Health inspection·March 15, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview and record review, the facility failed to ensure services provided met professional standards of quality for one of 27 residents (Resident 28), when Resident 28 was not offered water to rinse her mouth after aerosol oral inhaler (a medication used to prevent difficulty breathing administered by way of inhalation both oral and nasal) administration as ordered by the physician. Residents Affected - Few This failure had the potential for the inhaler medication to accumulate in Resident 28's mouth and placed Resident 28 at risk to developed oral thrush (fungal infection). Findings: During an observation on 3/13/24 at 8:37 a.m., in Resident 28's room, the Director of Staff Development (DSD) administered aerosol oral inhaler to Resident 28. The DSD did not offer Resident 28 water to rinse her mouth after medication administration. During a review of Resident 28's Order Summary Report, dated 3/13/24 indicated, . 2 puffs inhale orally . rinse mouth with water and spit back into cup after use . During a review of Resident 28's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 12/27/23, the MDS section C indicated Resident 28 had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 12 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 28 was moderately impaired. During an interview on 3/14/24 at 4:09 p.m. with the Director of Nursing (DON), the DON stated her expectation was for the DSD to follow physician's order and rinse Resident 28's mouth after aerosol inhaler medication administration to prevent oral thrush. During a review of the facility's policy and procedure (P&P) titled, Provision of Physician Ordered Services, dated 10/2022, 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 . During a review of the Federal Drug Administration (FDA a government agency responsible for protecting public health by ensuring the safety, efficacy of human drugs) Highlights of Prescribing Information (PI), dated 4/2008, the PI for fluticasone propionate indicated, . for oral inhalation . localized infections: Candida albicans (thrush) infection of the mouth and throat may occur . advise patients to rinse the mouth following inhalation . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 were labeled with resident identifier and expiration date in accordance with the facility's policy and procedure Labeling Medications and Biological's (a substance such as vaccines or drugs derived from a living organism used for treatment) when one Fluticasone propionate salmeterol inhaler (medications used to treat respiratory disease, a mist or spray that the patient breathes in the nose or mouth) and one nasal spray ( liquid medicine spray into the nose) medication was stored in medication cart 1 without a resident identifier label (resident's name and date of birth ) and expiration date. This failure placed residents at potential risk for receiving the wrong medication and expired medications, which could lead to medication ineffectiveness and medication adverse reaction. Findings: During a concurrent observation and interview on 3/14/24 at 11:13 a.m. with the Infection Preventionist (IP), in front of the nurse's station, medication cart 1 stored one inhaler medication and one nasal spray medication without a resident identifier label and without an expiration date. The IP stated the inhaler and nasal spray medication should have been labeled with the resident name and expiration date to prevent giving the medication to the wrong resident and to ensure medication efficacy. During an interview on 3/14/24 with the Director of Nursing (DON), the DON stated her expectation was for the inhaler and nasal spray medication labeled with resident identifiers and expiration date. The DON stated inhalers and nasal spray medication without a resident identifier and expiration date placed residents at risk for medication error and residents receiving medications which are less effective. During a review of the facility's policy and procedure (P&P) titled, Labeling of Medications and Biological's, dated 2023, the P&P indicated, . all medications and biological will be labeled in accordance with applicable federal and state requirements and current accepted pharmaceutical principles and practices . labels for individual drug containers must include: the resident's name, the prescribing physician's name, the medication name (generic and/or brand name), the prescribed dose, strength, and quantity of the medication . the expiration date when applicable, the route of administration . labels for medications designed for multiple administrations (such as inhalers, eye drops), the label will identify the specific resident for whom it was prescribed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 observation, interview, and record review the facility failed to store, prepare, and serve food in accordance with the facility's policy and procedure and professional standards for food safety when: Residents Affected - Many 1. [NAME] and gray particles were found in the windowsill (ledge on bottom of window) next to the food preparation sink. 2. [NAME] build up was found on the exterior of the dish washing machine. 3. The ice machine and food preparation sink had no air gaps (a vertical space usually one inch or more between the end of a pipe or faucet and the top of a sink which creates a separation between the water supply and contaminated water). 4. The temperature of the dish washing machine was under the minimum 120° Fahrenheit (F- unit of measurement) requirement. 5. Oven mitts used to handle hot foods were soiled with orange and brown grime and debris. 6. Food stored in the resident's refrigerator was not labeled with resident's name and use-by-date (the last day for the consumption of food item while at peak quality). These failures had the potential to cause cross-contamination and food borne illness to residents. Findings: 1. During an observation on 3/12/24 9:26 p.m. in the kitchen, brown and gray particles were found on a windowsill which was above the food preparation sink. During an interview on 3/13/24 2:55 p.m. with the Registered Dietitian (RD), the RD stated the dirt and dust on the windowsill had the potential to contaminate (to make dirty) food prepared in the sink below it. The RD state the windowsill should have been cleaned daily. During a concurrent interview and record review on 3/15/23 at 3:30 p.m. with the Certified Dietary Manager (CDM), the facility's policy and procedure (P&P) titled, Sanitation Inspection, dated 10/2022 was reviewed. The P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food services weekly to ensure the areas are clean and comply with sanitation and food service regulations . The CDM stated dirt on the windowsill next to the food preparation sink did not follow the facility's policy. The CDM stated the dirt and debris on the windowsill could have contaminated the food prepared in the sink. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms (small germs which may cause illness) which employees may inadvertently (without meaning to) transfer to food. If these areas are not kept (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 clean, they may also provide harborage for insects, rodents, and other pests . Level of Harm - Minimal harm or potential for actual harm 2. During an observation on 3/12/24 at 9:26 p.m. in the kitchen, white sediment build-up was found on the exterior of the dish washing machine. Residents Affected - Many During an interview on 3/13/24 2:55 p.m. with the RD, the RD stated, the white build up on the dish washer should have been cleaned. The RD stated no build up should have been present on the dish washer; bacteria (germs which could lead to illness) could grow in the white build up and contaminate the dishes. During a concurrent interview and record review on 3/15/23 at 3:30 p.m. with the CDM, the facility's P&P titled, Sanitation Inspection, dated 10/2022 was reviewed. The P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food services weekly to ensure the areas are clean and comply with sanitation and food service regulations . The CDM stated the white build up on the dish washer did not follow the facilities policy. The CDM stated the buildup could have caused bacterial growth on the dish washing machine. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-602.13 Nonfood-Contact Surfaces. The presence of food debris or dirt on nonfood contact surfaces may provide a suitable environment for the growth of microorganisms which employees may inadvertently transfer to food . 3. During an observation on 3/12/24 at 9:26 a.m. in the kitchen, no air gap was found in the food preparation sink. During concurrent observation and interview on 3/13/24 11:15 a.m. with Plant Operations Supervisor (POS) in the kitchen, the POS stated the food preparation sink had no air gap. The POS stated without an air gap, the sewage water could back up into the sink and contaminate the food. During concurrent observation and interview on 3/13/24 11:15 a.m. with the POS in the break room, the POS stated the ice machine had no air gap. The POS stated without an air gap in the ice machine the sewage water could back up and contaminate the residents' ice. During an interview on 3/13/24 at 2:29 p.m. with RD, the RD stated the food preparation sink and ice machine did not have an air gap. The RD stated water could backflow from the sewer and contaminate residents' food. During an interview and record review on 3/15/23 at 3:30 p.m. with CDM, the facility's policy and procedure (P&P) titled, Sanitation Inspection, dated 10/2022 was reviewed. The P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations . the CDM stated the ice machine and food preparation sink should have an air gap installed to prevent water backflow from the sewage. The CDM stated the facility did not follow the facility's policy and procedure. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 5-202.13 Backflow Prevention, Air Gap. During periods of extraordinary demand, drinking water systems may develop negative pressure (when water flows in the opposite direction) in portions of the system. If a connection exists between the system and a source of contaminated (dirty) water during times of negative pressure, contaminated water may be drawn into and foul (to make dirty) the entire system. Standing water in sinks . and other equipment may become contaminated with cleaning chemicals or food residue . 4. During an observation on 3/12/24 at 9:26 a.m. in the kitchen, the dish washing machine had a temperature of 110 ° Fahrenheit (F). During a concurrent observation and interview on 3/12/23 at 2:00 p.m. in the kitchen with CDM, the dish washer's temperature gauge was at 100° F. The CDM stated the temperature of the dishwasher should have been at a minimum of 120° F but it was only reaching 100° F. During a concurrent observation an interview on 3/12/23 at 8:35 a.m. with cook (CK) 1 in the kitchen, CK 1 was washing plates in the dishwasher. CK 1 stated the temperature displayed on the dishwasher was 100 °F. CK 1 stated the temperature should have been at 120 ° F for the dishwasher to be most effective. CK 1 stated a temperature under 120°F may not thoroughly clean the dishes. During an interview on 3/13/24 at 2:57 p.m. with RD, the RD stated the dish washer temperature should have been between 120°F to 140 °F. The RD stated when the temperature does not reach the minimum of 120, it could lead to dishes not sanitized properly. During a concurrent interview and record review on 3/15/23 at 3:30 p.m. with CDM, the facility's P&P titled, Dishwashing Policy, dated March 2010 was reviewed. The P&P indicated, . 7. The operator will check temperatures using the machine gauge with each dishwashing machine cycle and will record the results in a facility approved log. The operator will monitor the gauge frequently during dishwashing machine cycle. Inadequate (not enough) temperatures will be reported to the supervisor and corrected immediately . CDM stated having the dishwasher under 120° F did not follow the facility's policy. CDM stated having the temperature under 120° F could have prevented dishes from being thoroughly cleaned. CDM stated staff should not have been washing dishes with the temperature under 120 ° F and they should have reported any temperature below the minimum to her. CDM stated kitchen staff did not do frequent checks of the temperature per policy. During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-501.15 Warewashing (dishwashing) Machines, Manufacturers' Operating Instructions. (A) A warewashing machine and its auxiliary (supporting) components shall be operated in accordance with the machine's data plate and other manufacturer's instructions . During a review of the dishwasher's Installation & Operating Instructions dated 12/05/2007, the form stated the dishwasher's required minimum temperature was 120° F. 5. During an observation on 3/12/24 at 9:26 a.m. in the kitchen, dietary staff used oven mitts covered in orange and brown debris. During an interview on 3/13/24 at 2:52 p.m. with RD, RD stated dietary staff should not use dirty or soiled oven mitts to prevent food contamination. RD stated the oven mitts should have been cleaned at the end of each day. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 an interview on 3/15/23 at 1:48 p.m. with CDM, CDM stated dietary staff should not use soiled oven mitts. The CDM stated the oven mitts should have been cleaned once a day to prevent cross contamination from other foods being handled. During a review of the facility's P&P titled, Sanitation Inspection dated 10/2022, indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food Code U.S Food and Drug Administration, dated 2022, indicated, . 4-601.11 equipment food-contact surfaces and utensils shall be clean to sight and touch. Microorganisms may be transmitted from a food to other foods by utensils, cutting boards, thermometers, or other food-contact surfaces . 6. During an observation on 3/12/24 at 2:16 p.m. in the break room the resident's refrigerator stored a food item not labeled with a resident's name and used by date. During an interview on 3/13/24 at 2:35 p.m. with RD, the RD stated food stored in the resident's refrigerator should be labeled with resident's name and used by date to prevent giving the food to the wrong resident and to ensure food quality. During an interview on 3/15/24 at 9:48 a.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated the first and last name must be on the resident's personal food stored in the resident's refrigerator to prevent giving the food to the wrong patient. During an interview on 3/15/24 at 1:51 p.m. with CDM, the CDM stated resident food item stored in the resident's refrigerator should be labeled with resident's name and used by date to prevent giving the food to the wrong resident and to ensure food quality. During a review of the facility's P&P titled, Food brought in by Family/Visitors dated 03/2022, indicated, . 5. Food that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food . b. [Food] containers are labeled with resident's name, the item and the 'use by' date . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain an accurate medical record consistent with professional standards and practices for four of 10 sampled residents (Resident 1, 4, 13, and Resident 34) when Resident 1, 4, 13, and 34's Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. These failures resulted in a medical record that did not reflect Resident 1, 4, 13, and 34's treatments for end-of-life care and services. Findings: During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with Medical Records Director (MRD), Resident 1's POLST, dated 8/2/23 was reviewed. MRD stated Resident 1's POLST was not completed. MRD stated Resident 1's POLST was missing all the physician's information, which included the physician's name, physician's address, physician's phone number, physician's license number and the physician's signature. MRD stated the Nurse Practitioner (NP) and Physician Assistant (PA)'s name was missing, the preparer of the POLST's name, title and phone number were missing, and Resident 1's additional contact information which included a name, phone number, and relationship to the resident were also missing. The MRD stated Resident 1's POLST should have been completed in the event Resident 1 gets transferred to another facility, the receiving facility would have the information they need to ensure Resident 1's POLST were followed. During a review of Resident 1's admission Record (AR - a summary of information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), dated 3/15/24, the AR indicated Resident 1 was admitted on [DATE] with diagnoses of acute kidney failure (a condition where the kidneys suddenly cannot filter waste from the blood), major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities), and schizophrenia (a disorder that affects a person's ability to think, feel, and behave clearly). During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool used to identify cognitive [mental processes] and physical functional level assessment), dated 2/13/24, the MDS section C indicated Resident 1 had a had a Brief Interview for Mental Status (BIMS - a test given by medical professionals to determine cognitive understanding on a scale of 1-15 ) score of 99 (a score of 0-7 suggests severe cognitive impairment, 8-12 suggests moderately impaired, 13-15 suggests cognitively intact), which indicated Resident 1 was unable to complete the interview due to severe impairment. During a review of Resident 4's Electronic Medical Record (EMR), on 3/14/24 at 11:22 a.m. Resident 4's EMR Profile indicated Resident 4's Code Status (means the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was Full Code (if a person's heart stopped beating and/or they stopped breathing, all resuscitation procedures will be provided to keep them alive.). Resident 4's Care Plan indicated Resident 4's Code Status was Do Not Resuscitate (DNR- a legal document that means a patient has decided not to have cardiopulmonary resuscitation a lifesaving procedure when a patients heartbeat stops) performed and would be allowed to die naturally (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 only if their heart stops beating and/or they stop breathing). Level of Harm - Minimal harm or potential for actual harm During a review of Resident 4's admission Record (AR), dated 3/14/24, the AR indicated Resident 4 was admitted on [DATE] with diagnoses of seizures (sudden, uncontrolled body movements and changes in behavior that occur because of abnormal electrical activity in the brain.), altered mental status, obesity (overweight) due to excess calories, type 2 diabetes mellitus (a disease in which the body does not control the amount of glucose (a type of sugar) in the blood and the kidneys make a large amount of urine), need for assistance with personal care. Residents Affected - Some During a review of Resident 4's MDS dated 1/30/24, the MDS Section C indicated Resident 4 had a BIMS (Brief Interview for Mental Status - a test given by medical professionals to determine cognitive understanding on a scale of 1-15) score of 12 out of 15 which indicated Resident 4 was moderately impaired. During a concurrent interview and record review on 3/14/24 at 11:50 a.m. with the MRD, Resident 4's EMR was reviewed. The MRD stated the EMR indicated Resident 4's code status was Full Code and compared to the paper chart which indicated Resident 4's code status was Do Not Resuscitate. The MRD stated Resident 4's code status in the EMR and paper chart did not match. The MRD stated Resident 4's code status should match to ensure Resident 4's life sustaining treatment were followed according to Resident 4's preference. During an interview on 3/14/24 at 11:54 a.m. with the facility DON, DON stated it is her expectation that nursing staff refer to the resident profile in the EMR to confirm resident code status and that resident medical records are maintained per facility policy. During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with MRD, Resident 13's POLST, dated 3/13/24 was reviewed. MRD stated Resident 13's POLST was incomplete. The MRD stated Resident 13's POLST was missing the physician's phone number. The MRD stated in the event Resident 13 needs to be transferred to another facility and the POLST was incomplete the receiving facility would not have the physician contact information to verify Resident 13's life sustaining treatment wishes. During a review of Resident 13's AR, dated 3/15/24, the AR indicated Resident 13 was admitted on [DATE] with diagnoses of respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), epilepsy (a seizure [a burst of uncontrolled electrical activity between brain cells that causes temporary abnormalities in muscle tone or movements, behaviors, sensations, or states of awareness] disorder), chronic kidney disease (a condition when the kidneys suddenly are unable to filter waste products from the blood), and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). During a review of resident 13's MDS, dated 1/25/24, the MDS section C indicated Resident 13 had a BIMS score of 99, which indicated Resident 13 was unable to complete the interview due to severe impairment. During a concurrent interview and record review on 3/14/24 at 5:11 p.m. with MRD, Resident 34's POLST, dated 1/11/24 was reviewed. The MRD stated Resident 34's POLST was not completed. The MRD stated the physician's printed name and phone number were missing. The MRD reviewed Resident 34's paper chart and stated the preparers information, and the additional contact information were not completed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 - Some The MRD stated the physician's information, additional contact information and preparer's information should have been completed. During a review of Resident 34's AR, dated 3/15/24, indicated Resident 34 was admitted on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles) following cerebral infarction (damage to tissues in the brain due to a loss of oxygen to the area), heart failure (a condition when the heart muscle doesn't pump enough blood to meet the body's needs which can cause fatigue and shortness of breath), acute respiratory failure (a serious condition that occurs when the lungs cannot get enough oxygen into the blood or remove enough carbon dioxide [a waste gas] from the blood), blindness, and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). During a review of Resident 34's MDS, dated 1/18/24, the MDS sections C indicated Resident 34 had a BIMS score of 15, which indicated Resident 34 was cognitively intact. During a review of the job description (JD) titled, Medical Records Clerk, dated 2020, the JD indicated, . ensures resident records are properly completed, assembled, coded, etc., before filing . During a review of the facility's policy and procedure (P&P) titled, Documentation in Medical Record, dated 10/22, indicated, . licensed staff and interdisciplinary team members shall document all assessments, observations, and services provided in the resident's medical record in accordance with state law and facility policy. documentation shall be accurate, relevant, and complete, containing sufficient details about the resident's care and/or responses to care . sign each entry with name and credentials of the person making the entry . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on observation, interview, and record review, the facility failed to follow policy and procedure to monitor and maintain essential equipment in a safe operating condition for one of six residents, (Resident 4), when Resident 4's oxygen concentrator (a medical device to deliver oxygen) was not routinely monitored and maintained in accordance with facility policy and procedure. Residents Affected - Few This failure had the potential for Resident 4's oxygen concentrator to break down and fail which could result in Resident 4 going without oxygen. Findings: During a concurrent observation and interview on 3/13/24 at 8:54 a.m. with Certified Nurse Assistant (CNA) 1, in Resident 4's room, Resident 4's oxygen concentrator had gray particles on the surface. CNA 1 stated the oxygen concentrator had a lot of dust and should be cleaned. CNA 1 stated maintenance was responsible to ensure the oxygen concentrator was clean. During a concurrent observation and interview on 3/14/24 at 12:15 p.m. with Licensed Vocational Nurse (LVN) 1 in Resident 4's room, LVN 1 opened the oxygen concentrator filter cover and LVN 1 stated the filter was not clean and had a lot of dust. LVN 1 stated the filter should be clean to ensure proper functioning. LVN 1 stated she did not know when the last time maintenance cleaned the filter. During an interview on 3/14/24 at 12:20 p.m. with Resident 4, Resident 4 stated she expected the oxygen concentrator used to deliver her oxygen was clean. Resident 4 stated she wanted her oxygen concentrator clean and properly maintained. During an interview on 3/14/24 at 4:27 p.m. with the Director of Nursing (DON), the DON stated the facility was expected to follow manufacturer instructions for use of the oxygen concentrator and to ensure it was well maintained. DON stated she would provide a copy of the maintenance log and IFUs for the oxygen concentrator but did not. During a review of the facility Oxygen Concentrator Policy and Procedure (P&P), dated 10/22, the P&P indicated Policy: The purpose of this policy is to establish responsibilities for the care and use of oxygen concentrators . 5. Care of the Concentrator: a. Follow manufacturer recommendations for the frequency of cleaning filters . c. Nurse Responsibilities: . iv. The main body cabinet should be dusted when needed and can be wiped clean . During a review of the Brand Name Company Service & Technical Reference (Manual), undated, the Manual indicated, .Chapter 6. Maintenance 6.1 .Routine maintenance is very important in prolonging dependability and in reducing costly repairs. Long-term maintenance and regular checking of the filters helps assure the efficient operation of the unit .6.1.1 Filters Brand Name Company recommends. Replacing the Inlet Filter every two (2) years. During a review of the facility Resident -Care Equipment Policy and Procedure (P&P), dated 10/22, the P&P indicated Policy: Resident-care equipment can be a source of indirect transmission of pathogens (an organism causing disease). Reusable resident-care equipment will be cleaned and disinfected in accordance with current Centers for Disease Control (CDC) recommendations in order to break the chain of infection . 3. Staff shall follow established infection control principles for cleaning . j. Follow manufacturer recommendations for cleaning equipment. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 - Potential for minimal 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 3/12/24 to 3/15/24, the facility failed to provide and maintain a minimum of at least 80 square feet per resident room for 10 of 16 rooms (Rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, & 17). This failure had the potential to place residents at risk for not having sufficient space to accommodate their needs, privacy, and comfort. Findings: Resident rooms 1, 2, 4, 5, 6, 11, 12, 14, 15, 16, & 17 did not meet the required square footage requirements; however, the residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver did not adversely affect the health and safety of any of the residents residing in these rooms. Room # Square Feet Number of Residents 1 156 square feet 2 2 156 square feet 2 4 253 square feet 4 5 221 square feet 3 6 221 square feet 3 11 221 square feet 3 12 221 square feet 3 14 221 square feet 3 15 156 square feet 2 16 156 square feet 2 17 156 square feet 2 Recommend waiver continue. ________________________________ Health Facilities Evaluator Supervisor Date (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 Request waiver continue. Level of Harm - Potential for minimal harm _________________________________ Administrator Signature Residents Affected - Some Date FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to provide a clean and safe environment for residents, staff and the public when: Residents Affected - Many 1.The kitchen dry storage floor had areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. 2.The facility floors in the common areas and resident rooms, had black-colored stains, uneven surfaces, cracked linoleum with accumulation of black and brown debris and missing baseboards. This failure to ensure the physical environment was maintained in a safe, clean, and sanitary manner as evidenced by multiple contact surfaces in disrepair placed residents, staff, and the public at potential risk for falls and cross contamination (the process by which bacteria are unintentionally transferred from one substance or object to another with harmful effect) which could lead to foodborne illness (caused by food contaminated with bacteria). Findings: 1. During an observation on 3/12/24 at 9:26 a.m. in the kitchen's dry food storage room, the floor had multiple areas of brown stains, missing and cracked linoleum, exposing the cement underneath with accumulation of dark gray debris. During an interview on 3/13/24 at 11:21 a.m. with Certified Dietary Manager (CDM), the CDM stated the floor was difficult to clean because of the missing and cracked linoleum and which should have been repaired. The CDM stated the damaged floor was unsanitary and could contaminate the food stored in the dry food storage room. During an interview on 3/13/23 at 11:23 a.m. with Plant Operations Supervisor (POS), the POS stated the damaged floor in the dry food storage room should have been repaired. The POS stated having dirty uncleanable flooring could have contaminated residents' food. During an interview on 3/13/24 at 2:43 p.m. with Registered Dietitian (RD), the RD stated the damaged floor in the dry food storage room should have been repaired to prevent cross contamination of food stored in the dry food storage room. During a review of the facility's policy and procedure (P&P) titled, Sanitation Inspection dated 10/2022, the P&P indicated, . 1. All food service areas shall be kept clean, sanitary, free from litter, rubbish . 2. The department shall establish a sanitation program for food services based on applicable state and federal requirements . 4. Sanitation inspections will be conducted in the following manner: . b. weekly: The dietary manager shall inspect all food service areas weekly to ensure the areas are clean and comply with sanitation and food service regulations . During a review of the Food and Drug Administration (FDA) Food Code, dated 2022, indicated, 6-101.1 floors shall be smooth, durable, and easily cleanable for areas where food establishment operations are conducted . Floors, walls, and ceilings that are constructed of smooth and durable surface materials are more easily cleaned . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555918 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/15/2024 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 0921 Level of Harm - Minimal harm or potential for actual harm During a review of the facility Facility Responsibilities Policy and Procedure (P&P), dated 10/23, the P&P indicated Policy: It is the policy of this facility to uphold and comply with the facility responsibilities . 16. Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment . b. housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . Residents Affected - Many 2. During an observation on 3/13/24 at 2:27 p.m. the flooring throughout the facility had some areas of uneven surfaces, missing baseboards, and cracked linoleum with accumulation of black and brown debris in the cracks and floor edges with the missing baseboards. During an interview on 3/14/24 at 10:43 a.m. with the POS, the POS stated he would not find it acceptable if the flooring in his house looked like the facility floors. The POS stated he was not aware of any resident or staff complaint of safety. During a concurrent observation and interview on 3/13/24 at 3:29 p.m. with the facility Infection Preventionist (IP), the IP stated part of her duties as an Infection Preventionist was to conduct facility rounds to ensure the facility was free of potential hazard and infection control concerns. The IP stated The floors were old, there is supposed to be a plan for remodeling the floor. The IP stated she was aware the kitchen dry food storage room needs new linoleum and should have been repaired. The IP stated the uneven floor surfaces could cause falls for residents and staff. The IP stated clean floors are important to prevent the spread of germs and residents getting sick, so they don't contaminate other locations. During an interview on 3/15/24 at 1:56 p.m. with the facility Administrator (ADM), the ADM stated she was aware of the damage flooring in the facility and should have been repaired to promote a homelike environment and safety for the residents and staff. During a review of the facility Facility Responsibilities Policy and Procedure (P&P), dated 10/23, the P&P indicated Policy: It is the policy of this facility to uphold and comply with the facility responsibilities . 16. Safe Environment. The resident has a right to a safe, clean, comfortable, and homelike environment . b. housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555918 If continuation sheet Page 15 of 15