Other·February 14, 2020

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health Licensing and Certification during an ABBREVIATED SURVEY for Facility Reported Incident (FRI) CA00654416. Representing the California Department of Public Health - Licensing and Certification by Federal ID 39957, RN, HFEN, and 42466, RN, HFEN The ABBREVIATED SURVEY was limited to the specific FRI investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for FRI number CA00654416.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 02/15/2020 §483.25(d) Accidents. The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide adequate supervision for one of three sampled residents (Resident 1) when Resident 1 who was at risk for elopement (define) left the facility. Staff LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 1 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE disarmed the door alarm and Resident 1 left the facility before the door alarm was reactivated on 9/12/19. As a result of this failure Resident 1 was not found for 4 days until 9/15/19. Resident 1 during this time wandered about outdoors in temperatures ranging from 82 -101 degrees Fahrenheit. Resident 1 was found outside near a homeless encampment and his physical appearance was visibly dirty and his clothes soiled in his own urine and feces. he was diagnosed with severe altered mental status (AMS), uremia (high level of urea [toxic waste] in the blood occurs when the kidney is damaged or does not function properly), dehydration (decrease in the amount of water in the body), and hypernatremia (high level of salt in the blood, possible cause could be inadequate water intake or dehydration). Resident 1 was admitted to the GACH for higher level of care. As of 11/19/19, Resident 1 remained in the hospital as an inpatient. Findings: During a review of the clinical record for Resident 1, the "Admission Record" (record containing resident personal information) undated, indicated Resident 1 was a 68-yearold admitted to the SNF on 8/2/19, with diagnoses which included traumatic hemorrhage of cerebrum (bleeding that occurs within the brain tissue), Diffuse traumatic brain injury with loss of consciousness ( brain injury caused by an outside force, usually a violent blow to the head), muscle weakness, unsteadiness on feet, urinary tract infection (bladder infection), Alcohol intoxication, Closed fractures (broken bone) of the ribs of left side. Resident 1's Brief Interview of Mental status assessment (BIMS - screening tool used in nursing home to assess cognition) dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 2 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 8/30/19 indicated Resident 1 scored 10 of 15 points which indicated Resident 1 was moderately impaired with cognitive skills for daily decision making. During an interview with the Director of Nursing (DON), on 9/13/19, at 10:01 a.m., the DON stated she learned Resident 1 was missing at approximately 8 a.m. on 9/12/19. The DON stated staff immediately started searching for Resident 1 in all rooms, bathrooms and the outside premises of the facility. The DON stated staff was not able to locate Resident 1 in or out of the facility. The DON stated the Social Service Director (SSD) went to a local nearby homeless shelter and Resident 1 was not there. The Administrator (ADM) on 9/12/19 searched the neighborhood near the facility and could not locate Resident 1. The DON stated the search for Resident 1 lasted until 10:30 a.m., on 9/12/19 without success. The DON stated the Director of Staff Development (DSD) reported to the local police department on 9/12/19 of Resident 1's elopement and the unsuccessful search. The DON stated she viewed the facility video surveillance footage in the Administrator's office that showed Resident 1 had exited from the exit door by the Kitchen on 9/12/19. During an interview with the DON, on 9/13/19, at 10:01 a.m., the DON explained how Resident 1 left the building. The DON stated the exit door to the outside near the kitchen was equipped with an alarm that does not respond to the wander guard (a tracking application designed to prevent person at risk from leaving a facility unaccompanied) alarm placed on Resident 1. The alarm on the exit door to the outside requires staff to set the alarm to an on position. Once the exit door has been set to arm the door has a delay of 15 seconds before the alarm was armed. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 3 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE DON stated the dietary aide (DA) 1 who was working in the kitchen on 9/12/19 had disarmed the exit door to take out trash and saw Resident in the kitchen hallway near the exit door. Once the DA 1 had completed the task of taking out the trash, DA 1 armed the exit door and returned to the kitchen. The DON stated Resident 1 remained in the kitchen hallway near the exit door and left the building prior to the 15-second alarm delay was completed to re-arm the exit door. The DON stated the facility video surveillance recording of the hallway and exit door used by DA 1 and Resident 1 showed DA 1 speaking to Resident 1 and DA 1 going back into the kitchen behind closed doors. The DA 1 did not see Resident 1 leave the building. During a concurrent interview and record review with the DON, on 9/13/19, at 10:15 a.m., the DON stated they had an elopement binder in each nurses' station. The DON reviewed the elopement binder which contained the photos of each resident who was in the facility. The elopement binder contained resident face sheet, and the elopement policy and procedure which indicated, " ...Process 1. Staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) ...and Missing Resident Procedure Form and Mechanical Alarm System policy..." During a review of the clinical record for Resident 1, the physician's order dated 8/17/19, indicated, "Apply Wander guard due to resident [1] at risk for elopement..." During a review of the clinical record for Resident 1, the nurses note titled "Weekly Summary" dated 8/19/19, at 7:07 a.m., indicated, "[Resident 1] ... At risk for elopement ...apply wander guard due to resident [1] at risk for elopement ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 4 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During a concurrent record review, interview with the DON, and on a speaker phone, a telephone interview with Licensed Nurse (LN) 1, on 9/13/19, at 4:30 p.m., LN 1 stated she received the physician order for the wander guard bracelet alarm on 8/17/19 for Resident 1 because Resident 1 was pacing around the facility and exit seeking. The DON reviewed Resident 1's physician orders and verified the order for the wander guard was dated 8/17/19. LN 1 stated she applied the wander guard bracelet alarm on Resident 1's ankle on the same day the physician's order was obtained, 8/17/19. LN 1 stated she forgot to perform the elopement risk assessment after obtaining the wander guard bracelet physician's order. The DON reviewed Resident 1's clinical record and verified that an elopement risk assessment was not completed on 8/17/19. The LN 1 stated she should had performed the elopement assessment after she had witnessed Resident 1's exit seeking behavior on 8/17/19. During a concurrent interview and record review, on 9/13/19, at 5 p.m., with the DON, the DON reviewed Resident 1's Elopement Risk Assessment, dated 8/24/19 which indicated Resident 1's elopement risk score was 6 which meant Resident 1 was identified as having a moderate risk for elopement. During a concurrent interview and record review, on 9/13/19, at 5 p.m., with the DON, the DON reviewed Resident's 1's elopement care plan, dated 8/18/19 which indicated, "[Resident 1] ... At risk for Elopement ... [Resident 1 was] Disoriented to place. Resident [1] wanders aimlessly ... Interventions ...Redirect resident ..." During a concurrent interview and record review, on 9/13/19, at 5:20 p.m., with the DON, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 5 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the DON reviewed Resident 1's elopement care plan, dated 8/27/19 which indicated, "Focus: Resident [1] exhibits the following behavior excessive pacing without any reason ...Interventions: Document resident [1's] behavior on the monitoring in Medication Administration Record (MAR). The DON reviewed Resident 1's MAR dated 8/2019, and stated she was unable to find documented interventions in the MAR for the wandering behavior, " ... Redirect [Resident 1's wandering behavior] ... Remove resident [1] from stimulus ..." During an interview with Certified Nursing Assistant (CNA) 1, on 9/13/19, at 12 p.m., CNA 1 stated she was assigned to care for Resident 1 on 9/12/19 prior to his elopement. CNA 1 stated on 9/12/19 at approximately 7 a.m., she assisted Resident 1 with his dressing needs before she left him in his room and went out to other areas of the facility to distribute breakfast trays to other residents. She stated at approximately 7:30 a.m., she went and checked on Resident 1 and he was not in his room. CNA 1 went searching for him throughout the facility and was unable to find him. CNA 1 reported to Resident 1's nurse that he was missing. CNA 1 stated after reporting to the nurse, she then called a "code 10 (code for missing resident)." She stated all staff except the charge nurse and 1 to 2 CNAs conducted a search of the facility for Resident 1. CNA 1 stated she was told Resident 1 was seen on the surveillance video leaving out the exit door by the kitchen at approximately 7:30 a.m., on 9/12/19. During an interview with the DSD, on 9/13/19, at 12:13 p.m., the DSD stated she was the nurse for Resident 1 on 9/12/19. The DSD stated she was at Station 2 at around 7:45 a.m., receiving exchange of shift report from FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 6 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the night shift charge nurse. The DSD stated she heard the announcement of Code 10 and directed staff to start searching for Resident 1. The DSD stated staff searched the front and back parking lot and immediate neighborhood surrounding the facility and were unable find Resident 1. The DSD stated she called the police department and reported Resident 1 was missing. The DSD stated the last time she saw Resident 1 was around 7 a.m. and he was wearing a hospital gown and holding his water pitcher in the hallway. The DSD stated another LN asked him to go back to his room to change into his clothes and the LN assisted him to his room. During a concurrent observation and interview with DA 1, on 9/13/19, at 1:56 p.m., DA 1 explained his work assignment at the time of Resident 1's elopement. DA 1 demonstrated turning off the alarm from the exit door near the kitchen and then taking boxes outside and reentering the facility and turning on the alarm. DA 1 stated he remembered Resident 1 came near him by the exit door the day Resident 1 went missing 9/12/19. The DA stated he redirected Resident 1 to leave the area but Resident 1 remained in the kitchen hallway near the exit door. DA 1 stated he was not aware Resident 1 had exited from the unarmed exit door. DA 1 stated he was not aware Resident 1 was a risk for elopement. DA 1 stated he was not aware the facility had a binder with a list of residents that were identified as risk for elopement. During an interview with the ADM, on 9/13/19, at 2:53 p.m., the ADM stated she was not aware DA 1 and dietary staff did not know Resident 1 was a risk for elopement. During a concurrent observation and interview with Maintenance Supervisor (MS), on 9/13/19, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 7 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE at 2:40 p.m., the MS tested the wander guard alarms on exit doors and found the alarms were functional and working except for the kitchen hallway exit door. The MS stated all exit doors had wander guard alarms except the Northwest side of the building exit door next to the kitchen where Resident 1 exited. The MS stated the exit door next to the kitchen had a different alarm that staff could disarm and when staff would re-arm the alarm had a 15 seconds delay to where the door can be opened, and the alarm would not go off. During a concurrent observation, interview and review of the video surveillance recording (no audio) with the ADM, on 9/13/19 at 3:30 p.m., Resident 1 was observed coming into view and was standing in the kitchen hallway watching DA 1 carrying boxes toward the Northwest side exit door. The video showed DA 1 disarming the alarm to the exit door near the kitchen, open the door and placed the kitchen boxes outside the door. DA 1 walked back into the facility and reset the alarm, turned and looked at Resident [1] standing in the hallway. DA 1 appeared to tell Resident 1 to "go over there" pointing away from the door. The video surveillance showed that as soon as DA 1 walked into the kitchen, Resident 1 exited the door at 7:36 a.m., before the 15-second delay of the alarm was reactivated. During telephone interview with the ADM, on 9/16/19, at 12:56 p.m., the ADM stated a local hospital called the facility informing them that Resident 1 had been found and was in their hospital. During a review of Resident 1's hospital clinical record titled, "Emergency Department Reports" dated 9/19/19, indicated. "[Resident 1 was admitted with] severe Altered Mental Status (AMS- confused and disoriented), Acute Kidney FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 8 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE injury (AKI- condition in which the kidney suddenly can't filter waste from the blood) Uremia, hypernatremia and dehydration (significant loss of body fluid that impairs normal body functions). Resident 1 noted to have hematemesis (vomiting of stomach contents mixed with blood) with coffee ground emesis (the presence of clotted blood within the vomit). The hospital Clinical Record indicated, "Patient [Resident 1] dirty, feces and urine on clothes ...right hip area with redness ...Buttocks area with redness ...Bedside glucose (blood sugar) 280 mg [milligrams]/dl [deciliter] (unit of measurement) ...patient vomited approx. 100 ml (milliliter - unit of measurement) coffee ground/reddish emesis (vomit). The hospital Clinical Record indicated, "Staff member from [ name] nursing home called and stating they were looking for this patient which went missing from their facility two days ... [ prior on 9/12/19] ..." During a review of Resident 1's hospital clinical record titled, "Discharge Summary" dated 12/3/19, indicated " ...admit date 9/15/19, [through] 12/3/19 [ a total of 79 days' hospitalization] ...Patient ... found by other homeless people, confused, soiled [with] urine and feces." The hospital Clinical Record indicated Resident 1 was admitted into CPCU (Cardiac [heart] Progressive Care Unit- unit that provides specialized care to patients requiring heart monitoring for various cardiovascular [heart] disorders) ..." During a review of the facility's policy and procedure titled, "Elopement/Wandering Resident", dated 6/2017, indicated, "Policy the facility will strive to prevent unsafe wandering ... for residents who are at risk for wandering ...1. The staff will identify residents who are at risk for harm because of unsafe wandering (including elopement) ... 2. The staff FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 9 of 10 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555426 (X3) DATE SURVEY COMPLETED 01/16/2020 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FRESNO POSTACUTE CARE 1233 A St Fresno, CA 93706 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE will assess at risk individuals for potentially correctible risk factors related to unsafe wandering ..." During a review of the facility's policy and procedure titled, "Mechanical Alarm System," dated 6/2017, indicated, "Policy- To provide an environment that is hazard free ...control and supervision and assistive device are used to ensure that avoidable incident of accidents as a result of elopement ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: Y5PT11 Facility ID: CA040000004 If continuation sheet 10 of 10