Other·February 25, 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 during an investigation of an ABBREVIATED SURVEY for Complaints: CA00588030, CA00588864, CA00598684, CA00598760, CA00599257, and CA00599461 and Facility Reported Incidents: CA00600906, CA00602291, and CA00602347. Representing the California Department of Public Health - Licensing and Certification: 28531 RN HFEN, 29470 RN HFEN, 39227 RN HFEN, 39982 RN HFEN, 40030 RN HFEN, 40125 RN HFEN,40233 RN HFEN, 40358 RN HFEN, and 40641 RN HFEN. Complaint CA00588030: Unsubstantiated. Complaint CA00588864: Substantiated; Refer to F697. Complaint CA00598684: Substantiated; Refer to F725. Complaint CA00598760: Substantiated; Refer to F656. Complaint CA00599257: Substantiated; Refer to F656 and F689. Complaint CA00599461: Substantiated; Refer to F684. FRI CA00600906: Substantiated; Refer to

F656. FRI CA00602291: Substantiated with no deficiencies. 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: AL2L11 Facility ID: CA040000014 If continuation sheet 1 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 FRI CA00602347: Substantiated with no deficiencies.

F656 SS=H Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 03/18/2019 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 2 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan based on the assessment of a resident's identified risks for falls for three of 20 sampled residents, (Resident 1, Resident 2, and Resident 3), when: 1. Resident 1 did not have individualized fall prevention interventions developed and implemented after falls occurred. 2. Resident 2 was assessed as impulsive and independent-minded with poor safety awareness, and required a one person assist for transfer, toileting and mobility. Specific interventions for fall risk prevention based on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 3 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Resident 2's assessed needs and behaviors were not implemented. 3. Resident 3's fall was not identified in his fall care plan and there were no updated fall interventions documented after a fall occurred. As a result of these failures Resident 1 sustained six falls. Resident 1's fifth fall on 8/6/18 resulted in multiple facial fractures with bleeding behind the eye which required emergency transfer to the general acute care hospital (GACH) for evaluation and treatment. Resident 2 sustained six falls within 48 days of admission to the skilled nursing facility (SNF). Resident 2's sixth fall resulted in a right sided scalp hematoma (collection of blood under the skin) and a change in mental status which required transfer to the GACH for observation and treatment. Resident 2 expired on 8/6/18 in the GACH from unknown causes. Resident 3 was placed at risk for injury from falls. Findings: 1. Review of Resident 1's undated clinical record, titled, "Face sheet" (a document with personal identifiable information) indicated Resident 1 was admitted to the SNF on 7/11/18 with medical diagnoses of hypertensive encephalopathy (brain impairment due to significantly high blood pressure) and history of falling. Review of Resident 1's clinical record, titled, "Minimum Data Set" (MDS) assessment (a resident assessment tool used to plan care), dated 7/18/18, indicated, Resident 1's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was five of 15 points, which indicated severe cognitive (pertaining to memory, judgement and reasoning) impairment. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 4 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 MDS assessment indicated Resident 1 required extensive assistance (staff provided weight-bearing support) for bed to chair transfers. The MDS indicated Resident 1 was unsteady when moving from one surface to another and was only able to stabilize with staff assistance. Review of Resident 1's clinical record, titled, "Admission fall risk assessment," dated 7/11/18, indicated Resident 1 had a fall risk score of 19 which indicated the resident was a high risk for falls (High Risk 16-60, Moderate Risk 6-15, Low Risk 0-5). Review of Resident 1's clinical record, titled, Fall care plan dated 7/11/18, indicated an actual fall occurred 7/11/18 with no injury secondary to poor balance. On 8/14/18 at 11:50 a.m. during a concurrent observation and interview, Resident 1 sat in her wheelchair on the facility patio. Resident 1's left eye was swollen shut and had dry crusted drainage surrounding the eye. Resident 1 stated, "I fell. That's why my eye is swollen." On 8/14/18 at 12 p.m. during a concurrent observation and interview, Physical Therapist (PT) 3 stated Resident 1's swollen eye occurred as the result of a fall on 8/6/18. PT 3 stated Resident 1 should have been placed on the falling star program (a program to alert staff a resident was a high risk for falls) when she was first identified as a high fall risk. PT 3 stated residents who were high risk for falls should have a falling star sign on the back of their wheelchair and on their room door name plate. Resident 1's wheelchair was observed and no falling star sign was seen. PT 3 stated there was no falling star sign on the back of Resident 1's wheelchair or on her door name plate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 5 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 8/14/18 at 12:45 p.m., during an interview, Licensed Nurse (LN) 7 stated, "The falling star sign is our first intervention for high fall risk residents." On 8/15/18 at 7 a.m., during an interview, LN 11 stated the falling star sign should be placed on the resident's door name plate and wheelchair. LN 11 stated the falling star sign alerted staff that a resident was a high fall risk. LN 11 stated, "If there is no falling star sign the staff from the other station or a new employee will not know that the resident is a high fall risk." On 8/20/18 at 4:35 p.m., during a concurrent interview and record review, PT 1 reviewed Resident 1's "Physical Therapy Plan of Care" dated 7/13/18. PT 1 stated Resident 1 was evaluated on 7/13/18 and required moderate assistance (requires 26 to 75 percent assistance of staff to accomplish activity) with bed mobility and a one person assist with walking while using a walker. PT 1 stated Resident 1's balance was not steady enough to transfer on her own without staff assistance. Review of Resident 1's PT [Physical Therapy] Daily Treatment Note dated 7/16/18, indicated, "Resident fatigues easily and tends to lean to her R [right] side, needed assistance to assume upright sitting...impaired safety awareness needing constant redirection, resident also noted to have impaired vision, unable to see what is in front of her, unable to manage obstacle avoidance." On 8/21/18 at 3:49 p.m., during a concurrent observation and interview, Resident 1 sat in a wheelchair in the hallway across from the nurses' station. Resident 1 was observed to have bruising under both eyes. Resident 1 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 6 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 stated she fell from her wheelchair. Resident 1 stated she had fallen three or four times. Resident 1 started to lean forward in her wheelchair. Resident 1 was asked why she was leaning forward and Resident 1 stated the middle of her back hurt since her last fall (fall on 8/6/18). On 8/25/18 at 4 p.m., during an interview, LN 2 stated Resident 1 was impulsive and required redirection to sit back down in wheelchair. LN 2 stated one on one staff supervision for Resident 1 was the last intervention left to implement for fall prevention. LN 2 stated the facility did not use one on one staff assistance due to not having enough staff available to implement the intervention. On 9/10/18 at 2:25 p.m., during a concurrent interview and record review, LN 2 stated Resident 1 had a witnessed fall (first fall in the facility) without injury on 7/11/18 (the day Resident 1 was admitted to the SNF). LN 2 stated a certified nursing assistant (CNA) observed Resident 1, on 7/11/18, stand up unsteadily from her bed and fall onto the floor on her knees. LN 2 stated she should have looked at the care plans to make sure a fall care plan was in place after Resident 1's fall. LN 2 reviewed Resident 1's clinical record and stated she was unable to find a fall care plan created for Resident 1's fall on 7/11/18. LN 2 stated it was her responsibility to create the fall care plan. On 9/11/18 at 11:22 a.m., during a concurrent interview and record review, the Chief Nurse Executive (CNE) stated a fall care plan for Resident 1's fall of 7/11/18 was initiated on 7/11/18 and revised on 7/12/18. The CNE stated the fall care plan dated 7/11/18 indicated Resident 1 had fallen but had no identified interventions to prevent further falls for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 7 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Resident 1. Review of Resident 1's clinical record, titled, "Care plan" dated 7/11/18, indicated, Resident 1 fell on 7/11/18 secondary to poor balance. The care plan section titled, "Goals" indicated, "...The resident will resume usual activities without further incident through the review date [review date not indicated]." The care plan section titled, "Interventions/Tasks" was left blank without any documented fall risk prevention interventions identified. Review of Resident 1's clinical record, titled, "Progress note" dated 7/12/18, indicated, Resident 1 had a fall (second fall) on 7/12/18. The progress note indicated, "Pt [patient] was found on the floor by nursing staff, yelling help on the floor next to her bed..." On 9/10/18 at 10:28 a.m., during a concurrent interview and record review, LN 11 stated she was the nurse on duty on 7/12/18 when Resident 1 fell the second time. LN 11 stated she initiated the falling star program after Resident 1 fell on 7/12/18. LN 11 stated she verbally alerted the CNAs on duty on 7/12/18 to include Resident 1 in the falling star program. LN 11 stated she did not document the fall alert in the electronic record, Resident 1's care plan or the Kardex (a written system used by staff including CNAs that provided pertinent resident care information) and she should have. LN 11 stated she did not update Resident 1's fall risk assessment on 7/12/17 and she should have after the fall. LN 11 stated Resident 1's fall risk care plan should have been updated after the fall to include new interventions to prevent falls and she was responsible to complete the updates. LN 11 reviewed Resident 1's care plan and stated she could not find an updated fall risk care plan for 7/12/18 with interventions to prevent falls. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 8 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Review of Resident 1's clinical record, titled, "Interdisciplinary (IDT) (a team of healthcare providers including nurses, social service, activity and dietary staff who meet to plan resident care) notes," dated 7/20/18, indicated Resident 1 had a witnessed fall (third fall) without injury on 7/20/18. On 9/6/18 at 10:30 a.m., during an interview, CNA 3 stated she was assigned to provide care for Resident 1 on 7/20/18 (the day of the third fall). CNA 3 stated she started to propel Resident 1's wheelchair when Resident 1 leaned forward and stated she wanted to lay down. CNA 3 stated she assisted Resident 1 to the floor as she leaned forward. CNA 3 stated Resident 1 constantly leaned forward while sitting in her wheelchair and made statements that she was going to fall. Review of Resident 1's clinical record, titled, "Fall Risk Assessment" dated 7/20/18 following the third fall indicated Resident 1 had a fall risk score of 22 (high risk for falls). Review of Resident 1's clinical record, titled, "IDT Meeting Summary" dated 7/20/18, indicated, "1. Meeting Type a) fall...4. IDT Recommendations...allow resident to have choices as possible and have resident by the nurses station..." Review of Resident 1's clinical record, titled, "Revised care plan", dated, 7/20/18, indicated, "Focus...The resident is high risk for falls [related to] Confusion, Deconditioning, Gait/balance problems, Hypotension, Poor communication/comprehension, Vision/hearing problems, [history] of falls...Goal...Risk for fall/injury will be minimized with interventions thru [through] next review...Interventions...Anticipate and meet the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 9 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 resident's needs for toileting, mobility, and nourishment. Inquire to the resident's needs throughout shift and before leaving the resident's room...Be sure the resident's call light is within reach at all times and encourage the resident to use it for assistance as needed...Educate the resident/family/caregivers about safety risk factors...The resident needs a safe environment free from spills or clutter, and adequate, glare-free light. Inspect resident's room [every] Shift and when providing care..." The revised care plan dated 7/20/18 did not include the IDT recommendations of allowing Resident 1 to have choices as possible and to have Resident 1 by the nurses' station. On 9/10/18 at 9:26 a.m. during a concurrent interview and record review, Minimum Data Set Coordinator (MDSC) 3 reviewed Resident 1's fall care plan interventions created on 7/20/18. MDSC 3 stated the care plan interventions were not individualized to Resident 1's fall risk needs. MDSC 3 stated the care plan interventions to keep the call light within reach and to provide a safe environment were standard interventions used for all residents in the facility and not specific for Resident 1's fall risks. On 9/11/18 at 10:56 a.m., during a concurrent interview and record review, the Chief Nurse Executive (CNE) reviewed Resident 1's risk for falls care plan dated 7/20/18 and stated the intervention for anticipating Resident 1's needs were not specific to Resident 1. The CNE reviewed the intervention regarding educating resident/family/caregiver about safety risk factors and stated the intervention did not specify the specific education to be provided. The CNE stated all residents in the facility had an intervention to keep the environment safe; it was not specific for Resident 1's needs. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 10 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 CNE could not explain what individual approaches would be made to meet Resident 1's need for safety. Review of Resident 1's clinical record, titled, "Progress notes" dated 7/28/18, indicated Resident 1 had a witnessed fall (fourth fall) on 7/28/18. Resident 1's "nurse's note" dated 7/28/18, indicated, "[Resident 1] was observed by writer, lowering herself to the floor on her knees. [Resident 1] had left knee on the floor, holding onto door knob of utility room. [Resident 1] stated "[Resident 1] on the floor ..." On 9/11/18 at 11:35 a.m., during an interview, the CNE stated the fall on 7/28/18 was considered a fall because Resident 1 had lowered herself onto the floor on her knees. The CNE stated there no fall risk assessment, incident note, or IDT note completed after Resident 1's fall on 7/28/18. The CNE stated the fall risk assessment and incident note should have been completed following the fall per facility policy. On 9/14/18 at 10:17 a.m., during a concurrent phone interview and record review, LN 1 stated she was on duty on 7/28/18 and witnessed Resident 1's (fourth) fall. LN 1 stated Resident 1's fall care plan and interventions were not updated following the fall on 7/28/18 and should have been. LN 1 stated, "In hindsight, [Resident 1] needed supervision." Review of Resident 1's clinical record, titled, "Incident note," dated, 8/6/18 at 7:03 p.m., indicated, Resident 1 had an unwitnessed fall (fifth fall) on 8/6/18. Resident 1's incident note dated 8/6/18, written by LN 3, indicated, "At 7:03 p.m. writer at nursing station area, heard loud noise thump like sound in front of nursing station, ran to check, found resident on floor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 11 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 laying on her left side...noted abrasion at left lower eye lid...approximately 5 cc [cubic centimeter, unit of volume measurement] fresh blood dripped from left nostril...paramedic arrived...[Resident 1] left facility via stretcher..." Review of Resident 1's GACH clinical record dated 8/6/18, indicated, "History Chief Complaint...Fall [from] wheelchair sent from [Skilled Nursing Facility]...female who presents to the ED [Emergency Department] via ambulance for blunt trauma. Per [Emergency Medical Service], the patient fell out of her wheelchair at her skilled nursing facility and landed on her left face at approximately [7 p.m.]...En route, she was hypertensive [high blood pressure] in the 220's [normal: less than 120 millimeters of mercury]. In the ED now, the patient complains of a headache and [nausea and vomiting]...CT [computed tomography scan] (specialized x-ray that provides crosssectional images of the bones, blood vessels and soft tissues inside the body) Head ...Left facial trauma including multiple facial fractures, retro-orbital hemorrhage [bleeding behind the eye] in proptosis [bulging of the eye]...CT Maxillofacial [the jaw and face]... Fractures of the left lateral orbital wall, orbital floor, maxillary sinus [below the cheeks, above the teeth and on the sides of the nose], and zygomatic arch [the bony arch at the outer border of the eye socket]...Lateral canthotomy [a procedure used to decompress bleeding or swelling of the eye] performed emergently [required to be completed urgently]." Review of Resident 1's GACH clinical record titled, "Discharge Summary," indicated, Resident 1 remained in the GACH for five days following the fall on 8/6/18 for treatment of multiple facial fractures, increased intraocular pressure (pressure within the eye), persistent oozing of blood from the left lateral canthus FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 12 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 (inner corner of the eye) and "complex medical problems." On 9/6/18 at 3:55 p.m., during a concurrent interview and record review, LN 3 reviewed Resident 1's care plan dated 8/6/18 (following the fifth fall) and stated the only intervention identified was "Sent to acute ( GACH)." The care plan did not include any new interventions to prevent future falls for Resident 1. Review of Resident 1's clinical record, titled, "Face sheet" indicated Resident 1 was readmitted to the SNF from the GACH on 8/11/18. Resident 1's revised fall care plan dated 8/11/18, indicated, "Focus...The resident has a history of falls resulting in fracture of face, Cerebrovascular Accident, Poor Balance, Unsteady gait...Goal...Resident will not experience an avoidable fall with a major injury within next 30 days...Interventions/Tasks...Assist the resident with [Activities of Daily Living] and transfers as indicated...Determine causal factors related to previous falls. Address each causal factor in the care plan...Ensure the resident has adequate light in their room...Instruct the resident to use the call light to request assistance. Ensure the call light is within reach of the resident..." The care plan did not include any new resident specific interventions related to causal factors to prevent future falls for Resident 1. Review of Resident 1's clinical record, titled, "Incident note" dated 8/24/18 at 4:20 p.m., indicated Resident 1 had a fall (sixth fall) on 8/24/18. The incident note indicated, "...informed by nursing staff that [Resident 1] fell ...found that resident is on the floor...Resident is on her R [right] side lying position, right arm is underneath her, both lower extremities are extended...It has been FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 13 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 noted that resident is very impulsive, tries to get out of her chair constantly. Yelling for help and when staff goes and asked what she needs she will state "I just need you to be here."...When resident was asked what happened, resident cannot give definite answer and stated "I don't know. I just can't help it...complaint of pain on her right side of face/head..." On 9/20/18 at 10:25 a.m., during an interview, CNA 10 stated Resident 1 required someone with her at all times because Resident 1 frequently moved from her wheelchair. CNA 10 stated if Resident 1 moved from her wheelchair or bed she could fall down. On 9/20/18 at 10:50 a.m., during an interview, CNA 11 stated since Resident 1 was first admitted to the SNF, Resident 1 would get up by herself from her wheelchair. CNA 11 stated staff needed to watch Resident 1 for safety. On 9/21/18 at 12:22 p.m., during a telephone interview, LN 8 stated Resident 1 had a behavior of attempting to stand up on her own for no known reason since she was first admitted to the SNF. LN 8 stated staff offered to take Resident 1 to the toilet every two hours to decrease her risk of falling. LN 8 stated the intervention was not always effective because Resident 1 would continue to stand up from her wheelchair. LN 8 stated staff monitored Resident 1's behavior every 30 minutes to decrease her risk for falls. LN 8 stated other licensed nurses in the facility told her the SNF did not provide one to one supervision for residents for fall prevention. LN 8 stated Resident 1 was impulsive and needed someone to watch her. LN 8 stated Resident 1 had a fall on 8/24/18 which could have been prevented if Resident 1 had been provided with one on one supervision by staff. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 14 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 facility policy and procedure titled, "Care Plans" dated 11/24/17, indicated "...To standardize the development and update of resident care plans that address the physical, mental and psychosocial needs of the resident...5. The resident's care plan is to be updated per the resident's request, including their preferences. If a resident's preference could cause harm to the resident, the IDT is to discuss the risks vs benefits of the resident's preference(s)...8. Interventions are those services, items and approaches that specific staff is to carry out to aide the resident in attaining and maintaining their highest functional level and prevent further decline, when possible..." The facility policy and procedure titled, "Fall Program" dated 11/24/17, indicated, " Purpose: To identify resident's who are at risk of falling and prevent accidents by providing an environment that is free from hazards. To enhance each resident's mobility by removing the risk of falls when possible and reduce the incidence of falls and injuries that may accompany falls. Policy: It is the policy of this facility that each resident is to be evaluated upon admission, quarterly and as needed by a Licensed Nurse to determine factors that place the resident at a risk for falls. The resident's care plan is to be developed by the interdisciplinary team to include the least restrictive methods possible to keep the resident safe. The resident's environment is to remain as free of accident hazard as is possible and all residents are to receive adequate supervision and assistive devices to prevent accidents...5. The Fall Risk care plan should include those factors identified on the risk assessment and interventions to prevent falls. 6. Residents identified as being "High Risk" for falls should have specific interventions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 15 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 that address each of the resident's factors and potential factors ...8. Residents at "High Risk" may be placed on a Falling Star Program that alerts staff to monitor residents who have a higher risk of falling. a. Place a star on the resident's door name plate or door frame...b. Alerts should be added to the Special Instructions in the electronic record...c. Indicate participation in the resident's care plan that is sent to the Kardex..." 2. Review of Resident 2's clinical record, titled, "Face sheet" indicated an admission date of 5/20/18 with diagnoses which included dysphasia (a condition that affects the ability to produce and understand spoken language) following cerebral vascular disease (a variety of medical conditions which affect the blood vessels and circulation of blood in the brain), muscle weakness, difficulty in walking, anxiety, and unspecified psychosis (a mental disorder characterized by a loss of contact with reality and an inability to think rationally). Resident 2's physician orders dated 5/20/18 indicated Resident 2 was admitted to the facility for skilled nursing services with a diagnosis of altered mental status. Review of Resident 2's clinical record, titled, "Nursing Admission Assessment" dated 5/20/18, indicated Resident 2 had falls in in the past six months prior to admission to the facility. Review of Resident 2's clinical record, titled, "Fall Risk Assessment" dated 5/20/18 at 4:26 p.m., indicated a fall risk assessment was completed for the resident with a fall score of 18 which reflected the resident was at a high risk for falls. Review of Resident 2's clinical record, titled, "Fall care plan" dated 5/20/18, indicated, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 16 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 "Focus...The resident states having a recent fall, and has a high risk for falls r/t [related to] Vision/hearing/gait problems..." Resident 2's initial fall care plan interventions dated 5/20/18, indicated,"...Anticipate and meet the resident's needs for toileting, mobility and nourishment. Inquire into the resident's needs throughout shift and before leaving the resident's room...Be sure the resident's call light is within reach at all times and encourage the resident to use it for assistance as needed...PT [Physical Therapy] evaluate and treat as ordered or PRN [as needed]..." Review of Resident 2's clinical record, titled, "Care plan" revealed, "Focus... The resident has limited physical mobility r/t [related to]Weakness..." dated 5/20/18, indicated, "...Interventions...Mobility: The resident requires 1 staff participation for mobility..." Review of Resident 2's clinical record, titled, "Nurses notes" dated 5/22/18 at 6:43 p.m., indicated, "Per family Resident has a history of falls. Resident loves to walk and use the toilet whenever possible. However, resident has tendency getting out of the bed anytime without using the call light button. Family is requesting bed/chair alarm for the resident..." Review of Resident 2's clinical record, titled, "Physician orders" dated 5/22/18 at 7:07 p.m., indicated the physician ordered a pad alarm while in bed and chair for 30 days. Resident 2's physician orders dated 6/18/18 at 9:55 a.m., indicated the pad alarm was discontinued. Review of Resident 2's clinical record, titled, "Care plan" revealed, "Focus...The resident is resistive to care r/t adjustment to nursing home..." dated 5/24/18, indicated, " Interventions......Allow the resident to make decisions about treatment regime, to provide FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 17 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 sense of control...Educate the resident/family/caregivers of the possible outcome of not complying with treatment or care...Encourage as much participation/interaction by the resident as possible during care activities...Give clear explanation of all care activities prior to and as they occur during each contact..." The care plan indicated no further updated interventions were developed. Review of Resident 2's clinical record, titled, "Admission Minimum Data Set" assessment, (MDS) (an assessment of a resident's functional and cognitive status) dated 5/27/18, indicated Resident 2's BIMS score was 11 of 15 points, which indicated moderate cognitive impairment. The MDS indicated Resident 2 required extensive assistance with one-person physical assist for transfer, limited assistance with one-person physical assist for walking in her room, and limited to extensive one-person physical assist for locomotion with a wheelchair. The MDS indicated Resident 2 was not steady and was only able to stabilize with staff assistance when moving from seated to standing position, ambulating with and without a device, moving on and off the toilet and during transfers from bed to chair or wheelchair. Review of Resident 2's clinical record, titled, "Progress notes" indicated Resident 2 had six unwitnessed falls on the following dates: 6/17/18, 6/18/18, 7/8/18, 8/1/18, and 8/3/18. Resident 2's fall on 8/3/18 resulted in an injury and transfer to the acute hospital. Review of Resident 2's progress notes indicated Resident 2 had an unwitnessed fall (first fall in facility) on 6/17/18 in her room. Resident 2's progress notes indicated Resident 2 was found sitting on the floor in the bathroom door frame and stated she hit her head. Resident 2's record indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 18 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 there was no post fall risk assessment completed for Resident 2. Review of Resident 2's clinical record, titled, "Interdisciplinary Team (IDT) (facility department managers, including the director of nursing, licensed nurses, MDS coordinators, who review resident care needs and create recommendations to be implemented in the residents plan of care) Meeting Summary" dated 6/21/18 at 9:22 a.m., indicated Resident 2 had a fall on 6/17/18. The IDT summary indicated under Root Cause/ Contributing Factors, "poor safety awareness, attempting to maintain independence." Review of Resident 2's clinical record, titled, "Fall care plan" dated revised 6/21/18, indicated, "...toileting program AC [before meals] and HS [at bedtime]..." Review of Resident 2's clinical record, titled, "Progress notes" dated 6/18/18 at 6:44 a.m., indicated on 6/18/18, Resident 2 had an unwitnessed fall (second fall in facility) in her room. Resident 2's progress notes indicated Resident 2 was found sleeping on the floor next to her bed. The progress notes indicated Resident 2 had a skin tear on her left elbow from the fall. Resident 2's record indicated a fall risk assessment was completed for Resident 2 with a score of 21 which indicated a high risk for falls. Review of Resident 2's clinical record, titled,"IDT Meeting Summary" dated 6/18/18 at 9:19 a.m., indicated Resident 2 had a fall on 6/18/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Resident wanted to sleep on the floor." The IDT recommendation was to place nonskid strips on the floor next to the resident's bed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 19 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Review of Resident 2's clinical record, titled, "Fall care plan" indicated, "...Family refused to be close to nurse station...Initiated: 06/18/2018...NON skid strips on floor next to bed...Initiated: 06/21/2018." Review of Resident 2's clinical record, titled, "Care plan" for Activities of Daily Living (ADL, bathing, grooming, eating and other activities of daily living) indicated, "Focus...the resident states she needs assistance with ADL Self Performance Deficit r/t Limited Mobility..." The updated care plan interventions initiated on 6/18/18, indicated Resident 2 required one staff assistance for toilet use and transfer, and one staff participation for mobility. On 9/10/18 at 10:20 a.m., during an interview, LN 18 stated Resident 2 fell (2nd fall) on 6/18/18. LN 18 stated he and LN 19 found Resident 2 lying on the floor next to her bed with a pillow under her head and covered with a blanket. LN 18 stated Resident 2 stated she wanted to sleep on the floor. LN 18 stated he did not think Resident 2 fell, but deliberately got out of bed and laid on the floor. LN 18 stated Resident 2 understood others and directions but was not consistent with the use of her call light. LN 18 stated the staff often observed Resident 2 getting up, unassisted, to go to the bathroom. LN 18 stated Resident 2 wanted to be independent with her ADLs. LN 18 stated Resident 2 had an unsteady gait and needed to be supervised when she ambulated. LN 18 stated a resident with frequent falls should have care plan interventions based on why the resident was falling and the interventions should be specific to that resident's needs. LN 18 stated because Resident 2 wanted to be independent and did not always use the call light for assistance, she (Resident 2) needed one on one supervision. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 20 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 9/10/18 at 3:20 p.m., during an interview CNE stated non-skid strips were placed on the floor at the side of Resident 2's to prevent a resident from slipping and falling. The CNE stated she was not aware LN 18 thought Resident 2 had got up out of bed and just laid down on the floor on 6/18/18. The CNE stated the IDT reviewed the incident note regarding the fall but did not necessarily talk to the nurse about the fall. Review of Resident 2's progress notes dated 7/8/18 at 2 p.m., indicated Resident 2 had an unwitnessed fall (third fall in the facility) on 7/8/18 in the hallway. Resident 2's progress notes indicated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. The progress note indicated Resident 2 reported she stood up, her legs were tired and she sat down. The progress notes indicated a fall risk assessment was completed for Resident 2 with a score of 17 which indicated a high risk for falls. Review of Resident 2's clinical record, titled, "Care plan" revealed, "...Focus The resident states she has had an actual fall on 7/8/18 with no injury, Poor Balance, Unsteady gait" and dated 7/8/18 indicated, "...Interventions...Apply bed alarm (a device that alarms when the resident gets out of bed) q (every) shift and check for its functional...Continue with interventions on the at-risk [falls] plan...Neuro checks [assessment of a resident's alertness, ability to follow directions and reaction of pupils to light as indicators of possible nervous system damage] x [times] 72 hours..." The interventions were dated 7/8/18. Review of Resident 2's clinical record, titled, "Physician orders" for 7/18 indicated no orders for a bed alarm for Resident 2. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 21 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Review of Resident 2's clinical record, titled, "IDT Meeting Summary" dated 7/9/18 at 9:51 a.m., indicated Resident 2 had a fall on 7/8/18. The IDT summary indicated under Root Cause/ Contributing Factors, "poor safety awareness, resident chooses to ambulate independently." Review of Resident 2's clinical record, titled, "Fall care plan" dated 5/20/18, indicated, "Interventions...anti roll back bars on wheelchair...initiated 7/9/18..." On 9/6/18 at 9:10 a.m., during an interview, LN 1 stated Resident 2 had a tab alarm (an alarm attached to a resident's clothing and to the bed or wheelchair intended to alert staff when the resident stands up) for a while but it was discontinued and she did not remember when it was removed. On 9/6/18 at 2:48 p.m., during an interview, LN 15 stated she was Resident 2's nurse on 7/8/18 (the day of the third fall). LN 15 stated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. LN 15 stated Resident 2's wheelchair wheels were not locked and it was possible Resident 2 slipped while trying to sit back down on the wheelchair seat. LN 15 stated a fall care plan intervention was initiated to place anti roll back bars on Resident 2's wheelchair. On 9/6/18 at 2:56 p.m., during a concurrent interview and record review, LN 15 stated Resident 2 was a high risk for falls and should have been on the falling star program. LN 15 reviewed Resident 2's care plans and was unable to find an intervention which indicated Resident 2 was placed on the falling star program. LN 15 stated Resident 2 should have been on the falling star program after her first fall. LN 15 stated the falling star program was "One of the basic interventions for a resident at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 22 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 a high risk of falls." LN 15 stated the falling star program consisted of placing small signs with yellow stars on a resident's door name plate, wheelchair, and on the head of the resident's bed to alert staff to a resident at high risk of falls. Review of Resident 2's clinical record, titled, "progress notes" dated 7/18/18 at 7:32 p.m., indicated Resident 2 had an unwitnessed fall (fourth fall in the facility) on 7/18/18 in the hallway. Resident 2's progress notes indicated at 6:35 p.m. the LN was told by a resident that Resident 2 was on the floor in the hallway. Resident 2 was found lying on the hallway floor next to her wheelchair, just a few doors down from her room. The progress notes indicated a fall risk assessment for Resident 2 was completed by the LN with a score of 23, which reflected Resident 2 was a high risk for falls. Review of Resident 2's clinical record, titled, "IDT Meeting Summary" dated 7/19/18 at 9:51 a.m., indicated, Resident 2 had a fall (fourth fall) on 7/18/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." The IDT recommendation was to educate the resident and responsible party on the risks versus benefits of independent ambulation. Review of Resident 2's clinical record, titled, "Fall care plan" dated revised 7/19/18 indicated, "...resident and family educated on risks vs [versus] benefits of independent ambulation..." Review of Resident 2's clinical record, titled, "Progress notes" dated 8/1/18 at 4:38 a.m., indicated Resident 2 had an unwitnessed fall (fifth fall in the facility) on 8/1/18 in her room. Resident 2's progress notes indicated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 23 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 2 was found on the floor at the side of her bed putting on her pants. The progress notes indicated Resident 2 reported she fell while changing her clothes. The progress notes indicated Resident 2 was assessed by the LN and had no injuries but complained of a pain level of seven of 10 (where 0 is no pain and 10 is the worst pain imaginable) which indicated severe pain. Resident 2's progress notes did not indicate the location of Resident 2's pain. Resident 2's progress notes indicated a fall risk assessment was completed by the LN with a score of 22 which reflected a high risk of falls. Review of Resident 2's clinical record, titled, "IDT Meeting Summary" dated 8/1/18 at 9:44 a.m., indicated Resident 2 had a fall on 8/1/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." The IDT recommendation was to place neon green tape on the resident's call light to remind the resident to call for help. Review of Resident 2's clinical record, titled, "Fall care plan" dated revised 8/1/18 indicated, "...Apply bright green tape to call light to remind resident to use it..." On 9/6/18 at 2:30 p.m., during an interview, LN 15 stated Resident 2 knew she needed assistance with Activities of Daily Living (ADL) but was impulsive and would not wait for assistance. LN 15 stated Resident 2 often refused assistance. LN 15 stated Resident 2 would change her clothes multiple times, often unassisted. On 9/10/18 at 10:50 a.m., during an interview, LN 19 stated she was Resident 22's nurse when Resident 22 had the fifth fall on 8/1/18. LN 19 stated Resident 2 was sitting on the floor at the side of her bed putting on her pants. LN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 24 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 19 stated Resident 2 often got up out of bed without assistance. On 9/10/18 at 3:04 p.m., during an interview, LN 1 stated Resident 2 was impulsive and did not always use her call light for assistance. Review of Resident 2's clinical record, titled, "Progress notes" dated 5/22/19, 6/9/18, 6/10/18, 6/20/18, 6/28/18, 6/30/18, 7/5/18, 7/9/18, 7/10/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 8/1/18 and 8/2/18 indicated Resident 2 got up unassisted, did not use her call light, ambulated without assistance, wandered into other residents' rooms, and had an unsteady gait. Review of Resident 2's clinical record, titled, "Progress notes" dated 6/9/18, 6/20/18, 7/5/18, 7/10/18, 7/21/18 indicated the LNs provided Resident 2 education on the use of her call light for assistance in transferring and ambulating. Resident 2's progress notes indicated education on the use of the call light was not effective. Review of Resident 2's clinical record, titled, "Progress notes" dated 8/3/18 at 2:20 a.m., indicated Resident 2 had an unwitnessed fall (sixth fall) on 8/3/18 in her room. Resident 2's progress notes indicated, "Writer [LN 22] was alerted by CNA in hallway that resident [Resident 2] had fallen. Writer entered resident room, resident was laying on right side on ground with approximately 30 ml (milliliter-a liquid unit of measure) of blood under right side of head...Emergency services called. Resident breathing w/ (with) small amount of white foam coming from mouth. Not responsive to name or situation...Pupils equal, sluggish to respond...transferred to [GACH]...for acute care." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 25 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Review of Resident 2's clinical record, titled, "GACH" records with an admit date of 8/3/18 indicated, "CHIEF COMPLAINT...Fall Found down, unresponsive, at SNF, pt (patient) is a GCS (Glasgow Coma Scale- a scoring system used to gauge the severity of an acute brain injury) of 8 (8 or less indicated severe brain injury)...bleeding hematoma (a collection of clotted blood under the skin)...CT ( Computerized Tomography) (a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) head showed hematoma with no fracture or intracranial hemorrhage (bleeding). CT C [cervical-pertaining to bones in the neck] spine showed no fracture." The GACH clinical record indicated, "Invasive Procedures: 1. Intubation [tube placed into the lungs to assist breathing] 2. NG [nasogastric] tube [tube placed through the nose into the stomach for the purpose of administering medications, food or fluids]." Review of Resident 2's acute hospital records dated 8/7/18 indicated, "Expiration Discharge Summary...Patient pronounced dead at: 20:29 (8:29 p.m.) on 8/6/18...Findings and Hospital events leading to death: R (right) scalp (skin on head) hematoma...Presumed cause of death: unknown..." Review of Resident 2's clinical record, titled, "IDT Meeting Summary" dated 8/3/18 at 9:40 a.m., indicated Resident 2 had a fall on 8/3/18 (sixth fall.) The IDT summary indicated under Root Cause/Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." The IDT recommendation indicated, "Resident sent out to acute hospital for further evaluation related to head injury and LOC [loss of consciousness]." On 9/6/18 at 2:30 p.m., during an interview, LN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 26 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 15 stated Resident 2 knew she needed assistance with ADL but was impulsive and would not wait for assistance. On 9/7/18 at 4:35 p.m., during a telephone interview, CNA 9 stated she was Resident 2's CNA when she fell (6th fall) on 8/3/18. CNA 9 stated she knew Resident 2 was a high fall risk and needed more attention, monitoring and assistance with ADLs. CNA 9 stated at approximately 2 a.m. on 8/3/18 she heard Resident 2 crying and went into Resident 2's room. CNA 2 stated Resident 2, who was in bed B, was awake and wanted to go to the bathroom. CNA 9 stated she transferred Resident 2 from her bed to her wheelchair, took her to the bathroom and transferred her onto the toilet. CNA 9 stated after Resident 2 was toileted, she transferred the resident on to her wheelchair and to the sink to wash her hands. CNA 9 stated she then took Resident 2 to the side of her bed. CNA 9 stated she aligned Resident 2's wheelchair lateral to the side of the bed and facing the wall at the head of her bed. CNA 9 stated Resident 2 began to straighten the blue disposable pad on her bed and she (CNA 9) did not want to rush getting the resident back into bed. CNA 9 stated she wanted to get Resident 2 back into bed but Resident 2's roommate had disrobed and had her legs over the side of her bed. CNA 9 stated she told Resident 2 to stay seated and Resident 2 nodded and said "Okay." CNA 9 stated she turned away from Resident 2, took two to three steps and attended to Resident 2's roommate. CNA stated less than one minute later, she heard a "flop," turned and saw Resident 2 on the floor between bed A and B. CNA 9 stated Resident 2's head was between the bedside cabinet and her bed. CNA 9 stated she left the room for assistance. CNA 9 stated she could have called for assistance to help Resident 2's roommate and not left Resident 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 27 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 unattended. CNA 9 stated the correct thing to do was to "finish the task" and put Resident 2 back into bed before she assisted the resident in bed A. On 9/6/18 at 9:10 a.m., during an interview, LN 1 stated Resident 2 was identified as a higher risk for falls because of a history of falls. LN 1 stated Resident 2 was slightly confused, restless, very active and would frequently get up and walk by herself without calling for assistance. LN 1 stated Resident 2 wanted to exert her independence and provide her own care, which included ambulation. LN 1 stated Resident 2 could not relax or sit still, "...she was busy..." and not easily redirected. On 9/6/18 at 9:10 a.m., during an interview, LN 1 stated a Restorative Nurse Assistant (RNA) would ambulate with Resident 2 while she (Resident 2) used a front wheel walker. LN 1 stated Resident 2's gait was not steady when she ambulated with or without her walker. LN 1 stated Resident 2 would lose her balance with the walker when she turned or went through doorways. LN 1 stated Resident 2 was able to self-propel in the wheelchair and was "quick." LN 1 stated she did not think Resident 2 understood the risks and safety concerns of ambulating without assistance and did not understand the consequences of her actions. On 9/6/18 at 2:30 p.m., during an interview, LN 15 stated Resident 2 was alert to self, location, and her family's names. LN 15 stated Resident 2 was a high risk for falls. LN 15 stated Resident 2 was frantic, impulsive, and anxious about walking; it stemmed from wanting to go home with her (Resident 2's) family. LN 15 stated Resident 2 needed to be watched closely because she would get up unassisted and it was difficult to redirect the resident. LN 15 stated the RNA would walk with Resident 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 28 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 and used a front wheel walker. On 9/7/18 at 9:06 a.m., during an interview, CNA 7 stated Resident 2 "always" needed supervision when she (Resident 2) ambulated. CNA 7 stated Resident 2 needed assistance for all ADLs. CNA 7 stated she observed Resident 2 ambulating in the hallway at times with no supervision. CNA 7 stated sometimes Resident 2 used a four wheel walker (instead of the front wheel walker) and would sit on the seat of the walker because she said she was tired. On 9/7/18 at 9:15 a.m., during an interview, CNA 8 stated Resident 2 was impulsive. CNA 8 stated Resident 2 would sometimes ambulate, unsupervised, with her walker or her wheelchair. On 9/7/18 at 4:05 p.m., during an interview, LN 16 stated she was assigned as Resident 2's nurse on 7/18/18 when Resident 2 had her fourth fall. LN 16 stated she observed Resident 2 ambulating down the hallway, unsupervised, with her four-wheel walker. LN 16 stated within a minute another resident came up to the nurses' station and said Resident 2 fell in the hallway. LN 16 stated she assessed Resident 2 after the fall and there were no injuries. LN 16 stated she did not know how Resident 2 fell. LN 16 stated Resident 2 needed to be supervised when she ambulated with her walker but she (LN 16) was on the phone at the time of the fall and did not assist the resident. LN 16 stated Resident 2 was spontaneous and ambulated alone despite being told it was not safe without assistance. LN 16 stated Resident 2 would "sometimes" use her call light. LN 16 stated Resident 2's fall interventions were not effective. LN 16 stated Resident 2 should have had one on one supervision for safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 29 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 9/10/18 at 9:30 a.m., during an interview, Physical Therapist Aid (PTA) 1 stated he observed Resident 2 walking unsupervised with a walker. PTA 1 stated Resident 2 had a shuffling gait and was not safe ambulating unsupervised. PTA 1 stated Resident 2 needed stand by supervision when she ambulated with or without her walker. PTA 1 stated Resident 2 would sometimes "park" her walker and ambulate without any device. On 9/10/18 at 9:36 a.m., during an interview, PTA 2 stated Resident 2 was not safe ambulating unsupervised, "We [PT staff] told staff [nursing staff] she [Resident 2] was not safe by herself." On 9/10/18 at 10:15 a.m., during an interview, CNA 5 stated Resident 2 was always walking in her room and in the hallways unsupervised. CNA stated supervision means being near the resident to assist when help was needed. On 9/10/18 at 10:20 a.m., during an interview LN 18 stated he had been a CNA and his training was to stay with the resident until the task was completed. On 9/10/18 at 10:50 a.m., during an interview, LN 19 stated Resident 2 needed to be supervised when she was out of bed or ambulating. LN 19 stated Resident 2's family brought the resident's pink colored four-wheel walker to the facility for the resident. LN 19 she had observed Resident 2 ambulating with her four-wheel walker in the hallway unsupervised. LN 19 stated Resident 2 was not stable when she ambulated and Resident 2's four-wheel walker was "too fast" for Resident 2. LN 19 stated Resident 2 did not know how to use her four-wheel walker properly. On 9/10/18 at 11 a.m., during an interview, LN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 30 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 21 stated Resident 2 was compulsive about ambulating. LN 21 stated if Resident 2 was not monitored, she would be up ambulating without assistance. LN 21 stated, "I think she should have been a one to one [one staff providing supervision to Resident 2 at all times]." On 9/10/18 at 11:09 a.m., during a concurrent interview and record review, LN 19 stated Resident 2's fall care plan did not identify the specific behaviors which placed Resident 2 at risk for falls such as confusion, impulsive movement, a need for independence, and her inconsistent use of the call light. LN 19 stated Resident 2's fall care plan interventions did not adequately address Resident 2's risk for falls based on her behaviors. LN 19 stated a bed alarm, a room closer to the nurses' station and one on one supervision could have reduced Resident 2's risk of falls. On 9/10/18 at 11:15 a.m., LN 19 stated she knew about Resident 2's fall on 8/3/18. LN 19 stated the CNA caring for Resident 2 on 8/3/18 should have completed the task of assisting Resident 2 to bed before assisting another resident. Review of Resident 2's clinical record, titled, "Therapy to Nursing Communication Form" dated 6/12/18, indicated a referral from physical therapy to RNA. The form indicated under problems/ needs, "Decreased safety awareness leading to fall risk." Review of Resident 2's clinical record, titled, "PT- Therapist Progress & Discharge Summary" dated 6/15/18 indicated, " ...Transfers, Stand to Sit...contact guard assist (contact with patient [resident] due to unsteadiness)...Transfers, Bed< > [to and from] Chair...contact guard assist...Gait tasks: Assistive Devices ...The patient requires front FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 31 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 wheeled walker and contact guard assist (contact with patient due to unsteadiness) for safe ambulation for about 400 ft [feet] with rest breaks ..." Review of Resident 2's clinical record, titled, "Physician orders" dated 6/12/18, indicated, "RNA (Restorative Nursing Aide) 5 x/wk (five times per week) to be reviewed every 4 weeks for ambulation using FWW (front wheel walker) as tolerated..." On 9/10/18 at 12 p.m., during an interview, the RNA stated she provided stand by assistance while Resident 2 ambulated with the front wheel walker. The RNA stated Resident 2's gait and balance were unsteady and she would make sudden turns or stops. On 9/10/18 at 3:38 p.m., during an interview and concurrent record review, LN 1 stated there were no interventions on Resident 2's fall care plans which identified and addressed Resident 2's impulsive behaviors and ambulating without supervision. LN 1 stated fall care plan interventions based on Resident 2's assessed risks for falls such as impulsiveness, weakness due to previous strokes, and ambulating without assistance should have been developed and implemented. LN 1 stated there was no care plan or interventions in the fall care plan which indicated Resident 2 would not use her call light. On 9/10/18 at 3:40 p.m., during an interview and concurrent record review, the CNE stated care plan interventions did not reflect and address Resident 2's impulsive behavior and ambulation without supervision. The CNE stated a resident at risk for falls should have a care plan with identified issues which are resident specific. The CNE stated the care plan should be based on the admission FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 32 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 assessment and with ongoing assessments of additional risks and the effectiveness of the interventions. The CNE stated Resident 2's fall care plan interventions "could have been better." On 9/10/18 at 4 p.m., during an interview and concurrent record review, the CNE stated the IDT root cause analyses after each of Resident 2's falls were " ...pretty cryptic [mysterious, unclear]" and "not good." The CNE stated the IDT did not evaluate the causes of Resident 2's falls. On 9/11/18 at 9:25 a.m., during an interview PT 2 stated any resident devices brought into the facility needed an evaluation by the therapy department for safety. PT 2 stated she knew Resident 2 had a personal four-wheel walker in the facility. PT 2 stated Resident 2 was supposed to be ambulated with the facility's front wheel walker. PT 2 stated Resident 2 needed to be checked for safe use of the fourwheel walker if it was used for ambulation. PT 2 stated a four-wheel walker would not be safe for a resident if the resident was not able to properly use the brakes on the handles. On 9/11/18 at 9:33 a.m., during an interview and record review, PT 3 stated devices brought from home should have a referral by nursing to the therapy department. PT 3 stated the therapy staff screened and evaluated the device and the safe use of the device by the resident. PT 3 stated the nursing referral to the therapy department should be in the resident's chart. PT 3 was unable to find documentation of a safety evaluation of Resident 2's personal four wheel walker. On 9/11/18 at 11 a.m., during an interview LN 1 stated Resident 2's family brought a fourwheel walker for Resident 2. LN 2 stated when FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 33 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 a device was brought into the facility, it was the facility policy to notify physical therapy to evaluate the device and the resident's safe use of the device. LN 1 stated the LN should document if an evaluation of a device was done by physical therapy. On 9/11/18 at 12 p.m., during an interview and concurrent record review, LN 1 stated she was part of the IDT. LN 1 reviewed Resident 2's IDT root causes after the falls on 6/17/18, 6/18/18, 7/8/18, 7/18/18, 8/1/18, and 8/3/18. LN 1 stated the IDT root causes after Resident 2's falls were basically the same. LN 1 stated the root causes for Resident 2's falls were not specifically identified by the IDT. LN 1 stated the facility did not adequately evaluate Resident 2's risk for falls or her behaviors which placed her at a high risk for falls. LN 1 stated "We could have done better." On 9/11/18 at 2:15 p.m., during an interview, the RNA stated Resident 2 ambulated with RNA five times a week with a front wheel walker, which was the order from the therapy department. The RNA stated every time she saw Resident 2 in the hallways walking alone, she (Resident 2) used the four wheel walker brought in to the facility by her family. The RNA stated she was not aware whether PT evaluated Resident 2 using the four wheel walker. On 9/11/18 at 2:30 p.m., during an interview, LN 20 stated Resident 2 used her four-wheel walker to ambulate but the RNA staff used the front wheel walker when they ambulated Resident 2. LN 20 stated she often told Resident 2 to use the brakes on the four-wheel walker. LN 20 stated she did not know if therapy had evaluated Resident 2's use of the four-wheel walker for safety. LN 20 stated she knew Resident 2 needed to be supervised FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 34 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 while ambulating with the walker. LN 20 stated because Resident 2 was very quick, the staff supervised the resident, "as much as we could." On 9/11/18 at 2:03 p.m., during an interview, Occupational Therapist (OT) 2 stated if a resident's walker was brought into the facility, nursing should have sent a referral to PT for a safety evaluation. OT 2 stated a resident who used a four-wheel walker needed to be screened for safe use of the brakes on the walker. OT 2 stated Resident 2 was not safe with a four wheel walker because it moved faster than a front wheel walker. OT 2 stated he did not know how or why Resident 2 was allowed to use her four-wheel walker. OT 2 stated the RNA ambulated Resident 2 with a front wheel walker. OT 2 stated nursing should have referred Resident 2 to PT and/or OT after her first fall and it was not done. OT 2 stated he was not aware of Resident 2's four wheel walker being checked for safety. On 9/11/18 at 2:50 p.m., during an interview, the Administrator (ADM) stated there was no referral from nursing to physical therapy for a safety evaluation of Resident 2's four-wheel walker. The ADM stated there was no policy on safety checks for devices brought in to the facility. On 9/26/18 at 1:30 p.m., during an interview, Resident 2's Family Member (FM) 4 stated she had informed the staff at a meeting that Resident 2 needed supervision all of the time. FM 4 stated she told the staff Resident 2 wanted to be independent and would get up without assistance. FM 4 stated she thought Resident 2 would have direct supervision but the staff did not have time to provide supervision. FM 4 stated staff said the facility did not provide one on one supervision for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 35 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 residents. On 9/26/18 at 1:30 p.m., during an interview, FM 4 stated Resident 2's family brought in the four wheel walker for Resident 2 to use for walking. FM 4 stated the family thought the four wheel walker would be better for Resident 2 because it had a seat for Resident 2 if she became tired. FM 4 stated Resident 2 had not used the four wheel walker before it was brought to the facility. FM 4 stated she did not know if the facility PT checked the four wheel walker for safety but it should have been checked. FM 4 stated Resident 2 should not have used the four wheel walker if it was not safe. FM 4 stated the four wheel walker should not have been left in Resident 2's room. Review of the facility policy and procedure titled, "Care Plans" dated 11/24/17, indicated "...To standardize the development and update of resident care plans that address the physical, mental and psychosocial needs of the resident...5. The resident's care plan is to be updated per the resident's request, including their preferences. If a resident's preference could cause harm to the resident, the IDT is to discuss the risks vs benefits of the resident's preference(s)...8. Interventions are those services, items and approaches that specific staff is to carry out to aide the resident in attaining and maintaining their highest functional level and prevent further decline, when possible.." Review of the facility policy and procedure titled, "Fall Program" and dated 11/24/17 indicated, " ...each resident is to be evaluated upon admission, quarterly and as needed by a Licensed Nurse to determine factors that place the resident at a risk for falls ...all residents are to receive adequate supervision and assistive devices to prevent accidents ...Residents FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 36 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 identified as being "High Risk" for falls should have specific interventions that address each of the resident's factors and potential factors ...The higher a resident's risk for falls is, the more individualized interventions should be considered: ...i. Supervised walking program ...Residents at "High Risk" may be placed on a Falling Star Program that alerts staff to monitor residents who have a higher risk of falling...Consider previous occupation, social patterns, need for control or independence. These factors could produce a better understanding of the resident's activities as they relate to falls and help identify interventions that could decrease fall risk ..." 3. Resident 3's face sheet indicated Resident 3 was admitted to the SNF on 2/13/18 with diagnoses that included a history of falling and a fracture of the upper end of the left tibia (a bone in the lower leg). On 9/6/18 at 1:55 p.m., during an observation and concurrent interview, Resident 3 was in bed watching television. Resident 3 stated he fell getting out of bed on 6/18/18. Resident 3 stated he was impatient waiting for the staff to answer his call light and did things without waiting for assistance. Resident 3 stated he did not remember if he used the call light when he fell on 6/18/18 while transferring himself. Resident 3's progress notes dated 6/18/18 at 1:30 p.m., indicated Resident 3 fell to the floor after he attempted to transfer himself. The notes indicated Resident 3's family member was in the room at the time of Resident 3's fall and summoned the staff into the room. Resident 3 was found sitting on the floor and had no injuries when assessed by the staff. Review of Resident 3's clinical record, titled, "Care plan" dated 2/14/18 indicated, "The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 37 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 resident has a history of falls resulting in a fracture of left lower extremity. He is at risk for further falls...resident had an actual fall on 6/18/18 while transferring himself..." The care plan indicated under "Interventions/Tasks" interventions initiated on 2/14/18 but no new intervention after the fall on 6/18/18 was documented in the care plan. On 9/10/18 at 3:10 p.m., during a concurrent interview and record review, the CNE reviewed Resident 3's clinical record and stated she was unable to find documentation of new fall prevention interventions in Resident 3's care plan after the fall on 6/18/18. The CNE stated the care plan should have been updated with a new intervention after Resident 3's 6/18/18 fall. Review of the facility policy titled, "Care Plans" dated 11/24/17, indicated, "Purpose: To standardize the development and update of resident care plans that address the physical, mental and psychosocial needs of the resident...The care plan is to be updated when the resident experiences acute, temporary changes, in their medical, psychological and functional condition...The focus/problem list is to identify those areas that the resident has actual or potential risk for injury...Interventions are those services, items and approaches that specific staff is to carry out to aide the resident in attaining and maintaining their highest functional level and preventing further decline, when possible..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 38 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F684 Quality of Care CFR(s): 483.25

F684 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/18/2019 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 20 sampled residents (Resident 4) received specialized wound treatment and care to meet the resident's physical needs when orders for a negative pressure wound therapy (NPWT) (vacuum dressing to treat wounds - wound vac) and immobilizer (a brace to support a body FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 39 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 part) were not implemented upon Resident 4's admission to skilled nursing facility (SNF) 1. This failure placed Resident 4 at risk for delayed healing of the surgical wound site. Findings: Review of Resident 4's undated facesheet (a document with personal identifiable information) indicated Resident 4 was admitted to SNF 1 on 8/20/18 with medical diagnoses that included left great toe amputation (surgical removal) and chronic ulcer (a shallow wound) of the lower leg. The facesheet indicated Resident 4 was admitted to the SNF following a transfer from SNF 2. Review of Resident 4's physician's orders from the transferring facility (SNF 2) with a start date of 8/20/18, indicated " ...Surgical incision to L [left] great toe s/p [status post] amputation, irrigate with NS [normal saline], pack with GranuFoam [foam dressing used for NPWT] dressing cut into shape, apply skin prep [protective film to help reduce friction] to the surrounding skin and apply transparent dressing, then connect to wound vac [NPWT], set at 125 mmHg [millimeters of mercury][unit of measurement] intermittent/continuous pressure. Apply kerlix [gauze dressing], then ace bandage [elastic compression wrap] to support tubing. Every day shift every Mon [Monday], Wed [Wednesday], Fri [Friday] for 30 Days ...Start Date 8/20/18 ...Wear immobilizer over wound vac to LLE [Left Lower Extremity] at all times. May remove for wound change and hygiene purposes ..." On 8/21/18 at 10:17 a.m., during a concurrent observation and interview, Resident 4's left foot had a boot cover with white gauze visible from the toes. Family Member (FM) 1 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 40 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 wound vac was supposed to be on the left foot. FM 1 stated on admission (8/20/18), the head floor nurse told him (FM 1) the wound vac would be placed on Resident 4's foot that day but the wound vac was not placed on Resident 4's foot as ordered because the nurse (treatment nurse) went home for the day. On 8/27/18 at 3:45 p.m., during a concurrent interview and record review, LN 5 reviewed Resident 4's transfer orders from SNF 2 dated 8/20/18. LN 5 stated the transfer orders indicated Resident 4 was to wear an immobilizer over a wound vac to the left lower extremity at all times. LN 5 reviewed Resident 4's transfer order for the wound vac to be applied every day shift on Monday, Wednesday, and Friday for 30 days. LN 5 was unable to find the wound vac order or the immobilizer order for Resident 4 in the electronic medical record. LN 5 stated the wound vac order was not put into the physician's orders on admission to SNF 1 on 8/20/18. LN 5 stated there was no wound vac in Resident 4's room on the day of admission to SNF 1. LN 5 stated she did not notify Resident 4's physician of the wound vac and immobilizer orders received from SNF 2 on 8/20/18. LN 5 stated she did not ask the physician for clarification of the order. LN 5 stated delay in the implementation of wound vac therapy had the potential to result in wound healing complications. On 8/29/18 at 2:24 p.m., during a phone interview, MD 1(Resident 4's foot surgeon) stated SNF 1 did not follow his orders to implement a wound vac to Resident 1's foot upon admission on 8/20/18. MD 1 stated he was upset about the failure to implement the wound vac on 8/20/18. MD 1 stated Resident 4 was a "sweet lady" and he did not want her to have wound complications that could result in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 41 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 loss of her foot. On 9/5/18 at 3:15 p.m., during a concurrent interview and record review, LN 7 stated she was the treatment nurse assigned to Resident 4 on 8/21/18. LN 7 stated she observed Resident 4 to have a wet to dry gauze dressing and no wound vac on her left great toe on 8/21/18. LN 7 stated there were no orders from the transferring SNF (SNF 2) for a wet to dry dressing to the wound to the left great toe. LN 7 reviewed the SNF 2 transfer orders dated 8/20/18 and stated the order for the wound vac treatment to Resident 4's left great toe was not carried over to SNF 1's admission orders dated 8/20/18 and it should have been. Review of Resident 4's SNF 1 physician orders dated 8/21/18 indicated, "...apply wound vac at 65-75 mmHg every day shift every Tues [Tuesday], Thu [Thursday], Sat [Saturday]..." with a start date of 8/23/18. The facility policy and procedure titled "Physician Orders" dated 11/24/17, indicated " ...It is the policy of this facility to maintain a system of transcribing and noting physicians orders at the time they are received so to minimize the chance of errors ...7. Physician's orders include: b. Treatments...and any treatment may not be administered to the resident without an order from the attending physician ... FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 42 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION)

F689 Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) SS=G ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 03/18/2019 §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 interview and record review, the facility failed to provide supervision to prevent accidents for one of twenty sampled residents, (Resident 2) when Resident 2, who was assessed as impulsive, independent minded and having an unsteady gait, was not provided one staff supervision for mobility and transfers as identified in the care plan, and when Resident 2 was allowed to use a device which had not been evaluated by the therapy department for safety. These failures resulted in Resident 2 sustaining six falls within 48 days of admission to the skilled nursing facility (SNF). Resident 2's sixth fall resulted in a right sided scalp hematoma (collection of blood under the skin) and a change in mental status which required transfer to the General Acute Care Hospital (GACH) for observation and treatment. Resident 2 expired on 8/6/18 in the GACH from unknown causes. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 43 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Findings: Review of Resident 2's undated face sheet (a document with personal identifiable information) indicated an admission date of 5/20/18 with diagnoses which included dysphasia (a condition that affects the ability to produce and understand spoken language) following cerebral vascular disease (a variety of medical conditions which affect the blood vessels and circulation of blood in the brain), muscle weakness, difficulty in walking, anxiety, and unspecified psychosis (a mental disorder characterized by a loss of contact with reality and an inability to think rationally). Resident 2's "Physician orders" dated 5/20/18 indicated Resident 2 was admitted to the facility for skilled nursing services with a diagnosis of altered mental status. Review of Resident 2's "Nursing Admission Assessment" dated 5/20/18, indicated Resident 2 had falls in in the past six months prior to admission to the facility. Review of Resident 2's "Fall Risk Assessment" dated 5/20/18 at 4:26 p.m., indicated a fall risk assessment was completed for the resident with a fall score of 18 which reflected the resident was a high risk for falls. Resident 2's fall care plan dated 5/20/18, indicated, "Focus...The resident states having a recent fall, and has a high, risk for falls r/t [related to] Vision/hearing/gait problems..." Resident 2's initial fall care plan interventions dated 5/20/18, indicated,"...Anticipate and meet the resident's needs for toileting, mobility and nourishment. Inquire into the resident's needs throughout shift and before leaving the resident's room...Be sure the resident's call light is within reach at all times and encourage FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 44 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 resident to use it for assistance as needed...PT [Physical Therapy] evaluate and treat as ordered or PRN [as needed]..." Review of Resident 2's care plan titled, "Focus... The resident has limited physical mobility r/t Weakness..." dated 5/20/18, indicated "...Interventions...Mobility: The resident requires 1 staff participation for mobility..." Review of Resident 2's nurses notes dated 5/22/18 at 6:43 p.m., indicated, "Per family Resident has a history of falls. Resident loves to walk and use the toilet whenever possible. However, resident has tendency getting out of the bed anytime without using the call light button. Family is requesting bed/chair alarm for the resident..." Review of Resident 2's admission "Minimum Data Set" (MDS) assessment (an assessment of a resident's functional and cognitive status) dated 5/27/18, indicated Resident 2's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was 11 of 15 points, which indicated moderate cognitive (pertaining to reasoning, judgment and memory) impairment. The MDS indicated Resident 2 required extensive assistance with one-person physical assist for transfer, limited assistance with one-person physical assist for walking in her room, and limited to extensive one-person physical assist for locomotion with a wheelchair. The MDS indicated Resident 2 was not steady and was only able to stabilize with staff assistance when moving from a seated to a standing position, ambulating with and without a device, moving on and off the toilet and during transfers from bed to chair or wheelchair. Review of Resident 2's "Progress notes" dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 45 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 6/17/18, 6/18/18, 7/8/18, 7/18/18, 8/1/18 and 8/3/18 indicated Resident 2 had six unwitnessed falls on those dates. Resident 2's fall on 8/3/18 resulted in a right sided scalp hematoma and transfer to the acute care hospital. Review of Resident 2's Progress notes" dated 6/17/18 indicated Resident 2 had an unwitnessed fall (first fall in facility) on 6/17/18 in her room. Resident 2's "Progress notes" indicated Resident 2 was found sitting on the floor in the bathroom door frame and stated she hit her head. Review of Resident 2's "Interdisciplinary Team (IDT) (facility department managers, including the director of nursing, licensed nurses, MDS coordinators, who review resident care needs and create recommendations to be implemented in the residents plan of care) Meeting Summary" dated 6/21/18 at 9:22 a.m., indicated, Resident 2 had a fall on 6/17/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, attempting to maintain independence." Review of Resident 2's "Progress notes" dated 6/18/18 at 6:44 a.m., indicated on 6/18/18, Resident 2 had an unwitnessed fall (second fall in facility) in her room. Resident 2's progress notes indicated Resident 2 was found sleeping on the floor next to her bed. The progress notes indicated Resident 2 had a skin tear on her left elbow from the fall. Resident 2's record indicated a fall risk assessment was completed for Resident 2 with a score of 21 which indicated the resident was a high risk for falls. Review of Resident 2's "IDT Meeting Summary" note dated 6/18/18 at 9:19 a.m., indicated Resident 2 had a fall on 6/18/18. The IDT summary indicated under Root Cause/ FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 46 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Contributing Factors, "Resident wanted to sleep on the floor." The IDT recommendation was to place nonskid strips on the floor next to the resident's bed. Review of Resident 2's "Care plan for Activities of Daily Living" (ADL- bathing, grooming, eating and other activities of daily living) dated revised 6/18/18 indicated, "Focus...the resident states she needs assistance with ADL Self Performance Deficit r/t [related to] Limited Mobility..." The updated care plan interventions initiated on 6/18/18, indicated Resident 2 required one staff assistance for toilet use and transfer, and one staff participation for mobility. On 9/10/18 at 10:20 a.m., during an interview, Licensed Nurse (LN 18) stated Resident 2 fell (2nd fall) on 6/18/18. LN 18 stated he and LN 19 found Resident 2 lying on the floor next to her bed with a pillow under her head and covered with a blanket. LN 18 stated Resident 2 stated she wanted to sleep on the floor. LN 18 stated Resident 2 understood others and directions but was not consistent with the use of her call light. LN 18 stated the staff often observed Resident 2 getting up, unassisted, to go to the bathroom. LN 18 stated Resident 2 wanted to be independent with her ADLs. LN 18 stated Resident 2 had an unsteady gait and needed to be supervised when she ambulated. LN 18 stated because Resident 2 wanted to be independent and did not always use the call light for assistance, she (Resident 2) needed one on one supervision. Review of Resident 2's "Progress notes" dated 7/8/18 at 2 p.m., indicated Resident 2 had an unwitnessed fall (third fall in the facility) on 7/8/18 in the hallway. Resident 2's progress notes indicated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. The progress note indicated Resident 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 47 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 reported she stood up, her legs were tired and she sat down. Review of Resident 2's care plan titled, "...Focus The resident states she has had an actual fall on 7/8/18 with no injury, Poor Balance, Unsteady gait" and dated 7/8/18 indicated, "...Interventions...Apply bed alarm (a device that alarms when the resident gets out of bed) q (every) shift and check for its function..." Review of Resident 2's physician orders dated 5/22/18 at 7:07 p.m., indicated a pad alarm while in bed and chair for 30 days was ordered. Resident 2's physician orders dated 6/18/18 at 9:55 a.m., indicated the pad alarm was discontinued. Review of Resident 2's physician orders for July 2018 indicated no new orders were written for a bed alarm for Resident 2. Review of Resident 2's "IDT Meeting Summary" note dated 7/9/18 at 9:51 a.m., indicated, Resident 2 had her third fall on 7/8/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." On 9/6/18 at 9:10 a.m., during an interview, LN 1 stated Resident 2 had a tab alarm (an alarm attached to a resident's clothing and to the bed or wheelchair intended to alert staff when the resident stands up) for a while but it was discontinued and she did not remember when it was removed. On 9/6/18 at 2:48 p.m., during an interview, LN 15 stated she was Resident 2's nurse on 7/8/18 (the day of the third fall). LN 15 stated Resident 2 was found sitting on the floor next to her wheelchair in the hallway. LN 15 stated a fall care plan intervention was initiated to place FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 48 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 anti roll back bars on Resident 2's wheelchair. On 9/6/18 at 2:56 p.m., during a concurrent interview and record review, LN 15 stated Resident 2 was a high risk for falls and should have been on the falling star program after the first fall. LN 15 reviewed Resident 2's care plans and was unable to find an intervention which indicated Resident 2 was placed on the falling star program. LN 15 stated the falling star program was, "One of the basic interventions for a resident at a high risk of falls." LN 15 stated the falling star program consisted of placing small signs with yellow stars on a resident's door name plate, wheelchair, and on the head of the resident's bed to alert staff to a resident at a high risk of falls. Review of Resident 2's "Progress notes" dated 7/18/18 at 7:32 p.m., indicated Resident 2 had an unwitnessed fall (fourth fall in the facility) on 7/18/18 in the hallway. Resident 2's progress notes indicated at 6:35 p.m. the LN was told by a resident that Resident 2 was on the floor in the hallway. Resident 2 was found lying on the hallway floor just a few doors down from her room. The progress notes indicated a fall risk assessment for Resident 2 was completed by the LN with a score of 23, which reflected a high risk for falls. Review of Resident 2's "IDT Meeting Summary" note, dated 7/19/18 at 9:51 a.m., indicated Resident 2 had a fall (fourth fall) on 7/18/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." The IDT recommendation was to educate the resident and responsible party on the risks versus benefits of independent ambulation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 49 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Review of Resident 2's "Progress notes" dated 8/1/18 at 4:38 a.m., indicated Resident 2 had an unwitnessed fall (fifth fall in the facility) on 8/1/18 in her room. Resident 2's progress notes indicated Resident 2 was found on the floor at the side of her bed putting on her pants. The progress notes indicated Resident 2 reported she fell while changing her clothes. Review of Resident 2's "IDT Meeting Summary" note dated 8/1/18 at 9:44 a.m., indicated, Resident 2 had a fall on 8/1/18. The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." The IDT recommendation was to place neon green tape on the resident's call light to remind the resident to call for help. On 9/6/18 at 2:30 p.m., during an interview, LN 15 stated Resident 2 knew she needed assistance with ADLs but was impulsive and would not wait for assistance. LN 15 stated Resident 2 often refused assistance. LN 15 stated Resident 2 would change her clothes multiple times, often unassisted. On 9/10/18 at 10:50 a.m., during an interview, LN 19 stated she was Resident 2's nurse when Resident 2 had the fifth fall on 8/1/18. LN 19 stated Resident 2 was sitting on the floor at the side of her bed putting on her pants. LN 19 stated Resident 2 often got up out of bed without assistance. On 9/10/18 at 3:04 p.m., during an interview, LN 1 stated Resident 2 was impulsive and did not always use her call light for assistance. Review of Resident 2's progress notes dated 5/22/19, 6/9/18, 6/10/18, 6/20/18, 6/28/18, 6/30/18, 7/5/18, 7/9/18, 7/10/18, 7/19/18, 7/20/18, 7/21/18, 7/22/18, 8/1/18 and 8/2/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 50 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 indicated Resident 2 got up unassisted, did not use her call light, ambulated without assistance, wandered into other residents' rooms, and had an unsteady gait. Review of Resident 2's "Progress notes" dated 6/9/18, 6/20/18, 7/5/18, 7/10/18, 7/21/18 indicated the LNs provided Resident 2 education on the use of her call light for assistance in transferring and ambulating. Resident 2's progress notes indicated education on the use of the call light was not effective. Review of Resident 2's "Progress notes" dated 8/3/18 at 2:20 a.m., indicated Resident 2 had an unwitnessed fall (sixth fall) on 8/3/18 in her room. Resident 2's progress notes indicated, "Writer [LN 22] was alerted by CNA in hallway that resident [Resident 2] had fallen. Writer entered resident room, resident was laying on right side on ground with approximately 30 ml (milliliter-a liquid unit of measure) of blood under right side of head...Emergency services called. Resident breathing w/ (with) small amount of white foam coming from mouth. Not responsive to name or situation...Pupils equal, sluggish to respond [indicative of a head injury]...transferred to [GACH]...for acute care." Review of Resident 22's GACH records with an admit date of 8/3/18 indicated, "CHIEF COMPLAINT...Fall Found down, unresponsive, at SNF (Skilled Nursing Facility), pt (patient) is a GCS (Glasgow Coma Scale- a scoring system used to gauge the severity of an acute brain injury) of 8 (8 or less indicated severe brain injury)...bleeding hematoma (a collection of clotted blood under the skin)...CT ( Computerized Tomography) (a procedure that uses a computer linked to an x-ray machine to make a series of detailed pictures of areas inside the body) head showed hematoma with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 51 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 no fracture or intracranial hemorrhage (bleeding). CT C [cervical-pertaining to bones in the neck] spine showed no fracture." The GACH clinical record indicated, "Invasive Procedures: 1. Intubation [tube placed into the lungs to assist breathing] 2. NG [nasogastric] tube [tube placed through the nose into the stomach for the purpose of administering medications, food or fluids]." Review of Resident 22's acute hospital records dated 8/7/18 indicated, "Expiration Discharge Summary...Patient pronounced dead at: 20:29 (8:29 p.m.) on 8/6/18...Findings and Hospital events leading to death: R (right) scalp (skin on head) hematoma...Presumed cause of death: unknown..." Review of Resident 2's "IDT Meeting Summary" note, dated 8/3/18 at 9:40 a.m., indicated Resident 2 had a fall on 8/3/18 (sixth fall.) The IDT summary indicated under Root Cause/ Contributing Factors, "Poor safety awareness, resident chooses to ambulate independently." The IDT recommendation indicated, "Resident sent out to acute hospital for further evaluation related to head injury and LOC [loss of consciousness]." On 9/7/18 at 4:35 p.m., during a telephone interview, Certified Nurse Assistant (CNA) 9 stated she was Resident 2's CNA when she fell (6th fall) on 8/3/18. CNA 9 stated she knew Resident 2 was a high fall risk and needed more attention, monitoring and assistance with ADLs. CNA 9 stated at approximately 2 a.m. on 8/3/18 she heard Resident 2 crying and went into Resident 2's room. CNA 9 stated Resident 2, was awake and wanted to go to the bathroom. CNA 9 stated she transferred Resident 2 from her bed to the wheelchair, took her to the bathroom and transferred her onto the toilet. CNA 9 stated after Resident 2 was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 52 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 toileted, she transferred the resident on to her wheelchair and to the sink to wash her hands. CNA 9 stated she then took Resident 2 to the side of her bed. CNA 9 stated she aligned Resident 2's wheelchair lateral to the side of the bed and facing the wall at the head of her bed. CNA 9 stated Resident 2 began to straighten the blue disposable pad on her bed and she (CNA 9) did not want to rush getting the resident back into bed. CNA 9 stated she wanted to get Resident 2 back into bed but Resident 2's roommate had disrobed and had her legs over the side of her bed. CNA 9 stated she told Resident 2 to stay seated, Resident 2 nodded and said "Okay." CNA 9 stated she turned away from Resident 2, took two to three steps and attended to Resident 2's roommate. CNA stated less than one minute later, she heard a "flop," turned and saw Resident 2 on the floor. CNA 9 stated Resident 2's head was between the bedside cabinet and the head of the bed. CNA 9 stated she left the room and called for assistance. CNA 9 stated she could have called for assistance to help Resident 2's roommate and not left Resident 2 unattended. CNA 9 stated the correct thing to do was to "finish the task" and put Resident 2 back into bed before she assisted Resident 2's roommate. On 9/10/18 at 10:20 a.m., during an interview LN 18 stated he had been a CNA and his training was to stay with the resident until the task was completed. On 9/10/18 at 11:15 a.m., LN 19 stated she knew about Resident 2's fall on 8/3/18. LN 19 stated the CNA caring for Resident 2 on 8/3/18 should have completed the task of assisting Resident 2 to bed before assisting another resident. On 9/6/18 at 9:10 a.m., during an interview, LN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 53 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 1 stated Resident 2 was identified as a higher risk for falls because of a history of falls. LN 1 stated Resident 2 was slightly confused, restless, very active and would frequently get up and walk by herself without calling for assistance. LN 1 stated Resident 2 wanted to exert her independence and provide her own care, which included ambulation. LN 1 stated Resident 2 could not relax or sit still, "...she was busy..." and not easily redirected. On 9/6/18 at 9:10 a.m., during an interview, LN 1 stated a Restorative Nurse Assistant (RNA) would ambulate with Resident 2 while she (Resident 2) used a front wheel walker. LN 1 stated Resident 2's gait was not steady when she ambulated with or without her walker. LN 1 stated Resident 2 would lose her balance with the walker when she turned or went through doorways. LN 1 stated Resident 2 was able to self-propel in the wheelchair and was "Quick." LN 1 stated she did not think Resident 2 understood the risks and safety concerns of ambulating without assistance and did not understand the consequences of her actions. On 9/6/18 at 2:30 p.m., during an interview, LN 15 stated Resident 2 was a high risk for falls. LN 15 stated Resident 2 was frantic, impulsive, and anxious about walking; it stemmed from wanting to go home with her (Resident 2's) family. LN 15 stated Resident 2 needed to be watched closely because she would get up unassisted and it was difficult to redirect the resident. LN 15 stated the RNA would walk with Resident 2 and used a front wheel walker. On 9/7/18 at 9:06 a.m., during an interview, CNA 7 stated Resident 2 "always" needed supervision when she (Resident 2) ambulated. CNA 7 stated Resident 2 needed assistance for all ADLs. CNA 7 stated she observed Resident 2 ambulating in the hallway at times with no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 54 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 supervision. CNA 7 stated sometimes Resident 2 used a four wheel walker instead of the front wheel walker ordered by physical therapy. On 9/7/18 at 9:15 a.m., during an interview, CNA 8 stated Resident 2 was impulsive. CNA 8 stated Resident 2 would sometimes ambulate, unsupervised, with her walker or her wheelchair. On 9/7/18 at 4:05 p.m., during an interview, LN 16 stated on 7/18/18, she observed Resident 2 ambulating down the hallway, unsupervised, with her four-wheel walker. LN 16 stated within a minute another resident came up to the nurses' station and said Resident 2 fell (4th fall) in the hallway. LN 16 stated she did not know how Resident 2 fell. LN 16 stated Resident 2 needed to be supervised when she ambulated with her walker but she (LN 16) was on the phone at the time of the fall and did not assist the resident. LN 16 stated Resident 2 was spontaneous and ambulated alone despite being told it was not safe to ambulate without assistance. LN 16 stated Resident 2 would "Sometimes" use her call light. LN 16 stated Resident 2's care plan fall interventions were not effective. LN 16 stated Resident 2 should have had one on one supervision for safety. On 9/10/18 at 9:30 a.m., during an interview, Physical Therapist Aid (PTA) 1 stated he observed Resident 2 walking unsupervised with a walker. PTA 1 stated Resident 2 had a shuffling gait and was not safe ambulating unsupervised. PTA 1 stated Resident 2 needed stand by supervision when she ambulated with or without her walker. PTA 1 stated Resident 2 would sometimes "park" her walker and ambulate without any device. On 9/10/18 at 9:36 a.m., during an interview, PTA 2 stated Resident 2 was not safe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 55 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 ambulating unsupervised, "We [PT staff] told staff [nursing staff] she [Resident 2] was not safe by herself." Review of Resident 2's "PT- Therapist Progress & Discharge Summary" dated 6/15/18 indicated, " ...Transfers, Stand to Sit...contact guard assist (contact with patient [resident] due to unsteadiness)...Transfers, Bed< > [to and from] Chair...contact guard assist...Gait tasks: Assistive Devices ...The patient requires front wheeled walker and contact guard assist (contact with patient due to unsteadiness) for safe ambulation for about 400 ft [feet] with rest breaks ..." Review of Resident 2's physician orders dated 6/12/18, indicated, "RNA (Restorative Nursing Aide) 5 x/wk (five times per week) to be reviewed every 4 weeks for ambulation using FWW (front wheel walker) as tolerated..." On 9/10/18 at 10:15 a.m., during an interview, CNA 5 stated Resident 2 was always walking in her room and in the hallways unsupervised. CNA 5 stated supervision means being near the resident to assist when help was needed. On 9/10/18 at 10:50 a.m., during an interview, LN 19 stated Resident 2 needed to be supervised when she was out of bed or ambulating. LN 19 stated Resident 2's family brought the resident's pink colored four-wheel walker (not PT ordered) to the facility for the resident. LN 19 stated she had observed Resident 2 ambulating with her four-wheel walker in the hallway unsupervised. LN 19 stated Resident 2 was not stable when she ambulated and Resident 2's four-wheel walker was "too fast" for Resident 2. LN 19 stated Resident 2 did not know how to use her fourwheel walker properly. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 56 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 9/10/18 at 11 a.m., during an interview, LN 21 stated Resident 2 was compulsive about ambulating. LN 21 stated if Resident 2 was not monitored, she would be up ambulating without assistance. LN 21 stated, "I think she should have been a one to one [one staff providing supervision to Resident 2 at all times]." On 9/10/18 at 11:09 a.m., during a concurrent interview and record review, LN 19 stated Resident 2's fall care plan interventions did not adequately address Resident 2's assessed risk for falls such as being impulsive, independent minded and inconsistent with use of her call light. LN 19 stated a bed alarm, a room closer to the nurses' station and one on one supervision could have reduced Resident 2's risk for falls. On 9/10/18 at 12 p.m., during an interview, the RNA stated she provided stand by assistance while Resident 2 ambulated with the physical therapy ordered front wheel walker. The RNA stated Resident 2's gait and balance were unsteady and needed assistance. On 9/10/18 at 3:40 p.m., during an interview and concurrent record review, the Chief Nursing Executive stated care plan interventions did not reflect and address Resident 2's impulsive behavior and ambulation without supervision. On 9/11/18 at 12 p.m., during an interview and concurrent record review, LN 1 stated she was part of the IDT. LN 1 reviewed Resident 2's IDT root causes after the falls on 6/17/18, 6/18/18, 7/8/18, 7/18/18, 8/1/18, and 8/3/18. LN 1 stated the IDT root causes after Resident 2's falls were basically the same. LN 1 stated the root causes for Resident 2's falls were not specifically identified by the IDT. LN 1 stated the facility did not adequately evaluate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 57 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Resident 2's risk for falls or her behaviors which placed her at a high risk for falls. LN 1 stated "We could have done better." On 9/11/18 at 9:25 a.m., during an interview PT 2 stated any resident devices brought into the facility needed an evaluation by the therapy department for safety. PT 2 stated she knew Resident 2 had a personal four-wheel walker in the facility. PT 2 stated Resident 2 was supposed to be ambulated with the facility's front wheel walker. PT 2 stated Resident 2 needed to be checked for safe use of the fourwheel walker if it was used for ambulation. PT 2 stated a four-wheel walker would not be safe for a resident if the resident was not able to properly use the brakes on the handles. On 9/11/18 at 9:33 a.m., during an interview and record review, PT 3 stated devices brought from home should have a referral by nursing to the therapy department. PT 3 stated the therapy staff screened and evaluated the device and the safe use of the device by the resident. PT 3 stated the nursing referral to the therapy department should be in the resident's chart. PT 3 was unable to find documentation of a safety evaluation of Resident 2's personal four-wheel walker. On 9/11/18 at 11 a.m., during an interview LN 1 stated Resident 2's family brought a fourwheel walker for Resident 2. LN 2 stated when a device was brought into the facility, it was the facility policy to notify physical therapy to evaluate the device and the resident's safe use of the device. LN 1 stated the LN should document if an evaluation of a device was done by physical therapy. On 9/11/18 at 2:15 p.m., during an interview, the RNA stated Resident 2 ambulated with RNA five times a week with a front wheel FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 58 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 walker, which was the order from the therapy department. The RNA stated every time she saw Resident 2 in the hallways walking alone, she (Resident 2) used the four wheel walker brought in to the facility by her family. The RNA stated she was not aware whether PT evaluated Resident 2 using the four wheel walker. On 9/11/18 at 2:30 p.m., during an interview, LN 20 stated Resident 2 used her four-wheel walker to ambulate but the RNA staff used the physical therapy ordered front-wheel walker when they ambulated Resident 2. LN 20 stated she did not know if physical therapy had evaluated Resident 2's use of the four-wheel walker for safety. LN 20 stated she often told Resident 2 to use the brakes on the four-wheel walker. LN 20 stated she knew Resident 2 needed to be supervised while ambulating with the walker but staff was not always able to supervise. LN 20 stated the staff supervised the resident, "As much as we could." On 9/11/18 at 2:03 p.m., during an interview, Occupational Therapist (OT) 2 stated if a resident's walker was brought into the facility, nursing should have sent a referral to PT for a safety evaluation. OT 2 stated a resident who used a four-wheel walker needed to be screened for safe use of the brakes on the walker. OT 2 stated Resident 2 was not safe with a four wheel walker because it moved faster than a front wheel walker. OT 2 stated he did not know how or why Resident 2 was allowed to use her four-wheel walker. OT 2 stated the RNA ambulated Resident 2 with a front wheel walker. OT 2 stated nursing should have referred Resident 2 to PT and/or OT after her first fall and it was not done. OT 2 stated he was not aware of Resident 2's four wheel walker being checked for safety. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 59 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 9/11/18 at 2:50 p.m., during an interview, the Administrator (ADM) stated there was no referral from nursing to physical therapy for a safety evaluation of Resident 2's four-wheel walker. On 9/26/18 at 1:30 p.m., during an interview, Resident 2's Family Member (FM) 4 stated she informed the staff at a meeting that Resident 2 needed supervision all of the time. FM 4 stated she told the staff Resident 2 wanted to be independent and would get up without assistance. FM 4 stated she thought Resident 2 would have direct supervision but the staff did not have time to provide supervision. FM 4 stated staff said the facility did not provide one on one supervision for the residents. On 9/26/18 at 1:30 p.m., during an interview, FM 4 stated Resident 2's family brought in the four wheel walker for Resident 2 to use for walking. FM 4 stated the family thought the four wheel walker would be better for Resident 2 because it had a seat for Resident 2 if she became tired. FM 4 stated Resident 2 had not used the four wheel walker before it was brought to the facility. FM 4 stated she did not know if the facility PT checked the four wheel walker for safety but it should have been checked. FM 4 stated Resident 2 should not have used the four wheel walker if it was not safe. FM 4 stated the four wheel walker should not have been left in Resident 2's room. Review of the facility policy and procedure titled, "Fall Program" and dated 11/24/17 indicated, " ...each resident is to be evaluated upon admission, quarterly and as needed by a Licensed Nurse to determine factors that place the resident at a risk for falls ...all residents are to receive adequate supervision and assistive devices to prevent accidents ...Residents identified as being "High Risk" for falls should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 60 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 have specific interventions that address each of the resident's factors and potential factors ...The higher a resident's risk for falls is, the more individualized interventions should be considered: ...i. Supervised walking program ...Residents at "High Risk" may be placed on a Falling Star Program that alerts staff to monitor residents who have a higher risk of falling...Consider previous occupation, social patterns, need for control or independence. These factors could produce a better understanding of the resident's activities as they relate to falls and help identify interventions that could decrease fall risk ..."

F697 SS=E Pain Management CFR(s): 483.25(k)

F697 03/18/2019 §483.25(k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to provide effective pain management for two of 20 sampled residents (Resident 4 and Resident 5) when: 1. Resident 4 was assessed to have a pain level of ten (on a scale of zero to ten with zero being no pain and ten being the worst pain FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 61 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 imaginable) and was not provided physician ordered pain medication to effectively treat the pain. 2. Resident 5 was not provided physician ordered, regularly scheduled medication for treatment and control of chronic pain. These failures resulted in Resident 4 and Resident 5 suffering unrelieved pain. Findings: 1. Review of Resident 4's undated clinical record, titled, "Facesheet" (a document with personal identifiable information) indicated Resident 4 was admitted to the skilled nursing facility (SNF) on 8/20/18 at 4:20 p.m. with medical diagnoses of left great toe amputation and chronic ulcer (shallow wound) of the lower leg. Review of Resident 4's clinical record, titled, "Physician's orders" dated 8/20/18, indicated, "Hydrocodone-Acetaminophen (narcotic medication used for moderate to severe pain) Tablet 5-325 [5 mg of hydrocodone and 325 mg of acetaminophen] mg [milligram, a dosage measurement] Give 1 tablet by mouth every 8 hours as needed for Pain Scale 1-5...Tramadol HCL [narcotic medication used for moderate to severe pain] 50 mg every four hours as needed for moderate and severe pain...Tylenol [Acetaminophen, a medication to treat mild pain] Tablet 325 mg every 6 hours as needed for Mild Pain of 1-3..." On 8/21/18 at 10:17 a.m., during an interview, Resident 4 stated she "begged for a pain pill" on the day of admission (8/20/18). Resident 4 stated the nurse gave her Tylenol for the pain. Resident 4 stated Tylenol did not help relieve her pain. Resident 4 stated she did not get any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 62 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 other pain medication until one in the morning the following day. Resident 4 stated both lower legs hurt. Resident 4 stated she wanted something to relieve her pain and stated, "I didn't care what it [medication] was at that point. I just wanted something for pain." Resident 4 stated she waited too long for her pain medication and stated, "I feel like they [staff] should be on top of it (the pain)." On 8/23/18 at 3:45 p.m., during an interview, the Director of Nursing (DON) stated when a resident was admitted, it was the Licensed Nurses (LNs) responsibility to notify the physician and the pharmacy and then obtain authorization for administration of the narcotic pain medication to the resident. The DON stated the nurses needed a pharmacy authorization number to remove either the Norco (brand name for hydrocodoneacetaminophen) or the Tramadol pain medication from the medication dispensing machine. The DON stated Tylenol was available but Tylenol was not going to help residents who were in a lot of pain. On 8/24/18 at 10:34 a.m., during an interview, LN 5 stated as she completed Resident 4's admission, on 8/20/18, LN 3 reported to her that Resident 4 was complaining of pain. LN 5 stated she assessed Resident 4 and Resident 4 verbalized a pain level of 10 out of 10 in her lower legs. LN 5 stated she entered the orders for Tramadol and Norco into the facility electronic record system and faxed the two narcotic pain medication orders to the physician for his signature. LN 5 stated she then continued to input other physician orders into the electronic record system. Review of Resident 4's clinical record titled, "Nursing Admission Assessment" not timed, dated 8/20/18 and signed by LN 5 indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 63 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 Resident 4 had a pain rating score of 10 out of 10 for both the right and left lower leg. The Nursing Admission Assessment indicated the pain was "constant and sharp." On 8/24/18 at 11:58 a.m., during a concurrent interview and record review, LN 6 reviewed Resident 4's Medication Administration Record (MAR) dated August 2018. LN 6 stated Resident 4 received Norco on 8/21/18 at 1:14 a.m. LN 6 stated Resident 4 had not received pain medication, other than Tylenol, from the time of her admission at 4:20 p.m. on 8/20/18 until 1:14 a.m. on 8/21/18 (more than eight hours after admission to the facility). On 9/6/18 at 3:58 p.m., during a concurrent interview and record review, LN 3 stated she was Resident 4's nurse on 8/20/18 when Resident 4 was admitted to the facility. LN 3 reviewed Resident 4's MAR dated August 2018 and stated she (LN 3) administered Tylenol to Resident 4, who complained of a pain level of four of 10, on 8/20/18 at 8:57 p.m. LN 3 stated Tylenol was to be given for a pain level of one to three. LN 3 reviewed the pain medications ordered for Resident 4 and stated Norco was ordered for a pain level of one to five and Tramadol was ordered for moderate and severe pain. LN 3 stated she administered Tylenol because there was no pharmacy authorization received to dispense Tramadol or Norco. LN 3 stated it was the responsibility of the admitting nurse to call the pharmacy and physician for the pain medication authorization. LN 3 stated she did not follow up to obtain the narcotic pain medication authorization for Norco and Tramadol. On 9/10/18 at 11:27 a.m., during a concurrent interview and record review, LN 11 stated Tylenol was not effective for treatment of moderate or severe pain. LN 11 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 64 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 licensed nurse should have notified the physician of Resident 4's moderate to severe pain on 8/20/18 rather than administer Tylenol which was effective only for mild pain. LN 11 stated the LN should have requested another pain medication from the physician. LN 11 reviewed Resident 4's MAR for August 2018 and stated Resident 4's admission orders indicated Tramadol 50 mg one tablet every four hours as needed for moderate to severe pain. LN 11 stated moderate pain was a pain level rated four to six and severe pain was a pain level rated seven to 10. LN 11 stated Resident 4 had an order for Norco 5-325 mg, one tablet every 8 hours as needed for a pain level of one to five for mild to moderate pain. LN 11 stated Resident 4 had an order for Tylenol 325 mg two tablets every six hours as needed for a pain level of one to three, mild pain. LN 11 stated she dispensed one Norco at 1:14 a.m. to Resident 4 for a pain level of four of 10 from the medication dispensing machine. On 9/10/18 at 3:31 p.m., during an interview, LN 2 stated on 8/20/18 she received report from the transferring facility that Resident 4 was administered one Norco on 8/20/18 at 1:25 p.m., prior to transfer to the SNF. LN 2 stated controlled narcotic pain medications required a signed prescription from the physician before the medications could be released for administration. LN 2 stated there was often a delay in obtaining the physician's signature and forwarding the signed prescription to the pharmacy. LN 2 stated if pain medication was required before the pharmacy received the signed prescription the process was to call the medical director who could intervene on behalf of the resident to obtain the narcotic pain medication more urgently. On 9/11/18 at 8:09 a.m., during a concurrent interview and record review, LN 3 stated it was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 65 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 not appropriate to give Tylenol for a pain level rated four of 10. LN 3 stated she did not administer Tramadol or Norco to Resident 4 because she had not received authorization from the pharmacy to dispense the medications. LN 3 stated a pain level reported as 10 of 10 was excruciating pain and the nurse who assessed the pain should have notified the physician and the pharmacy immediately. The facility policy and procedure titled, "Pain Management" dated 11/24/17, indicated, " ...Policy: It is the policy of this facility to assess all residents for pain on admission, each time vital signs are monitored, when pain medication is given and as indicated ...Procedure: 1. The licensed nurse is to assess each resident for pain upon admission to the facility ...9. The licensed nurse is to administer pain medication as ordered and document the administration on the Medication Administration Record (MAR) for each medication ...12. PRN medications are to be administered per the physician order parameters. a. Mild Reported Pain 1-3 b. Moderate Reported Pain 4-6 c. Severe Reported Pain 7-10 ..." 2. Resident 5's undated "Face sheet" indicated the resident was admitted to the facility on 5/25/18. The facesheet indicated Resident 5's diagnoses included, removal of internal fixation device (a metal device inserted to treat and stabilize complex bone fractures), infection and inflammatory (a reaction to infection, injury which causes redness, swelling and pain) reaction due to internal device and chronic pain. Review of Resident 5's physician orders dated 5/25/18, indicated the resident had been admitted for skilled nursing services due to an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 66 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 infection of the right knee. Review of Resident 5's MAR indicated, "Methadone [a medication for pain and used as a part of drug addiction detoxification] ...Tablet 5 MG [milligram - a dry unit of measure] Give 14 tablet by mouth one time a day related to OTHER CHRONIC PAIN.." with a start date of 5/26/18 at 9:00 a.m. Resident 5's MAR also indicated, "Hydrocodone-Acetaminophen [medication for pain relief] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain..." Review of Resident 5's MAR indicated the Methadone was not administered on 5/26/18. Resident 5's MAR indicated the Methadone was administered on 5/27/18. Review of Resident 5's progress notes dated 5/27/18 at 9:30 a.m., indicated a prescription for Methadone was faxed to the Medical Director for a signature. Resident 5's progress notes dated 5/27/18 at 3:49 p.m. indicated the methadone was administered to Resident 5 by the LN. Resident 5's physician orders indicated: 1."Hydrocodone-Acetaminophen [Norco, medication for pain relief] Tablet 5-325 MG Give 1 tablet by mouth every 6 hours as needed for moderate pain..." with a start date of 5/25/18. 2."Gabapentin (nerve pain medication) Capsule 300 MG Give 1 capsule by mouth one time a day related to OTHER CHRONIC PAIN...until 06/01/2018..." with a start date of 5/26/18. 3."Gabapentin [a medication to treat nerve damage and pain] Capsule 300 MG Give 1 capsule by mouth every 12 hours related to OTHER CHRONIC PAIN..." with a start date of 6/2/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 67 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 6/13/18 at 5:01 p.m., during a telephone interview, Resident 5 stated it took a couple of days for the facility to get his Methadone. Resident 5 stated he got his Methadone at the acute care hospital prior to his transfer to the facility on 5/25/18. Resident 5 stated it was, "Rough going at first" and that his pain level was greater than a 10 on the first day at the facility. Resident 5 stated he sweated all night on the first night as well as the next day and some of that was due to withdrawals and some might have been due to his knee pain. On 9/6/18 at 10:45 a.m., during an interview and concurrent record review, LN 10 stated he remembered the LNs retrieved Resident 5's methadone from the Cubex ( a machine for removal of emergency medications) a couple times because he had to co-sign for the removal of a narcotic medication. LN 10 stated he recalled there was an argument with the facility pharmacy and the LN over who was to contact Resident 5's physician for authorization for the methadone. LN 10 reviewed Resident 5's MAR and stated the methadone was not given on 5/26/18 and was unable to find documentation in Resident 5's record which indicated why the medication was not given as ordered. On 9/7/18 at 11:40 a.m., during an interview, the Chief Nurse Executive (CNE) stated there was trouble getting Resident 5's methadone on 5/26/18 but, "...we covered the resident's [Resident 5] pain." The CNE stated Resident 5 had Gabapentin and hydrocodone ordered for pain as well as the Methadone. The facility policy titled, "Medication Administration" dated 11/24/17 indicated, "...SIX RIGHTS OF MEDICATION ADMINISTRATION 1. Right individual 2. Right medication 3. Right dose 4. Right time 5. Right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 68 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 route 6. Right documentation...Medications are to be administered according to physician's orders using the Six Rights of Medication Administration...Medications should be administered from the E-Kit or Cubex when not available in the cart." The facility policy and procedure titled, "Pain Management" dated 11/24/17, indicated, " ...Policy: It is the policy of this facility to assess all residents for pain...9. The licensed nurse is to administer pain medication as ordered and document the administration on the Medication Administration Record (MAR) for each medication..."

F725 SS=D Sufficient Nursing Staff CFR(s): 483.35(a)(1)(2)

F725 03/18/2019 §483.35(a) Sufficient Staff. The facility must have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). §483.35(a)(1) The facility must provide services by sufficient numbers of each of the following types of personnel on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans: (i) Except when waived under paragraph (e) of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 69 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 this section, licensed nurses; and (ii) Other nursing personnel, including but not limited to nurse aides. §483.35(a)(2) Except when waived under paragraph (e) of this section, the facility must designate a licensed nurse to serve as a charge nurse on each tour of duty. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure sufficient nursing staff to provide nursing services to meet residents' needs in a manner which promoted each residents' rights and physical and mental well being when call lights were not responded to in a timely manner to provide assistance for six of 20 sampled residents (Resident 15, Resident 16, Resident 17, Resident 18, Resident 19, and Resident 20). This failure resulted in a delay of care and services to meet the resident's needs. Finding: On 9/28/18 at 8:51 a.m., during an interview, Certified Nursing Assistant (CNA) 15 stated there was often not enough staff to provide care to the residents. CNA 15 stated CNAs who were on light duty were counted as staff even though there were restrictions on the amount and type of work and care provided to the residents. CNA 15 stated a CNA on light duty may not be allowed to assist in transfers or other tasks that involve physical exertion. CNA 15 stated call lights were to be answered as soon as they (light) were seen or heard. Resident 16's undated facesheet (a document with personal identifiable information) indicated Resident 16 was admitted on 2/17/06 and had FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 70 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 medical diagnoses of hemiplegia (paralysis on one side of the body), muscle weakness, and diabetes (a chronic disease due to high levels of glucose sugar in the blood). Resident 16's Minimum Data Set, (MDS) assessment (an evaluation of a resident's functional and cognitive status pertaining to memory recall) dated 7/22/18, indicated Resident 16's Brief Interview for Mental Status (BIMS) (an assessment of a resident's cognitive status) score was 12 of 15, which indicated a moderately impaired cognitive (pertaining to reasoning, judgment and memory) status. On 9/28/18 at 9:03 a.m., during an interview, Resident 16 stated, "Sometimes" the staff answered the call lights in a timely manner. Resident 16 stated yesterday (9/27/18), on night shift, he had his call light on for an hour before it was answered by the staff. Resident 16 stated he needed his brief changed because he was wet. Resident 17's undated facesheet indicated Resident 17 was admitted on 1/23/17 and had medical diagnoses of chronic kidney disease, gastroenteritis, muscle weakness and difficulty walking. Resident 17's MDS assessment dated 10/23/18, indicated Resident 17's BIMS score was 15 of 15, which indicated the resident was cognitively intact. Resident 18's undated facesheet indicated Resident 18 was admitted on 7/8/17 with a medical diagnoses of kidney disease, heart failure, muscle weakness, and atrial fibrillation. Resident 18's MDS assessment dated 9/10/18, indicated Resident 18's BIMS score was 13 of 15, which indicated the resident was cognitively intact. On 9/28/18 at 9:06 a.m., during an observation in the hallway of the "Vintage Court" unit, a light FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 71 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 above the door of Resident 17 and Resident 18's room was lit. On 9/28/18 at 9:08 a.m., during an interview in Resident 17's room, Resident 17 stated she often turned on the call light for her roommate, Resident 18, because she (Resident 18) was in her wheelchair and needed assistance to get into bed. Resident 17 stated sometimes there was no response by the staff to the call light for one to two hours. Resident 17 stated Resident 18 would have to sit in her wheelchair for extended periods, "It's awful." Resident 17 stated the call light had been turned on by Resident 18 about 30 minutes ago and staff had not come in to the room yet. On 9/28/18 at 9:11 during an observation, the call light by Resident 18's bed remained lit with no response by the staff. On 9/28/18 at 9:13 a.m., during an interview in Resident 17 and Resident 18's room, Resident 18 stated she turned her call light on about 30 minutes ago. Resident 18 stated she turned on the call light because, "I have to go to the bathroom." Resident 18 stated the evening shift was often short of staff. Resident 18 stated she played bingo or cards in the common room on the unit in the evening. Resident 18 stated afterwards she returned to her room and often waited one to two hours to have her call light answered. Resident 18 stated she needed assistance by the staff to transfer into and out of bed. Resident 18 stated she would turn on her call light, staff came in the room, turned off the light and left without assisting her. Resident 18 stated she then had to turn the call light on again. On 9/28/18 at 9:20 a.m., during an interview in Resident 17 and Resident 18's room, Resident 17 stated she observed Resident 18 asleep in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 72 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 her wheelchair in the evening because of the long wait for assistance from the staff to put her (Resident 18) in bed. Resident 17 stated the issue regarding call lights not being answered timely had been brought up in the Resident Council meetings, "Multiple times." Resident 17 stated the response time to call lights had not improved and was worse. On 9/28/18 at 9:28 a.m., during an observation, Licensed Nurse (LN) 1 entered Resident 17 and Resident 18's room. LN 1 asked Resident 18 if she needed assistance. On 9/28/18 at 9:30 a.m., during an interview, LN 1 stated a call light should not be unanswered for 30 minutes. LN 1 stated the CNAs were, "Busy." On 9/28/18 at 9:33 a.m., during an observation in the hall way of the Vintage Court unit, a light above the door of Resident 19's room was lit. Resident 19's undated "Facesheet" undated indicated Resident 19 was admitted on 5/5/18 and had medical diagnoses of heart failure, prostate cancer, and muscle weakness. Resident 19's MDS assessment dated 9/12/18, indicated Resident 19's BIMS score was 15 of 15, which indicated the resident was cognitively intact. On 9/28/18 at 9:35 a.m., during an interview, Family Member (FM) 3 stated she turned on Resident 19's call light because he needed his brief changed. FM 3 stated a CNA had answered the call light and FM 3 told the CNA Resident 19 needed to be changed. FM 3 stated the CNA said she would return, took Resident 19's breakfast tray and exited the room. FM 3 stated the CNA didn't return. FM 3 stated she turned the call light on again 15 minutes later. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 73 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 9/28/18 at 9:39 a.m., during an observation in Resident 19's room, LN 1 entered the room and asked if Resident 19 needed assistance. The facility policy and procedure dated 7/1/15, indicated, "...Answer call lights promptly...The resident's call light is to be turned off when their request has been resolved..." On 9/28/18 at 9:49 a.m., during an interview, CNA 5 stated there was often not enough staff and not enough time to provide care for the residents. CNA 5 stated there were times she could not get all her work finished for the residents. CNA 5 stated staff should respond to a resident's call light within three to five minutes. CNA 5 stated it was hard to respond to a resident's call light in a timely manner if there wasn't enough staff. On 9/28/18 at 11:09 a.m., during an interview, LN 14 stated call lights should be answered within three to five minutes. LN 14 stated the unit was short of staff today. LN 14 stated if the unit had enough staff there wouldn't be the long wait for call lights to be answered. Resident Council Meeting Minutes dated 4/3/18 at 10 a.m.,. indicated, " Review of past Months Issues... Nursing: Residents feel call lights are not being answered in timely manner...New Issues...Staff turning off call light before issues or need is resolved..." Resident Council Meeting Minutes dated 5/1/18 at 10 a.m., indicated, "...Nursing: Residents feel call lights are not being answered in timely manner, residents feel there should be more staff. (Unresolved in [2 units and seven resident rooms listed]) ..." Resident Council Meeting Minutes dated 6/5/18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 74 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 10 a.m., indicated, "...Nursing: Staff turning off call lights before issues or needs are met. (seven resident rooms listed) (unresolved)..." Resident Council Meeting Minutes dated 8/7/18 at 10 a.m., indicated, "...Nursing: Residents feel call lights are not answered in a timely manner. [six resident rooms listed]..." Resident 15's facesheet, undated, indicated Resident 15 had medical diagnoses of prostate and bone cancer. Resident 15's MDS dated 10/25/18, indicated Resident 15's BIMS score was 15 of 15, which indicated the resident was cognitively intact. On 9/28/18 at 9:35 a.m., during an interview, Resident 15 stated he waited about one and one half hour for nursing staff to assist him. Resident 15 stated he looked at the clock in his room to see how long it took for nursing staff to assist him. FM 3 stated it took staff a long time to receive help from nursing staff when the call light was on. On 9/28/18 at 10:15 a.m., during an interview, CNA 14 stated she did overtime when asked by staffing. CNA 14 stated she came during the night shift to help assist when the facility was short staffed. CNA 14 stated it was hard to care for residents when assisting a large group of residents. CNA 14 stated she stayed past her assigned shift time to finish resident showers. CNA 14 stated she felt responsible to provide good care to the residents. Resident 20's "Facesheet" undated, indicated Resident 20 had a medical diagnosis of gastroenteritis (irritation and inflammation of the stomach and intestines). Resident 20's MDS assessment dated 6/23/18, indicated Resident 20's BIMS score was 15 of 15, which indicated the resident was cognitively intact. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 75 of 76 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: _______________ 055199 (X3) DATE SURVEY COMPLETED 03/08/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE HORIZON HEALTH & SUBACUTE CENTER 3034 E Herndon Ave Fresno, CA 93720 (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 On 9/28/18 at 1:50 p.m., during an interview, Resident 20 stated staff never answered his call light for assistance in a timely manner. Resident 20 stated he waited about an hour for someone to come assist him. Resident 20 stated he watched the clock on the wall and counted how long it took for someone to assist him. The facility policy and procedure titled, "Resident Rights" dated 12/30/17, indicated "...It is the policy of this facility to protect and promote the rights of the residents, to provide care in a manner and in an environment, that maintains or enhances the resident's dignity and recognition of their individuality..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: AL2L11 Facility ID: CA040000014 If continuation sheet 76 of 76