there was no kitchen orientation for food safety handling documented for CKA 1. During a concurrent interview and record review on 5/4/23, at 1:47 p.m., with the CDM, KA 1's EF was reviewed. The CDM stated, there was no kitchen orientation for food safety handling documented for KA 1. According to the Food and Drug Administration (FDA) Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining . before contact with food. During a review of a professional reference, titled Can you stack wet dishes after you washed them?, dated 12/7/22, retrieved from https://mydelicioussweets.com/can-you-stack-wet-dishes-after-you-washed-them/, indicated, . It is not good practice to store wet dishes, as remaining moisture will promote the growth of microorganisms on the surface of the items and in kitchen cabinets . Review of a Food Service In-service titled Labeling and Dating Food Products dated 7/30/2019 showed It is important to label ALL items in your kitchen with product name, received date, and open date. It is important to label and date, as it: Prevents food-borne illness caused from spoiled foods Prevents wasting of food .Prevents staff from using the wrong ingredient. All items must be labeled with the food product name. Dates should include the month, day and year. Count the day the product was opened or made as day 1. During a review of a professional reference, titled State Operations Manual (SOM), dated 2/3/23, the SOM indicated, . Safe Food Preparation . to reduce cross-contamination . Store raw meat separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the refrigerator . methods to safely thaw frozen foods . During a review of a professional reference, titled, Are cardboard boxes bad for food safety in the kitchen?, dated 2023, retrieved from https://hygienefoodsafety.org/why-are-cardboard-boxes-bad-for-food-safety-in-the-kitchen/, indicated, . cardboard boxes in food safety .are not safe for usage and for storage of foods in a kitchen . boxes come in contact with areas that are dirty . the kitchen does not know how and in what conditions the boxes were kept . Pests have been known to lay eggs in the corrugated areas of boxes (spaces between the boards meant for insulation) . Harmful bacteria are able to survive on wet cardboard which encourages cross-contamination . During a review of a professional reference, titled State Operations Manual (SOM), dated 2/3/23, the SOM indicated, . Safe Food Preparation . to reduce cross-contamination . Store raw meat separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 19 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0802 refrigerator . methods to safely thaw frozen foods . Level of Harm - Minimal harm or potential for actual harm During a review of a professional reference, the SOM, the SOM indicated, . Employees should never use bare hand contact with any foods . the skin carries microorganisms, it is critical that staff involved in food preparation, distribution and serving consistently utilize good hygiene practices . gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded between and after each use . Hands must be washed before putting on gloves and after removing gloves . Residents Affected - Many According to the 2017 Food and Drug Administration (FDA) Food Code, Section 2-301.14 states: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .After touching bare human body parts other than clean hands and clean, exposed portions of arms; . During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .Before donning gloves to initiate a task that involves working with food; .and after engaging in other activities that contaminate the hands. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 20 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 review, the facility failed to ensure professional standards for food safety guidelines were followed when, Residents Affected - Many 1. Cake stored inside the kitchen refrigerator was not fully covered and placed on top of a torn cardboard boxes with moisture stains. 2. Cheese slices and whipped cream were placed inside unsealed plastic bags stored inside the kitchen refrigerator. 3. Wet bowls and cups were stacked and stored inside the cabinet. 4. Cooking spices were stored unsealed and in containers with debris. 5. Opened bag of frozen sausage patties was in the freezer without an opened date. 6. Five meal tray carts were stored in the kitchen storage room with 44 uncovered meal trays, and a bag of plastic forks placed on the top of a plate, more than two hours before meal service. 7. The kitchen backdoor was fully open without a closed-door screen during food preparation. 8. Uncooked frozen chicken thighs inside a cardboard box was thawed in the bottom of the refrigerator without a drip pan (a pan placed underneath thawed frozen food to catch the drippings and prevent food contamination) underneath. 9. Opened and unsealed box of cereal was stored in the dry food storage room without an open date and a use by date. 10. Glue traps were found with dust, debris, and a dead cockroach on the dry food storeroom. 11. The floors and baseboards in the kitchen, kitchen storage room, and dry food storage room had chips, cracks, and gaps with debris. 12. Cleaning chemicals were stored on the kitchen floor next to food preparation sink. 13. Kitchen Aide (KA) 1's personal backpack was stored on the floor in kitchen storage room. 14. The Kitchen walls and windowsills had peeled paint and windowsills had dead insects, dust and debris above the food preparation sink, dish washing, and dish drying areas. 15. The foot pedal on the kitchen waste bin was broken and required staff to use their hands to open. 16. The gas line to stove had a gray- green substance. 17. Kitchen Cooks did not demonstrate proper glove use and hand hygiene. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 21 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population of 44 residents who consumed food prepared in the kitchen. Findings: 1. During an observation on 5/1/23, at 9:12 a.m. in the kitchen, a cake stored inside the refrigerator was partially covered with foil and was placed on top of torn cardboard boxes with moisture stains. During a concurrent interview and record review on 5/1/23, at 3:04 p.m., with the Registered Dietitian (RD), photos taken on 5/1/23 of partially covered cake and cardboard boxes stored inside the kitchen refrigerator were reviewed. The RD stated, the cake should have been completely covered, and cardboard boxes should not be stored inside the refrigerator to prevent bug infestation and cross-contamination of food. During a review of a professional reference, titled, Are cardboard boxes bad for food safety in the kitchen?, dated 2023, retrieved from https://hygienefoodsafety.org/why-are-cardboard-boxes-bad-for-food-safety-in-the-kitchen/, indicated, . cardboard boxes in food safety .are not safe for usage and for storage of foods in a kitchen . boxes come in contact with areas that are dirty . the kitchen does not know how and in what conditions the boxes were kept . Pests have been known to lay eggs in the corrugated areas of boxes (spaces between the boards meant for insulation) . Harmful bacteria are able to survive on wet cardboard which encourages cross-contamination . 2. During an observation on 5/1/23, at 9:13 a.m., in the kitchen, cheese slices and whipped cream were placed inside unsealed plastic bags stored inside the refrigerator. During a concurrent interview and record review on 5/1/23, at 3:05 p.m., with the RD, photos taken on 5/1/23 of cheese slices and whipped cream placed inside unsealed plastic bag were reviewed. The RD stated, the plastic bags containing food items should have been resealed every time it was used. During a concurrent interview and record review on 5/1/23, at 5:47 p.m., with the Administrator (ADM), the photos taken 5/1/23 of cheese slices and whipped cream stored inside unsealed plastic bags were reviewed. The ADM stated, the plastic bags should have been properly sealed to maintain food quality and to prevent from drying out. During a review of Dietary In- Service (DIS), dated 5/1/23, indicated a 1:1 in-service was presented by the RD. The DIS indicate the subject of the in-service was . Food must be properly sealed when stored. Use Gallon storage bags, label & seal completely. Boxes will be eliminated as much as possible when storing food in refrigerator . During a review of a professional reference, titled Toss it? Top tips for keeping food fresh and safe, dated 2023, retrieved from https://www.today.com/food/toss-it-top-tips-keeping-food-fresh-safe-wbna17472632, indicated, . Never put uncovered foods in your refrigerator . you cannot see, taste or smell bacteria until it's too late and can cause serious food illnesses . 3. During a concurrent observation on 5/1/23, at 9:15 a.m., inside the kitchen, with Cook/Kitchen Aide (CKA), CKA 1 placed a tray of wet bowls inside the cabinet. CKA 1 lifted the bowls and water dripped from the bowls, and stated, the bowls were wet. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 22 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 concurrent interview and record review on 5/1/23, at 10:10 a.m., inside the kitchen, with CKA 1, CKA 1 stacked wet cups inside cabinet. CKA 1 stated, the cups were wet. During a concurrent interview and record review on 5/1/23, at 3:07 p.m., with the RD, the RD reviewed Nutrition Services Monthly Sanitation Report (NSMSR), dated 4/28/23, the RD stated, the NSMSR of the kitchen did not include checking for dishware stored wet. According to the Food and Drug Administration (FDA) Food Code 2017, Section 4-901.11 Equipment and Utensils, Air-Drying Required, After cleaning and sanitizing, equipment and utensils: (A) Shall be air-dried or used after adequate draining . before contact with food. During a review of a professional reference, titled Can you stack wet dishes after you washed them?, dated 12/7/22, retrieved from https://mydelicioussweets.com/can-you-stack-wet-dishes-after-you-washed-them/, indicated, . It is not good practice to store wet dishes, as remaining moisture will promote the growth of microorganisms on the surface of the items and in kitchen cabinets . 4. During an observation on 5/1/23, at 9:13 a.m., in the kitchen, six spice containers were unsealed with debris on the containers. During a concurrent interview and record review on 5/1/23, at 5:20 p.m., with the RD, photos taken on 5/1/23 of spices stores in unsealed containers with visible debris and the NSMSRs, the NSMSR dated 3/27/23 and 4/28/23, were reviewed. The RD stated, both NSMSRs indicated, the spice containers were not sealed and clean. The RD stated, the NSMSRs was sent to the Certified Dietary Manager (CDM) and the ADM but had not discussed the issue with the CDM. The RD stated, the unsealed and dirty spice containers was not addressed by the CDM. The RD stated, the expectations was for the CDM to addressed the issues once it was brought up to her attention. The RD stated, if the issues continued for more than two months, she would escalate the issue to the ADM. The RD stated she had not escalated the issue to the ADM. During a concurrent interview and record review on 5/1/23, at 5:48 p.m., with the ADM, the NSMSRs, dated 3/27/23 and 4/28/23, were reviewed. The ADM stated, he expected the RD and CDM to notify him for continued issues in the kitchen. The ADM stated, the RD and the CDM did not notify him, and perform intervention to address the issues identified on the NSMRS. The ADM stated, residents' immune systems were vulnerable and at risk for foodborne illnesses when kitchens are not kept clean and sanitary. During a concurrent interview and record review on 5/4/23, at1:50 p.m., with the CDM, the NSMSRs, dated 10/26/22, 11/30/22, 1/30/23, 3/27/23, and 4/28/23 were reviewed. The CDM stated, all the NSMSRs indicated, the spice containers were unsealed and not clean. 5. During a concurrent observation and interview on 5/1/23, at 10:20 p.m., in the kitchen with CKA 1, opened sausage patties were in the freezer without an open date and a used by date. CKA 1 stated the patties should have an opened date and a use by date to show when they should be used. During an interview on 5/1/23, at 3:10 p.m., with the RD, the RD stated open frozen foods needed to have a use by date on the package. During a review of a professional reference, titled How long does food last in the freezer?, dated 5/4/19, retrieved from (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 23 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 https://www.highspeedtraining.co.uk/hub/how-long-can-you-store-frozen-food-for/#:~:text=Food%20can%20remain%20froz indicated, . over time all frozen food will deteriorate in quality . keep frozen cooked meat for no longer than three to six months . 6. During a concurrent observation and interview on 5/1/23, at 10:00 a.m., with KA 1, in the kitchen, two meal carts were stored next to the kitchen stove and three meal carts were stored in the kitchen storage room. Each of the five meal carts had 44 meal trays. The meal trays did not have a cover and plastic forks had fallen on top of the meal trays. KA 1 stated, the meal trays were always stored in the meal cart two hours or more prior to meal service. During a review of Meal Service Times (MST), (undated), the MST indicated, breakfast was served from 7:00 a.m. to 7:15 a.m. and lunch was served from 12:00 p.m. and 12:15 p.m. During a concurrent interview and record review on 5/1/23, at 3:22 p.m., with the RD, the RD reviewed the photos taken on 5/1/23, at 10 a.m. of meal trays inside the meal carts. The RD stated meal trays prepared and placed on meal carts two hours or more prior to meal service was not the proper way. During a review of Dietary In- Service (DIS), dated 5/1/23, indicated a 1:1 in-service was presented by the RD. The DIS indicate the subject of the meeting was . Plates will not be placed on residents [sic] tray uncovered. Plates will be covered by lid or placed on base no earlier than 30 minutes before trayline [meal service] begins . 7. During an observation on 5/1/23, at 9:30 a.m., in the kitchen, the kitchen back door was fully opened, without a closed-door screen during food preparation. During an interview on 5/1/23, at 4:18 p.m., the RD stated, the kitchen back door should not be opened and should be closed during food preparation. During an interview on 5/1/23, at 5:55 p.m., the ADM stated, the kitchen back door should not be opened and should be closed to prevent pest from entering the kitchen which could lead to foodborne illness to residents. 8. During a concurrent observation and interview on 5/1/23, at 10:05 a.m., in the kitchen with CKA 1, uncooked frozen chicken thighs inside a cardboard box were thawed on the bottom of the refrigerator without a drip pan underneath. CKA 1 stated, there was no room in the freezer, so she placed the uncooked frozen chicken thighs inside the refrigerator. CKA 1 stated, the uncooked chicken thighs should have been placed in a pan, but she had no time to placed them in the pan. During an interview on 5/1/23, at 3:20 p.m., the RD stated, food items should not be placed inside a cardboard box and stored in the refrigerator to prevent cross contamination which could lead to foodborne illness. During a review of a professional reference, titled State Operations Manual (SOM), dated 2/3/23, the SOM indicated, . Safe Food Preparation . to reduce cross-contamination . Store raw meat separately and in drip-proof containers and in a manner that prevents cross-contamination of other food in the refrigerator . methods to safely thaw frozen foods . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 24 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 9. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the kitchen with KA 1, an opened and unsealed box of cereal was stored in the dry food storage room without an open date and a use by date. KA 1 stated, the opened cereal should have been sealed to prevent insects and bugs from entering the cereal container and have a use by date. During an interview on 5/1/23, at 3:21 p.m., the RD stated, the opened cereal should have been sealed to prevent bugs from entering the cereal container and have a use by date. The RD stated, the opened and unsealed cereal placed residents at high risk for cross contamination which could lead to foodborne illness. Review of a Food Service In-service titled Labeling and Dating Food Products dated 7/30/2019 showed It is important to label ALL items in your kitchen with product name, received date, and open date. It is important to label and date, as it: Prevents food-borne illness caused from spoiled foods Prevents wasting of food .Prevents staff from using the wrong ingredient. All items must be labeled with the food product name. Dates should include the month, day and year. Count the day the product was opened or made as day 1. 10. During a concurrent observation and interview on 5/1/23, at 9:53 a.m., with KA 1, in the dry food storage room, glue traps (a trap that uses glue, adhesive material as the mode of capture to trap rodents and insects) were found with a dead cockroach and dust debris. KA 1 stated, it was the first time she saw the glue trap with a dead cockroach. KA 1 stated, the glue trap with a dead cockroach should have been removed to prevent food contamination. During a concurrent interview and record review on 5/1/23, at 5:56 p.m. with the ADM, the photos taken 5/1/23, of glues traps with a dead cockroach and dust debris in the dry food storage room were reviewed. The ADM stated the expectation was for the kitchen and food storage areas to be free of pests and insects. 11. During an observation on 5/1/23, at 9:56, the linoleum floor (a water-resistant floor covering) in the kitchen, next to the back door had chips and cracks in multiple places with debris in between the cracks. During an observation on 5/1/23, at 9:50 a.m., in dry food storage room, the linoleum floor had cracks and gaps between baseboards and the gaps contained debris. During an observation on 5/1/23, at 9:59 a.m., in the kitchen storage room, the linoleum floor had large chips which shows the concrete underneath. The baseboard was separated from the wall with visible brown stains behind baseboard. During an interview on 5/1/23, at 3:24 p.m., with the RD, the RD stated, the kitchen floors have been in disrepair since she had been working in the kitchen. The RD stated, intact floors were important to prevent dirt and bugs collecting in the cracks and gaps which can cause cross-contamination. The RD stated, residents are at high risk for foodborne illnesses caused by cross-contamination. 12. During a concurrent observation and interview on 5/1/23, at 10:08 a.m., with KA 1, in the kitchen, cleaning chemical supplies were stored on the floor next to the food preparation sink. KA 1 stated, the cleaning chemicals are always stored on the floor next to the sink. During the review of a professional reference, titled State Operations Manual, dated 2/3/23, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 25 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 indicated, . Chemical Contamination . cleaning products and supplies, must be clearly marked as such and stored separately from food items . 13. During a concurrent observation and interview on 5/1/23, at 10:10 a.m., with KA 1, in the kitchen, KA 1's personal backpack was stored on the floor next to the refrigerator. KA 1 stated, she was not provided a locker to store her personal belongings. During an interview on 5/1/23, at 3:05 p.m., with the RD, the RD stated, kitchen staff should not store personal belongings on the kitchen floor and should have designated place to store personal belongings away from food and kitchen equipment to prevent cross contamination. 14. During an observation on 5/1/23, at 9:57 a.m., the windowsills above the food preparation sink, and behind the dishwasher had chipped paint, dust, and dead insects. During an observation on 5/1/23, at 10:22 a.m., in the kitchen, the kitchen wall and dish drying area backsplash had black debris. During a concurrent interview and record review on 5/1/23, at 5:25 p.m., with the RD, the RD reviewed the photos of kitchen walls and windowsills taken on 5/1/23 with peeled paint, dust, debris, and dead insects. The RD stated, she did a kitchen sanitation audit to make sure the staff were following policy and procedure and ensure the kitchen was sanitary. The RD declined to answer if kitchen was sanitary. During a concurrent interview and record review on 5/1/23, at 5:57 p.m. the ADM, the ADM reviewed the picture of the kitchen taken on 5/1/23 with peeled paint, dust, debris, and dead insects. The ADM stated, . I have seen enough. With the pics as presented, I would say the kitchen is not sanitary . During a concurrent observation and interview on 5/2/23, at 9:33 a.m., with the CDM, the CDM stated, the black debris on the wall and back splash were caused by the cleaning squeegee (a tool use to remove or control liquids across surfaces). The CDM demonstrated how the squeegee left black marks on his hand. During a concurrent observation and interview on 5/2/23, at 9:35 a.m., the CDM stated, the kitchen was deep cleaned every week and once a month. The CDM stated, the kitchen window above food preparation sink had dirt and dust. The CDM stated, when the window was wiped with a paper towel, a dust ball fell into sink. The CDM stated, the window was not where food was prepared and the dust . only fell in the sink because you [surveyor] wiped it off . the CDM declined to answer if the kitchen was sanitary. During a review of Dietary In- Service (DIS), dated 5/1/23, indicated a 1:1 in-service was presented by the RD. The DIS indicate the subject of the meeting was . Cleanliness of kitchen- Make sure your work area is clean & sanitized at end of each shift worked. Make sure to complete weekly & monthly cleaning schedule . 15. During a concurrent observation and interview on 5/2/23, at 9:33 a.m., the foot pedal on the waste bin was broken and the lid failed to open. The CDM attempted to open the waste bin by stepping on the foot pedal and failed to open the waste bin. The CDM stated, the waste bin foot pedal was broken. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 26 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 During an interview on 5/2/23, at 10:22 a.m., CKA 1 stated, the foot pedal on the waste bin was broken one or two weeks ago. CKA 1 stated, the kitchen staff had to use their hands or arms to open the waste bin. 16. During an observation on 5/2/23, at 12:21 p.m., the gas line to the stove next to the meal tray carts storage area had a green-gray substance. Residents Affected - Many During a concurrent interview and record review on 5/4/23, at 1:43 p.m., with the CDM, the CDM reviewed photos taken on 5/2/23 of the gas line to the stove with green-gray substance. The CDM stated he did not know what the green-gray substance on the gas line was. 17. During a concurrent observation and interview on 5/2/23, at 10:57 a.m., CKA 1 handled the recipe binder with a gloved hand and immediately handled food serving scoop without removing his gloves, performing hand hygiene, and putting on new gloves. CKA 1 stated, after handling the recipe binder she should have removed her gloves, performed hand hygiene, put on new gloves before handling the food serving scoop to prevent cross contamination. During a concurrent observation and interview on 5/2/23, at 11:23 a.m., with CK 2, in the kitchen, CKA 2 was making pudding without the use of gloves. CKA 2 stated, she should have worn gloves when preparing food. According to the 2017 Food and Drug Administration (FDA) Food Code, Section 2-301.14 states: Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles and: .After touching bare human body parts other than clean hands and clean, exposed portions of arms; . During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .Before donning gloves to initiate a task that involves working with food; .and after engaging in other activities that contaminate the hands. During a review of a professional reference, the SOM, the SOM indicated, . Employees should never use bare hand contact with any foods . the skin carries microorganisms, it is critical that staff involved in food preparation, distribution and serving consistently utilize good hygiene practices . gloved hands are considered a food contact surface that can get contaminated or soiled. Disposable gloves are a single use item and should be discarded between and after each use . Hands must be washed before putting on gloves and after removing gloves . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 27 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 - Few 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, accurately documented in accordance with accepted professional standards of practice for one of eight sampled residents (Resident 26) when Resident 26's Physician Order for Life Sustaining Treatment (POLST-a specific medical orders for resident treatment and wishes in the case of a medical emergency) for Do Not Resuscitate (DNR- is a medical order written by a doctor which instructs health care providers not to do resuscitation [the action of reviving someone from unconsciousness or apparent death] if a patient's breathing stops or if the patient's heart stops beating) was not signed. This failure had the potential risk for Resident 26's decisions regarding his healthcare and treatment options not being honored. Findings: During a review of Resident 26's admission Record (AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated [DATE], the AR indicated Resident 26 was admitted on [DATE] with diagnoses of Schizophrenia (a disorder that affects a person's ability to think, feel and behave clearly) , Major Depressive Disorder (a mental condition characterized by a persistently depressed mood and long-term loss of pleasure or interest in life), and Dysphagia (difficulty swallowing) following Cerebrovascular Disease (a group of conditions that affect blood flow and the vessels in the brain). During a review of Resident 26's Minimum Data Set (MDS- a standardized assessment and for facilitating care management in a nursing home) C, dated [DATE], the MDS indicated, Resident 26 had a Brief Interview for Mental Status (BIMS-assessment of cognitive status for memory and judgement) assessment score of 11 (a score of 13-15 indicates cognitively intact, 8-12 indicates moderate impairment, and 0-7 indicates sever impairment) indicating Resident 26 had moderate impairment. During a review of Resident 26's Order Summary Report (OSR), dated [DATE], the OSR indicated, Resident 26 had an order for DNR/Comfort Care. During a concurrent interview and record review, on [DATE] at 3:51 p.m., with the Director of Staff Development (DSD) Resident 26's POLST, dated [DATE] was reviewed. The POLST indicated, . (CPR Cardiopulmonary Resuscitation a medical technique for reviving someone whose heart has stopped beating by pressing on their chest and breathing into their mouth): If patient has no pulse and is not breathing, if patient is NOT in cardiopulmonary arrest, follow orders . [checked box] Do Not Attempt Resuscitation/DNR (Allow Natural Death) . INFORMATION AND SIGNATURES: .Signature of Patient or Legally Recognized Decisionmaker . Print Name: [blank area] . Signature: (required) [blank area] . Date: [blank area] . The DSD stated, Resident 26's POLST was not signed by Resident 26 or his Decision-maker (DM- someone who makes decisions for another person) and was incomplete. The DSD stated, the facility's practice was for the admission nurse to ensure the POLST form was signed and completed within 72 hours from admission. The DSD stated, the incomplete POLST placed Resident 26 at risk to received treatments against his wishes. During a concurrent interview and record review, on [DATE] at 8:28 a.m., with the Director of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 28 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 - Few Medical Records (DMR), Resident 26's POLST, dated [DATE] was reviewed. Resident 26's POLST did have a signature of Resident 26 or his DM and was incomplete. THE DMR stated, Resident 26's POLST should have been signed and completed. During an interview on [DATE], at 11:00 a.m., with the Director of Nursing (DON), the DON stated, Resident 26's POLST for DNR was not signed and was incomplete. The DON stated, the incomplete POLST would make Resident 26 a Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive) and placed Resident 26 at risk to received treatments against his wishes. During a professional reference review retrieved from https://emsa.ca.gov/dnr_and_polst_forms/, titled DNR and POLST Forms, dated 2023, indicated, .The Physician's Order for Life Sustaining Treatment (POLST) form is approved by the Emergency Medical Services Authority (EMSA) and the Commission on EMS, and developed by the Coalition for Compassionate Care of California. The POLST form is a medical order that gives seriously ill patients more control over their care by specifying the type of medical treatment a patient wishes to receive at the end of life. The EMSA approved POLST form must be signed and dated by a physician, or a nurse practitioner or a physician assistant acting under the supervision of the physician, and the patient or legally recognized health care decisionmaker. The POLST form should be clearly posted or maintained near the patient . During a professional reference review retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5297955/, titled How to keep good clinical records, dated [DATE], indicated, . Clinical record keeping is an integral component in good professional practice and the delivery of quality healthcare. Regardless of the form of the records (i.e. electronic or paper), good clinical record keeping should enable continuity of care and should enhance communication between different healthcare professionals. Consequently, clinical records should be updated, where appropriate, by all members of the multidisciplinary team that are involved in a patient's care . Continuity in clinical notes is of vital importance to patient care as, in the current medical environment, many different healthcare professionals are involved in the treatment of a single patient. Making sure that clinical notes are up to date and completed accurately with sufficient information will ensure that the proper information is provided to all relevant healthcare workers and will aid them in potential future decisions . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 29 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 effective infection control and prevention program when one of two sampled residents (Resident 29) nasal cannula (a device used to deliver supplemental oxygen or increase airflow through the nose to a person in need of respiratory help) was on the floor and not stored inside a plastic bag. Residents Affected - Few This failure placed Resident 29 at risk for cross-contamination (the physical transfer of harmful germs from person, object or place to another) and to developed respiratory infection (when germs enter the body, usually through the mouth or nose) from using contaminated nasal cannula. Findings: During a review of Resident 29's admission Record(AR- is a document that gives a patient's information at a quick glance which includes contact details, a brief medical history and the patient's level of functioning, along with patient preferences and wishes), dated 5/2/23, the AR indicated, Resident 29 had the diagnoses of Chronic Obstructive Pulmonary Disease (a condition involving constriction of the airways and difficulty or discomfort in breathing) and Acute and Chronic Respiratory Failure (a condition in which your blood doesn't have enough oxygen or has too much carbon dioxide) with Hypoxia (am absence of enough oxygen in the tissues to sustain bodily functions). During a review of Resident 29's Medication Profile (MP), dated 2/6/23, the MP indicated, Oxygen Intranasal -Both Nostrils 2 [liters- unit of measurement] Continuous . During an observation on 5/1/23, at 10:42 a.m., in Resident 29's room, Resident 29's nasal cannula was attached to an oxygen concentrator (medical device that gives extra oxygen) on the floor without a plastic bag cover. During a concurrent observation and interview on 5/1/23, at 11:10 a.m., with Licensed Vocational Nurse (LVN) 2, Resident 29's room, LVN 2 stated, Resident 29's nasal cannula was on the floor, not stored inside a plastic bag and should be disposed. LVN 2 stated, the facility process was for Resident 29's nasal cannula when not in used should be stored inside a plastic bag and off the floor to prevent cross contamination. LVN 2 stated, there was no plastic bag available to store Resident 29's nasal cannula. LVN 2 stated, there was a potential risk for Resident 29 to be infected with germs from the floor to his nose by way of using contaminated nasal cannula. During an interview on 5/4/23, at 10:42 a.m., with the Infection Preventionist (IP), the IP stated, the facility process for nasal cannula when not in use should be stored inside a plastic bag and off the floor to keep the nasal cannula clean, sanitary and prevent cross contamination. The IP stated there was a potential risk for Resident 29 to developed respiratory infection from using contaminated nasal cannula. During a concurrent interview and record review on 5/23/23, at 10:52 a.m., with the Director of Nursing (DON), the facility's policy and procedure (P&P) titled, Oxygen Administration, (undated), the P&P indicated, . Policy Explanation and Compliance Guidelines . Change oxygen tubing . as needed if it becomes soiled or contaminated . Keep delivery devices covered in plastic bag when not in use . The DON stated it was important for Resident 29's nasal cannula when not in used to be stored inside a plastic bag and off the floor to prevent cross- contamination which could lead to respiratory infection. The DON stated the facility's P&P was not followed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 30 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During a professional reference review retrieved from https://www.cdc.gov/infectioncontrol/spread/index.html, titled How Infections Spread, dated January 7, 2016, indicated, .An infection occurs when germs enter the body, increase in number, and cause a reaction of the body. Three things are necessary for an infection to occur: Source: Places where infectious agents (germs) live (e.g., sinks, surfaces, human skin) Susceptible Person with a way for germs to enter the body Transmission: a way germs are moved to the susceptible person . Transmission refers to the way germs are moved to the susceptible person . Germs don't move themselves. Germs depend on people, the environment, and/or medical equipment to move in healthcare settings. A Source is an infectious agent or germ and refers to a virus, bacteria, or other microbe. In healthcare settings, germs are found in many places. People are one source of germs including . Germs are also found in the healthcare environment. Examples of environmental sources of germs include: Dry surfaces in patient care areas (e.g., bed rails, medical equipment, countertops, and tables) Wet surfaces, moist environments, and biofilms (e.g., cooling towers, faucets and sinks, and equipment such as ventilators) . Event ID: Facility ID: 555918 If continuation sheet Page 31 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Based on observation and interview, during the survey period of 5/1/23 to 5/8/23, the facility failed to provide the minimum of at least 80 square feet per resident in 10 out of 17 rooms (Rooms 1, 2, 5, 6, 11, 12, 14, 15, 16 and 17). This failure had the potential for residents to not have reasonable accommodations for privacy or adequate space for care to be rendered. Findings: During a concurrent observation and interview with the Director of Maintenance (DOM) and Housekeeping Supervisor on 5/4/23, at 10:58 a.m., the DOM stated he was aware ten rooms did not meet the minimum square footage required. The room measurements were as follows: Room # Square Feet Number of residents 1 156.18 2 2 157.20 2 5 215.68 3 6 214.27 3 11 216.02 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 32 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0912 3 Level of Harm - Minimal harm or potential for actual harm 12 216.56 Residents Affected - Some 3 14 217.96 3 15 156.83 2 16 156.96 2 17 157.20 2 During multiple observations made between 5/3/23 to 5/8/23, and the residents had a reasonable amount of privacy. The residents had closets and bedside tables which provided adequate storage space. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Recommend room waiver remain in effect. _____________________________________ HFES Signature Date Request waiver continue in effect. ____________________________________ Facility Administrator Signature (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 33 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0912 Date 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: 555918 If continuation sheet Page 34 of 35 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 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Fowler Care Center 8448 East Adams Avenue Fowler, CA 93625 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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program, when a dead cockroach was found on a glue trap (a trap that uses glue, adhesive material as the mode of capture to trap rodents and insects) in the food storage room and dead insects were found on the kitchen windowsills above the food preparation area and dish sink. These failures had the potential to cause foodborne illnesses (illness caused by food contaminated with bacteria, viruses, and parasites) in a medically vulnerable resident population of 44 residents who consumed food prepared in the kitchen. Residents Affected - Many Findings: During an observation on 5/1/23, at 9:15 a.m., in the kitchen, the back door is fully open without a door screen while food is being prepared. During an observation on 5/1/23, at 9:42 a.m., inside the food storage room, one dead cockroach was captured in the glue trap. During a concurrent observation and interview on 5/1/23, at 9:52 a.m., in the food storage room, with the Dietary Aide (DA) 1, DA 1 stated, the cockroach should not be inside the food storage room, because it could get into the food. During an observation on 5/1/23, at 9:56 a.m., in the kitchen, the windowsills above the food preparation area and dish sink, had a dead large insect and multiple small dead insects. During a concurrent interview and record review on 5/1/23, at 3:10 p.m., with the Registered Dietitian (RD), the RD reviewed the photos of the cockroach inside the food storage room and the insects on the kitchen windowsills. The RD stated, the kitchen should have been check for pest infestation monthly as part of the monthly sanitation audit. The RD stated, she did look for dead insects in the windowsills during her sanitation audit on 4/28/23. During an interview on 5/1/23, at 4:18 p.m., the RD stated, the back door to the kitchen should have not been opened and should be closed during food preparation to prevent pest from entering the kitchen. During a concurrent interview and record review on 5/1/23, at 5:47 p.m., with the Administrator (ADM), the ADM reviewed the photos taken in the kitchen of the glue traps with a dead cockroach and dead insects on the windowsills. The ADM stated the expectation was for the kitchen and food storage areas to be free of pests and insects. During a review of a professional reference, titled California Code of Regulations (CCR), (undated), retrieved from, https://govt.westlaw.com/calregs/Document/IB97EE82C5B6111EC9451000D3A7C4BC3?viewType=FullText&originationC indicated, in Skilled Nursing Facilities, . All kitchens and kitchen areas shall be . protected from rodents, roaches, flies, and other insects . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 35 of 35