Other·April 3, 2019

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Date: June 14, 2022 - Amended to reflect scope and severity of E for F684 42 CFR 483.25 The following reflects the findings of the California Department of Public HealthLicensing and Certification during a RECERTIFICATION survey. Representing the California Department of Public Health by Federal ID: 38641 RN/HFEN, 39514 RN/HFEN, 40038 RN/HFEN, 40641 RN/HFEN, 40360 RN/HFEN, 40125 RN/HFEN, and 34975 Nutrition Consultant. Capacity: 99 Census: 97 Sample: 40 The survey findings validated an Immediate Jeopardy at the Code of Federal Regulations (CFR) 483.12 (F600) Freedom from Abuse, Neglect, and Exploitation with a scope and severity of J (isolated) and CFR 483.25(n)

F700 scope and severity of J; Immediate Jeopardy (IJ), a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in the facility. An IJ situation with a scope and severity of J was called on 12/19/18 at 1:45 p.m. with the Administrator (ADM), Director of Nursing, Chief Nursing Officer and Director of Operations in attendance. The IJ findings included the facility using four side rails on Resident 70 without an assessment, rationale and justification. The 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: S70D11 Facility ID: CA040000225 If continuation sheet 1 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 facility did not assess Resident 70 his risk for entrapment with the side rails prior to installation. The facility did not ensure the bed's dimension are appropriate for Resident 70's size and weight prior to the installation of the side rails. The facility did not place Resident 70 with the least restrictive form of restraint prior to installation of the side rails. Resident 70 had 10 falls since his admission to the facility on 4/19/18. On 11/15/18, Resident 70 sustained a fall and his right arm was caught between the side rail and the bed. Resident 70's fall care plan did not reflect an intervention to ensure safety measures were in place to protect Resident 70 from injuries and further falls. During an observation, Resident 70 had no activities in place to meet his needs and preferences. Resident 70 was on Ambien (a medication used to treat difficulty in sleeping) and Trazodone (a medication used to treat depression- feelings of prolonged sadness) and the facility did not follow the pharmacy recommendations to review both medications as a duplicate therapy. Resident 70 was admitted on Keppra (a medication used to treat seizure) medication without evaluation by the Primary Care Physician (PCP) to determine the need to continue the medication. Resident 70 was not diagnosed with seizures and Resident 70 did not had any seizure episode since admission to the facility. These deficient practices placed Resident 70 at risk for entrapment and further injuries from repeated falls. These deficient practices also placed Resident 70 at risk to receive unnecessary psychotropic medications (a medication that affects brain activities associated with mental processes and behavior) without an assessment from the physician. The facility submitted an acceptable Action Plan (AP) which included one on one supervision for Resident 70, identifying and monitoring his behaviors for the Interdisciplinary Team (a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 2 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 team of healthcare providers including nurses, social services staff, dietary staff and physician who meet to plan resident care) to determine the root cause of his falls. Resident 70's PCP reviewed his medication regimen, discontinued the use of Ambien and decreased the dose of Trazodone from 50 milligrams (mg- a unit of measurement) once a day [QD] at bedtime [HS] to 25 mg QD HS. The facility in-serviced all staff on side rails assessment, psychotropic medications, preventing falls, developing a care plan that is specific, measurable and resident centered was accepted on 12/20/18 at 3:05 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 12/21/18 at 11 a.m. An IJ situation with a scope and severity of J (isolated) for Fwas called on 1/3/19 at 3:29 p.m. with the ADM and Director of Operations in attendance. The IJ findings included when Resident 56 experienced a choking episode while eating a meal unsupervised in his room in bed on 11/29/18 and staff did not recognize the emergent situation and delayed calling emergency services or 9-1-1. Resident 56 was diagnosed with Progressive Supranuclear Palsy (PSP - a brain disorder that affects the ability to swallow and affects the ability to walk with a steady gait, balance and speech) on 4/18/18. Resident 56's diagnosis of PSP was not communicated to the Primary Care Physician and IDT which did not provide the benefit of an updated care plan and appropriate interventions such as possible need for supervision while eating and possible modification of food textures to his meal plan. Resident 56 had multiple tooth extractions and there was no documented assessment performed by Licensed Nurses after Resident 56 returned from his dental appointments. Resident 56's multiple tooth extractions which FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 3 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 could affect his chewing and swallowing ability was not communicated to the Speech Pathologist for a swallow evaluation to be done. These failures resulted in Resident 56 not receiving the care needed for a diagnosis of PSP, such as swallow evaluation, possible supervision during meals, modified meals and other services required for PSP. The facility did not respond timely to an emergent situation and the delay in response led to Resident 56's death. The facility submitted an acceptable AP on 1/3/19 at 6:47 p.m. to address the IJ situation which included providing education to all staff members how to recognize and respond to a life threatening emergency. The Licensed Nurses were also provided an inservice education on assessment and documentation when a resident returns from an appointment, has a new diagnosis that required special needs or supervision and a change in condition. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 1/4/19 at 12:23 p.m. The following Complaint and Facility Reported Incidents (FRI's) were investigated during the RECERTIFICATION Survey: Complaint CA00613704: Unsubstantiated with no deficiency Investigated by 40038 RN HFEN FRI CA00613789: Unsubstantiated with no deficiency Investigated by 40038 RN HFEN FRI CA00613999: Substantiated with deficiencies. Refer to F 684, F 600 Investigated by 38641 RN HFEN

F558 Reasonable Accommodations FORM CMS-2567(02-99) Previous Versions Obsolete

F558 Event ID: S70D11 01/28/2019 Facility ID: CA040000225 If continuation sheet 4 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D Needs/Preferences CFR(s): 483.10(e)(3) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of residents needs for two of 40 sampled residents (Resident 70 and Resident 54) when: 1. Resident 70's call light hung on the wall and was not within Resident 70's reach. 2. Resident 54's call light was at the edge of the left lower end of the side rail and was not within Resident 54's reach. These failures had the potential to result in Resident 70 and Resident 54 not assisted by staff in the event of need or in an emergency. Findings: 1. Resident 70's face sheet (a document containing resident profile information) indicated Resident 70 was admitted to the facility on 4/19/18 with diagnoses which included muscle weakness and dementia (memory loss) with behavior disturbance. Resident 70's Minimum Data Set (MDS- an assessment of healthcare and functional needs) assessment, dated 10/17/18, indicated Resident 70's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 5 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 of 0 of 15 points indicated Resident 70 was severely cognitively impaired. The MDS assessment indicated Resident 70 was totally dependent on staff members to transfer from one surface to another. On 12/7/18 at 8:30 a.m., during an observation in Resident 70's room, Resident 70 laid in bed on his right side, with Resident 70's call light hung on a hook on the wall at the left side of bed and was not within Resident 70's reach. On 12/7/18 at 8:31 a.m.,, during a concurrent observation in Resident 70's room and interview, Licensed Nurse (LN) 5 stated the call light should be within Resident 70's reach. On 12/7/18 at 9:45 a.m., during a concurrent observation in Resident 70's room and interview , Certified Nursing Assistant (CNA) 8 stated he did not know why the call light was hanging on the wall. CNA 8 stated the call light should be within Resident 70's reach at all times.2. Resident 54's facesheet indicated Resident 54 was admitted to the facility on 9/26/18 with diagnoses which included difficulty in walking and history of falling. Resident 54's MDS assessment dated 11/21/18 indicated Resident 54's BIMS score of 15 of 15 points indicated Resident 54 was cognitively intact. The MDS assessment indicated Resident 54 required extensive assistance to transfer from one surface to another. On 12/17/18 at 8:40 a.m., during an observation in Resident 54's room, Resident 54 laid in bed and was sleeping with both upper side rails up. Resident 54's call light was clipped at the lower edge of the left side rail and was not within Resident 54's reach. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 6 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/17/18 at 9:50 a.m., during a concurrent observation in Resident 54's room and interview, Resident 54 sat on the right side of the bed and the call light hung at the edge of the left side rail and was not within Resident 54's reach. Resident 54 stated, "I don't know where is my call light." Resident 54 stated if she needed help, she would yell for help if her call light was not within reach. Resident 54 called for help and stated, "Hey, I need help." Resident 54 stated she needed assistance to go to the bathroom. Resident 54's voice was not loud enough to be heard by facility staff and staff did not respond. On 12/17/18 at 10 a.m., during a concurrent observation in Resident 54's room and interview, CNA 7 stated Resident 54's call light was at the lower end of the left side rail and was not within Resident 54's reach. CNA 7 stated when she did her morning rounds at 8 a.m., the call light was located on top of the left side rail. CNA 7 stated the call light had probably rolled down to the bottom. CNA 7 stated Resident 54's immediate needs may not have been attended to without a delay if the resident could not reach her call light. CNA 7 stated should have clipped it or attached it to the bed or blanket or resident's clothes. On 12/17/18 at 10:05 a.m., during an interview, Licensed Nurse (LN) 2 stated she saw Resident 54 during the medication pass and had not noticed the location of the call light. LN 2 stated, "I should have checked this morning if [Resident 54's] call light was within her reach to prevent the risk of falls if her needs will not be attended immediately." LN 2 stated call lights should be within reach at all times. On 12/17/18 at 10:10 a.m., during an interview, the Director of Nursing (DON) stated facility staff should make sure call lights were always FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 7 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 within reach for all residents to avoid potential injury, fall or incontinent episodes. The facility policy and procedure titled, "Call Light System" dated, 11/24/17, indicated, "... Purpose: To respond to resident's request and needs... Policy: It is the policy of this facility that each resident's call light will be within reach, operable and will be answered by any staff.... Procedure... 8. Ensure call light is within reach of the resident prior to leaving the room..."

F600 SS=J Free from Abuse and Neglect CFR(s): 483.12(a)(1)

F600 07/27/2022 §483.12 Freedom from Abuse, Neglect, and Exploitation The resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms. §483.12(a) The facility must§483.12(a)(1) Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion; This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure residents were free from neglect for one of 40 sampled resident's (Resident 56) when Resident 56 experienced a choking episode while eating a meal unsupervised in his room in bed on 11/29/18 and staff did not recognize the emergent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 8 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 situation and delayed calling emergency services or 9-1-1. Resident 56 was diagnosed with Progressive Supranuclear Palsy (PSP - a brain disorder that affects the ability to swallow and affects the ability to walk with a steady gait, balance and speech) on 4/18/18. Resident 56's diagnosis of PSP was not communicated to the Primary Care Physician and Interdisciplinary team (IDTa group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient). Based on this new diagnosis and high risk for choking there was no updated care plan and no intervention in place. Resident 56 had multiple teeth extractions and there was no documented assessment performed by Licensed Nurses after Resident 56 returned from his dental appointments. Resident 56's multiple teeth extractions could have placed the resident at a higher risk of choking affecting his chewing and swallowing ability. These facts were not communicated to the Speech Pathologist for a swallow evaluation to be done. These failures resulted in Resident 56 not receiving the care needed for a diagnosis of PSP, such as swallow evaluation, possible supervision during meals, modified meals and other services required for PSP. The facility did not respond timely to an emergent situation and the delay in response led to Resident 56's death. Because of the actual harm to Resident 56 that resulted in a choking episode which led to Resident 56 's death, an IJ situation was called on 1/3/19 at 3:29 p.m. with the Administrator and Director of Operations in attendance. The facility submitted an Action Plan to address the IJ situation which included providing education to all staff members on how to recognize and respond to a life threatening emergency which included calling FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 9 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 911. The Licensed Nurses were also provided in-service education on assessment and documentation when a resident returns from an appointment, has a new diagnosis that required special needs or supervision and a change in condition. The Action Plan was accepted on 1/3/19 at 6:47 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 1/4/19 at 12:23 p.m. Findings: Resident 56's face sheet (a document containing resident profile information) indicated Resident 56 was 70 years of age, admitted to the facility on 4/7/17 with diagnoses which included dysphagia (difficulty in swallowing) and muscle weakness. Resident 56's Minimum Data Set assessment (MDS) (a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 10/4/18 indicated the following for Resident 56: Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgement) score of 9 of 15 points (moderate cognitive impairment)required supervision (oversight, encouragement or cueing) with setup assistance for meals and had no problems or difficulty with swallowing. On 12/5/18 at 8:30 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated, "I have been working in the facility for 17 years. I took care of [Resident 56] for 1 year. He eats breakfast in his room. I open the lid of his tray and he would feed himself. That's all I do for him and he will eat by himself, then I would get his tray back [once resident was finished with his meal]." CNA 1 stated on 11/29/18 while in the room giving Resident 56's roommate his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 10 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 breakfast tray, he heard Resident 56 cough. CNA 1 stated, "I went over [to Resident 56], he was sitting upright, he just nodded, he didn't say anything. I told the charge nurse [Resident 56] might be aspirating [breathing foreign objects into airways]. That was the only time I heard [Resident 56] cough like that." On 12/5/18 at 9:16 a.m., during an interview, Licensed Nurse (LN) 2 stated, "A CNA came to me [on 11/29/18] and told me [Resident 56] might be aspirating. [Resident 56] didn't talk. I told him to lift up his head, I looked into his mouth and I saw a white drool mixed with food. I ran out to the nurses' station [calling out] that I need help [Resident 56] is choking. I called [Name of Ambulance Company] at around 7:25 a.m. [11/29/18] that I need an emergency transport, a resident is choking. I told them to send an ambulance with lights and sirens. I need emergency transfer now." LN 2 pointed at a paper written with the name and number of the ambulance company located at the nurses station and stated that was the number she used to call for the ambulance. LN 2 stated, "I came back to the nurses station and [the time] was 7:55 a.m. I was angry. Where are [the paramedics]. I see them out there parked at the front door [located across the street from the facility]. I asked them are you guys the lights and siren guys and he said yeah that's how busy we are. I told them I think our patient just passed away and they said what room... I don't understand what took them so long. They could have saved him. They are well equipped. They didn't even come with the lights and sirens on. I would have heard it but I didn't hear it. I never have to send a resident on a real emergency. Usually it's planned and [paramedics] respond right away but this time, I don't know why they didn't come right away." Review of Resident 56's progress note dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 11 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 11/29/18 indicated, "... This writer [LN 2] was notified at 0725 [a.m.] by CNA [1] that [Resident 56] may be possibly choking on breakfast, immediately went to assess resident and [Resident 56] was found sitting up in bed with a tray in front of him containing a freshly served breakfast that included a partially eaten tortilla. Resident pulse at 65, SpO2 sat (oxygen saturation- level of oxygen in the blood) is only 65% on RA [room air], asked resident if he was choking and no response was given, had resident sit more upright and looked in his mouth and could see nothing, immediately went to nurses station to get help from NOC [night nurse], returned to resident with NOC nurse and he [NOC nurse] immediately began to do abdominal thrusts after quick assessment and attempting a finger sweep with no success because resident would not open his mouth and partially clenching his teeth, after NOC nurse gave approximately 4 abd [abdomen] trust [thrusts]with no success [LN 1] ran back to nurses station to call for emergency assistance from [name of Ambulance Company]... dispatcher states that she will send ambulance with lights and sirens due to patient's inability to breathe... at 7:45 [LN 1] went back to desk and called resident's emergency contact ... and notified them of situation [choking] ... returned to resident's bedside, abd thrust still are ineffective ... however resident still has strong pulse 65-68 and Sp02 in 60's, resident suddenly went limp, cyanotic [turned blue in color] and without a pulse at [7:55 a.m.] ..." Resident 56's progress note dated 11/29/18 at 8 a.m., indicated [name of Ambulance Company] arrived at [approximately] 0758 [a.m.] ... resident was no longer breathing ... time of death announced [sic] at [7:55 a.m., by [RN] ..." On 12/5/18 at 3:06 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 12 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 17 stated she was Resident 56's sister. Resident 17 stated, "I just don't understand, they knew he had problems with swallowing. He needed to have supervision while eating. Somebody should have been there watching him. Nobody supervised him. They just put his tray and leave. My sister comes in on Monday, Wednesday and Friday. We eat lunch together. When we eat together, he coughs a lot that's why he needed some supervision. My sister was not here every day to watch for him. Somebody with that problem shouldn't be left alone in the room while eating. We shouldn't have to be mourning his death if they would have supervised him." On 12/5/18 at 3:46 p.m., during a concurrent interview and record review, the Speech Pathologist (SP) reviewed Resident 56's speech therapy notes and plan of care dated 4/10/17 which indicated the facility referred Resident 56 to SP for a swallow evaluation due to reports from caregivers of Resident 56 having swallowing difficulties during meals. The SP stated he performed the initial swallow evaluation on 4/10/17 and documented Resident 56 was having difficulty masticating [chewing] foods, and was observed with occasional coughing during meals. The SP stated Resident 56 and the family report intermittent [swallowing] difficulty. The SP stated Resident 56 was at risk for aspiration on liquids and required intermittent supervision. The SP stated, "He [Resident 56] was admitted on mechanical soft diet (is a diet that includes soft and easy to chew foods for people who have difficulty chewing and swallowing), honey thick liquids. When I discharged him [on 5/5/17], he did not require cueing and supervision with mechanical soft texture. He was safe to eat by himself. I told him to take small sips, small bites and he was able to demonstrate it safely." The SP note dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 13 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 5/8/17 indicated, "The [Resident 56] wishes to remain on current mechanical soft texture diet with nectar thick liquids to minimize risk of aspiration ... Precautions: ...Aspiration ... [Resident 56] and family report intermittent [swallowing] difficulty]. The SP stated it was a team effort that involved Licensed Nurses and CNA's to observe him and supervise him while eating. The SP stated, "[The facility] would have to let me know if [Resident 56] had any problems and would make a referral for me to do another swallow [evaluation]." SP stated the facility did not request a second referral for Resident 56 to receive a swallowing evaluation. On 12/5/18 at 4:26 p.m., during a telephone interview, Family Member (FM) 1 stated she took Resident 56 to an appointment with Neurologist (Neuro- brain and spinal cord Medical Doctor [Neuro MD]) on 4/18/18 and Resident 56 was diagnosed with PSP. FM 1 stated she took Resident 56 to the neuro MD because Resident 56 began to have difficulty speaking and was falling frequently. FM 1 stated Resident 56's voice was, "Very soft spoken that you could hardly hear his voice or understand him." FM 1 stated she was concerned and wanted to know what was wrong with him. FM 1 stated she wanted to know if Resident 56 had Parkinson disease (a progressive disease of the nervous system marked by tremor, muscular stiffness, and slow, rough movement). FM 1 stated, "[Resident 56] got diagnosed last April [2018] with Progressive Supranuclear Palsy. It was paralysis in the muscles. It affected his speech, walking and swallowing. The [Neuro MD] told me it's a progressive disease." FM 1 stated she comes to the facility every Monday, Wednesday and Friday to visit Resident 56 and Resident 17 and they would have lunch together. FM 1 stated, "One time, we had lunch FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 14 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 something got stuck in his throat. I took [Resident 56] out to the nurses' station and told the nurse something got stuck in his throat. I told a [Licensed Nurse] and she just gave him a pudding. I cut [Resident 56's] food in small pieces when I am there. He needs supervision while eating. He coughs up a lot ... I wouldn't want it to happen to anybody else." Review of Resident 56's clinical record fax to physician dated 6/13/17, indicated, "[Attention] ... [Name of PCP] ... Problem, [Resident 56] and [FM] want [Resident 56] referred to Neurology. [FM] states [Resident 56] has slurred speech, swallowing problems (on thickened liquids) ... gait imbalance ..." The clinical record indicated Resident 56's PCP ordered a referral to a Neuro MD. On 12/6/18 at 9:10 a.m., during an interview, CNA 2 stated she had been working in the facility for 26 years and took care of Resident 56. CNA 2 stated Resident 56 was observed to decline for the past months. CNA 2 stated Resident 56's voice changed to a very low tone and was at times difficult to understand. CNA 2 stated Resident 56 was becoming weaker and began to fall more often. CNA 2 stated she was unaware if he had swallowing issues because she would only set-up the meal tray for Resident 56 to eat his meal in his room and was not present while Resident 56 was eating. CNA 2 stated Resident 56 was not supervised during his meals. On 12/6/18 at 9:47 a.m., during a concurrent interview and record review, LN 4 reviewed Resident 56's Neuro MD progress notes dated 4/18/18 indicating, "... Had PSP (Progressive Supranuclear Palsy) with degeneration... need to be monitored closely..." LN 4 stated she was the LN assigned to Resident 56 when he returned from his appointment with the Neuro FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 15 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 MD. LN 4 stated Resident 56 returned with a doctor progress note indicating Resident 56 was newly diagnosed with PSP. LN 4 stated, "I just gave the document to medical records and it would be filed [away from the clinical record] by medical records." LN 4 stated she did not know what PSP meant for Resident 56's care and did not inform the Unit Manager (UM), Director of Nursing (DON) or the IDT team about the new diagnosis. LN 4 stated she should have informed the UM and DON in order to communicate and plan Resident 56's care and needs especially with a new diagnosis that she was not familiar with. LN 4 reviewed Resident 56's clinical record and was not able to find a care plan for his new diagnosis of PSP and how to address his care needs. LN 4 stated, "I have never done a care plan. It should be care planned so the nursing team would communicate and take care of his needs. It should also be [added] in his diagnosis but I don't see it included in his diagnoses. When I received the document after his appointment I should have documented it [in the clinical record]. I just wrote "no new orders" and no new diagnosis. I should not have done that. It made it look like I didn't do it. I didn't put it in the electronic health care record (EHR). I should have put it (in the EHR). That is what we were trained as nurses." LN 4 stated Resident 56's Primary Care Physician (PCP) should have been informed of his new diagnosis but she did not communicate this to him. LN 4 stated, "If we noticed that residents are having problems with swallowing we get a referral for a speech therapist [evaluation]. He had no problems with eating and swallowing. Sometimes I see him when I pass meds [medications] and he was okay." The facility document titled, "Job Description LVN" undated, indicated, "... As LVN... you are delegated the administrative authority, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 16 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 responsibility, and accountability necessary for carrying out your assigned duties... Assist in developing methods for coordinating nursing services with other patient services to ensure the continuity of the patients' total regimen of care... Participate in the development of a written plan of care (preliminary and comprehensive) for each patient that identifies the problems/needs of the patient, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care..." On 12/6/18 at 9:59 a.m., during a concurrent interview and record review, the UM reviewed Resident 56's Neuro MD progress notes dated 4/18/18 indicating, "... Had PSP (Progressive Supranuclear Palsy) with degeneration... need to be monitored closely..." The UM stated she was not aware of Resident 56's new diagnosis of PSP when he went to his Neuro appointment. The UM stated, "It should have been communicated with all staff. It was not care planned and it should have been care planned. If I was the one doing the care plan, I would put it under ADL's [Activities of Daily Living] and to monitor for decreased ADL functions such as difficulty in swallowing, to monitor how he eats, decreased in mobility function and to monitor for falls. [Resident 56] does not have a progressive disease like Parkinson's [progressive nervous system disorder that affects movement] before but now that he has a diagnosis of a progressive disease with degeneration, it should have been communicated with staff in order to plan care and anticipate the residents' needs." The UM stated the SP and PCP should have been notified about his newly diagnosed condition but was not informed by the nursing staff. On 12/6/18 at 10:05 a.m., during a concurrent interview and record review, the DON reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 17 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 56's Neuro MD progress notes dated 4/18/18 and indicated, "... Had PSP (Progressive Supranuclear Palsy) with degeneration... need to be monitored closely..." The DON stated she was not familiar with PSP or what it meant for Resident 56's care needs. The DON stated, "I did not know that [Resident 56] had that diagnosis. The healthcare team should have been notified about the diagnosis. If it got worst, we would have to send him back to the doctor. A referral to Speech [Pathologist] should have been made with the new diagnosis. It is important to monitor his swallowing if it got worse." The DON reviewed Resident 56's clinical record and was unable to find a care plan addressing his needs with his new diagnosed condition of PSP. The DON was unable to find Resident 56's PSP diagnosis added to his list of diagnoses. The DON stated, "It should be included in the diagnosis and it should be care planned to better plan for his care especially with a new diagnosis. The supervision [how he eats and level of assistance when eating] for [Resident 56] might have been different if the facility was aware of the new diagnosed condition." The DON reviewed the Neuro progress note with the PSP diagnosis and stated LN 4 was aware of the diagnosis and failed to communicate the condition to all facility team members. On 12/6/18 at 11:44 a.m., during a telephone interview, the SP stated he was not aware of Resident 56's diagnosis of PSP. The SP stated, "That's the first time I've heard of that diagnosis. Unfortunately I wasn't aware. It would have warranted a [speech therapy] screen..." The SP stated a speech therapy screening was not requested by the facility. On 12/6/18 at 1:39 p.m., during a telephone interview, the PCP stated the new diagnosis of PSP for Resident 56 was not communicated to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 18 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 him by the nursing staff. The PCP stated, "I'm looking at [internet search engine name] right now for the meaning of PSP. It means the resident will have swallowing problems... [The facility] has my direct number. They can call me anytime but I was not informed about the new diagnosis. It's a progressive disease so all the symptoms he was having will get worse over time [swallowing problems]. The nurses need to monitor his swallowing, the food and diet texture is a big thing..." On 12/7/18 at 8:46 a.m., during a telephone interview, the Neuro MD stated, "I saw [Resident 56] last April 2018 and I diagnosed him with PSP. It means the patient cannot swallow, [he] will fall more. It's like a death sentence for the patient. With a swallow eval [evaluation] it may prolong his life... The facility should have known he had PSP. I wrote monitoring but [the facility] has their own speech therapist. They should have made a referral with the speech therapist when they saw the diagnosis that he had PSP. A speech evaluation should have been made. The resident needs supervision with eating and walking because [he] will have more difficulty with swallowing and walking as the disease progresses. It's a simple job they need to do. They need to look at the diagnosis and find out what the best care to give the patient. That's why nursing homes are there to provide the best care for the patient. They should not just file the paper with the diagnosis. They should read it and find out about it and what it means to the patient's care. That's what nursing care is for, to be able to provide a better care for the patient and their needs. [The facility] has a speech therapist that should work with him." Professional reference titled, "Progressive Supranuclear Palsy (PSP) information" undated, (found at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 19 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 www.movementdisorders.ufhealth.org) indicated, "... Treating speech and swallow impairments is equally important... Choking or swallow difficulty is very common in PSP and another potential hazard. Aspiration of food, liquids or saliva can result in death. As such, formal swallow evaluation is strongly recommended and should include regular follow-up exams..." On 12/7/18 at 9:14 a.m., during an interview, LN 5 stated she has been working in the facility for 6 years. LN 5 stated, "If [residents] are choking or having a stroke, I start the Heimlich maneuver... I would call 911 first because it's an emergency situation. I never had to send somebody out on an emergency. The most recent one I sent out was a resident had a [Urinary Tract Infection- infection of the bladder] so I called [Name of Ambulance Company] but if it's an emergency I would call 911. On 12/7/18 at 9:25 a.m., during an interview, LN 1 stated she would call 911 in a life and death situation such as when a resident was choking. LN 1 stated she would call the [name of Ambulance Company] for non-threatening situations. On 12/7/18 9:49 a.m., during an interview, CNA 3 stated, "I notify the nurse if I came across a resident that needs emergency attention, and after that the nurse takes over. I would call 911 for an emergency situation..." On 12/7/18 10:04 a.m., during an interview, CNA 4 stated, "For emergency situation, I call code blue from the nurses station. The nurses will do whatever they need to do for the resident and if delegated to me to call the ambulance, I will call 911. We have a different ambulance [phone number] for non-emergent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 20 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 situation. I will call 911 whether outside, home or in the facility for emergency situation." On 12/7/18 at 10:01 a.m., during a telephone interview, LN 2 stated, "We call [Name of Ambulance Company] for everything, for emergency and non-emergency... I will not call 911. That's what [licensed nurses] were trained when I got hired and that's what I did." On 12/7/18 at 9:35 a.m., during an interview, the CNO stated, "For both emergency and nonemergency, nurses are supposed to call [Name of Ambulance Company]. If it is an emergency, we specify lights and sirens. It will not make any difference if we call 911 because there's only one Ambulance Company in this area." The CNO stated new hires and current staff are given in-service training for unusual occurrence such as fall prevention program, skin integrity and choking. On 12/7/18 at 9:45 a.m., during an interview, the DON stated, "...If I am in that situation, I could have handled it differently. I would have called 911 directly since they will come immediately and 911 would have dispatched the fire department to respond competently in an emergency situation." The DON stated the facility does not have a specific policy for responding in an emergency situation. The DON stated it was included in the LN's Basic Life Support (BLS) training that they knew how to respond to an emergency like choking and how to perform the Heimlich maneuver. On 12/7/18 9:55 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated the LN's are in-serviced annually on how to respond to an emergency situation like choking prevention. The DSD was not able to provide a specific policy on how the facility responds to an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 21 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 emergency situation like choking. The DSD stated the facility does not have a specific policy on how to respond when a resident was choking. The DSD stated LN's are supposed to call 911 for an emergency situation. The DSD provided a facility document titled, "CPR [Cardiopulmonary Resuscitation- an emergency life-saving procedure performed when someone's breathing or heartbeat has stopped]" undated, indicated "... First Aid for the Choking Victim: The Heimlich maneuver... [the manual application of sudden upward pressure on the upper abdomen of a choking victim to force a foreign object from the trachea] Choking is caused by an obstructed airway and is one of the leading causes of death. Everyone should know how to help a person who is choking, and as medical professionals, all CNAs are required to know how to assist someone with an obstructed airway caused by a foreign body... It is sensible to have someone call 911. The Heimlich maneuver may be successful. But it may not work and it is much, much better to have emergency personnel on the way then wait until the person loses consciousness and then call for help... Always call 911 or have someone call for help..." The DSD stated she goes over this document when she performs her annual in-service training on choking with the Licensed Nurses. On 12/7/18 at 10:16 a.m., during an interview, LN 6 stated, "If it's an emergency, I would immediately call 911. If it's a non-emergency situation, I would assess the resident and I would call the PCP. If the PCP says to send resident out then I would call the ambulance which is [Name of Ambulance Company] but if they are having a heart attack or choking, I would definitely call 911 because it's an emergency. The nurses on the floor trained me what to do in case of an emergency situation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 22 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 they told me to call 911." On 12/7/18 at 10:43 a.m., during a telephone interview, [Ambulance Company] representative stated, "[The facility] usually gets a hold of us through 911 or by calling us directly. Sometimes it depends on the situation... but I would think if it's a real emergency situation [staff] would call 911 as far as I know." On 12/7/18 at 12:16 p.m., during a concurrent interview and record review, LN 7 opened a facility binder located at the nurse's station and pointed at the [Name of Ambulance Company] number and stated, "I would call [name of Ambulance Company] for any emergency situation. I was trained on orientation to call direct line [name of Ambulance Company] for all emergencies." On 12/10/18 at 9:40 a.m., during an interview, the DSD stated she would call 911 for an emergency situation such as when a resident was choking. The DSD stated she would call [Name of Ambulance Company] for nonemergency situations such as when a resident will be transferred out of the facility to General Acute Care Hospital (GACH) for a procedure. On 12/10/18 at 9:50 a.m., during an interview, LN 8 stated she would call 911 for every emergency situation such as when a resident was choking or having chest pain. LN 8 stated she would call [Name of Ambulance Company] for non-emergency situations and if residents were stable enough to be transferred to GACH for an evaluation. LN 8 stated, "The difference between calling 911 and the [name of Ambulance Company] is that, 911 can dispatch an ambulance that is available right away." On 12/10/18 at 10:41 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 23 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 LN 2 stated she was not sure if anybody checked to see if the ambulance arrived to the facility while Resident 56 was still choking. LN 2 stated she did not call the paramedics to ask if they were on the way to the facility. On 12/10/18 at 10:53 a.m., during an interview, the DON stated nobody from the facility staff checked to see if the ambulance arrived at the facility while Resident 56 was still choking. The DON stated, "Someone should have called [the ambulance to [ask] when they are arriving to the facility]. The [facility staff] should call 911..." On 12/27/18 at 9:17 a.m., during a telephone interview, [Ambulance Company] Compliance Officer stated, "If the facility needs emergency transport, they should call 911. They should not be calling for the ambulance number. The ambulance number is different from 911." The Ambulance Compliance Officer stated 911 was used for emergency situations and the ambulance direct phone number was used for non-emergency situations. On 1/3/19 at 8:20 a.m., during a telephone interview, FM 1 stated, "[Resident 56] was having a lot of problems with speech, swallowing and walking. That's why I wanted him seen by a neurologist. [The facility staff] were saying [Resident 56] was high functioning. I was trying to get my brother more help." FM stated Resident 56 was admitted to the facility on April 2017 FM stated, "[Resident 56's] voice was not clear enough. I have to tell him to speak louder and he told me he couldn't. I requested another appointment to a neurologist and the reason for the referral was his speech problem so he could communicate better and other things that needs to be addressed like swallowing." On 1/3/19 at 9:28 a.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 24 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 interview and record review at the nurse's station, LN 4 reviewed the appointment calendar and stated Resident 56 went to dental appointments on 4/18/18, 5/4/18, 5/23/18, 6/5/18, 6/15/18, 7/19/18, 7/24/18, 9/17/18 and 11/21/18. LN 4 stated, "I don't know why [Resident 56] went to the dentist." LN 4 stated she was not aware Resident 56 had tooth extractions whenever he would go to his dental appointments or what procedure was performed by the dentist on Resident 56. LN 4 stated, "[Resident 56] has never had any tooth extractions, not that I am aware of." LN 4 reviewed Resident 56's progress notes in the computer and was unable to find documented assessment for the reason Resident 56 went to multiple dental appointments. LN 4 stated, "It should be documented in the progress notes. It should have been documented when the [dental] appointment was made so [Licensed Nurses] knew why [Resident 56] was going to the [dentist]. It should be documented in case it doesn't get passed on [to the next shift]." LN 4 stated it was important Licensed Nurses assessed and documented in the nurse's progress notes every time Resident 56 went to his dental appointment and after Resident 56 comes back from his dental appointment to ensure continuity of care and provide his care needs. LN 4 stated Resident 56 has a low tone voice and it was difficult for staff to understand him at times. LN 4 stated, " ... In the morning, [Resident 56's] voice would be louder, it varies, but that would be his usual [tone of voice]. LN 4 stated, the facility would call the PCP to get an order for a referral to SP but a referral to SP was not made. LN 4 stated, "It should have been referred to the [SP]. [Resident 56] should have been evaluated [by SP]." LN 4 stated she did not inform the PCP on Resident 56's change of voice. LN 4 stated, "For me [Resident 56] has always been that way [difficult to understand speech]." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 25 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 1/3/19 at 10:24 a.m., during a telephone interview, FM stated Resident 56 was having dental pain and had tooth extractions. FM stated, "I do not know how many teeth [the dentist] pulled. He was complaining about tooth pain for about a year and the dentist was working with him for one year. I do not remember how many teeth [were extracted]. The facility should have notes from the dentist." On 1/3/19 at 12:03 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 1/11/18, indicated, " ... Treatment (Tx) Recommendation ... # (number) 27 [tooth] sharp edge... # 27 painful- cuts tongue [with] sharp edge ..." The DON stated the dental consultation notes should have been given to the Licensed Nurse for a follow up after the dentist evaluated Resident 56. The DON was unable to find a documented nurse's assessment or follow up in Resident 56's clinical record. The DON stated, "It would be painful for a resident when they are eating. If you have a cut in the tongue, it makes [the resident] not want to eat. It will hurt more with spices [on the food] ..." On 1/3/19 at 12:09 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 3/23/18, indicated, " ... Tx Recommendation ... [Extraction] # 21 [tooth] ..." The DON was unable to find documented nurse's assessment in Resident 56's clinical record, Licensed Nurses followed up after Resident 56 was evaluated by the dentist. The DON stated, "Social Service gets [the consultation notes] and files them away." On 1/3/19 at 12:10 p.m., during a concurrent interview and record review, the DON reviewed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 26 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 56's dental consultation notes dated 4/10/18, and indicated, " ... Referred for Extraction of Teeth ... [#] 6, [#] 21 ..." The DON stated, "For taking a tooth out, [facility] would monitor [the resident] for 72 hours, every shift." The DON was unable to find documented nurse's notes, documentation the Licensed Nurses performed an assessment on Resident 56 after his dental appointment. The DON stated the facility reviewed all the residents medical records once a month. The DON stated when a resident goes out on an appointment, the facility does not verify if the consultation notes or referral was followed up by the Licensed Nurses or if a documentation or follow up assessment was completed. On 1/3/19 at 12:12 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's x-ray results of the teeth dated 5/23/18 and stated she did not see a lot of teeth left. The DON stated, "I would have referred him to speech [pathologist]. As nurses, we can downgrade (a process when a SP changes a resident's diet to a consistency that is safe for residents to swallow) [a diet] but not upgrade [a diet]. Nurses are not getting the [dental consultation notes] so they will not be able to downgrade [Resident 56's diet]." On 1/3/19 at 12:13 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 6/5/18, indicated, " ... MD Progress Note ... #6 [tooth], # 21 [tooth] extracted without complications ... MD New Orders ... Soft foods only for at least 3 days ..." The DON reviewed Resident 56's clinical record and was unable to find a documented assessment performed by Licensed Nurses after Resident 56's tooth extraction. The DON stated the facility should monitor Resident 56 and document every shift for 72 hours if there was any change in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 27 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 condition such as bleeding or pain. On 1/3/19 at 12:14 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 5/23/18, indicated, " ... MD new orders ... [follow up] for extraction with [oral] sedation ... Date/Time of Next Appointment ... 6/15/18 [at] 9 a.m. ... procedure appointment ..." The DON reviewed Resident 56's nurse's progress notes dated 5/23/18 and stated the facility should document what the follow up dental appointment is for. The DON stated it was important to document in Resident 56's nurse's progress notes the reason why he went to the dentist and any procedures that would be done. On 1/3/19 at 12:20 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 6/15/18, indicated, " ... Tooth # 7, 22, 14 ... Pain ... Please evaluate and render appropriate treatment ..." The DON reviewed Resident 56's clinical record and was unable to find documented assessment Licensed Nurses evaluated Resident 56 for pain after his dental appointment. The DON stated, "There should be a nurse's note. They should be putting [Resident 56] on documentation making sure [Licensed Nurses are] addressing the pain in his mouth and making sure he can eat his meals properly and safely or if it's too much pain to downgrade [Resident 56's diet] for the time being." On 1/3/19 at 12:41 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 7/24/18, indicated, " ... MD Progress Note ... [Resident 56] has multiple missing Permanent teeth, needs replacement with upper and lower partial [dentures ... MD New Diagnosis: tooth # 14 has [dental] caries (tooth decay) ... MD New FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 28 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 Orders ... filling [plus] partials [dentures] ..." The licensed nurse did not note at the bottom of the dental consult note there was a new order from the dentist. The DON reviewed Resident 56's clinical record and was unable to find documentation of the new order after Resident 56 was seen by the dentist. The DON stated the Licensed Nurse did not document any new orders from the dentist. The DON stated, "It needs to be clarified as an actual order." On 1/3/19 at 12:54 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 11/21/18, indicated, " ... 2 x-rays taken for #7 [tooth], # 25 [tooth]. [Resident 56] is partially edentulous (lacking teeth), needs [Partial Upper Dentures] ..." The DON reviewed Resident 56's clinical record and was unable to find documentation Licensed Nurses referred Resident 56 to the SP to evaluate his swallowing abilities after the tooth extractions. The DON stated, "[Resident 56's] diet was not downgraded and remained the same diet after the tooth extraction." The DON stated Resident 56 should have been referred to the SP and the Licensed Nurses should have assessed and documented how Resident 56 tolerates the mechanical soft diet. On 1/3/19 at 1:27 p.m., during an interview, the DON stated in the event of a life threatening emergency, the facility could call the main line of [name of Ambulance Company]. The DON stated, "Nurses can call that number [name of Ambulance Company] for emergency and nonemergency situations." Because of the actual harm to Resident 56 that resulted in a choking episode which led to Resident 56's death, an IJ situation was called on 1/3/19 at 3:29 p.m. with the Administrator FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 29 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 Director of Operations. The facility submitted an Action Plan to address the IJ situation which included providing education to all staff members on how to recognize and respond to a life threatening emergency. The Licensed Nurses were also provided an inservice education on assessment and documentation when a resident returns from an appointment, has a new diagnosis that required special needs or supervision and a change in condition. The Action Plan was accepted on 1/3/19 at 6:47 p.m. The interventions to address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 1/4/19 at 12:23 p.m. On 1/4/19 at 7:18 a.m., during a concurrent observation and interview, LN 3 demonstrated how he performed the Heimlich maneuver on Resident 56. LN 3 stated LN 2 went out of Resident 56's room on 11/29/18 and informed him Resident 56 was choking. LN 3 stated he went inside Resident 56's room, went to the right side of the bed and Resident 56's right side rail was up. LN 3 stated he did not put the right side rail down as he was preparing to perform the Heimlich maneuver. LN 3 stated he positioned Resident 56's on the left side of the bed. LN 3 stated he placed his hands on the xiphoid process (lower part of the breast bone) and began abdominal thrusts. LN 3 stated, the Heimlich maneuver was not working and Resident 56 was still choking. LN 3 stated, "The ambulance took a long time to arrive because we didn't call 9-1-1." LN 3 stated LN 2 should have not left Resident 56's room when she found him choking but should have started the Heimlich maneuver right away. LN 3 stated he performed a finger sweep (a technique for clearing a mechanical obstruction from the upper airway. The rescuer opens the victim's mouth by grasping the lower jaw and tongue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 30 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 between the thumb and fingers. The rescuer then attempts to sweep the foreign object out of the victim's mouth with a finger) on Resident 56 to clear his airway. LN 3 stated, "I saw something in his mouth. I tried to [perform a finger sweep] but he bit me so I don't want to make [Resident 56] more nervous. It might dislodge [the food bolus] further down if you do a finger sweep." Professional reference titled, "Abdominal Thrusts" dated 12/17/18, (found at https://medlineplusgov/ency/article/000047 .htm) indicated, " ... If the person is choking, perform abdominal thrusts as follows ... Place your fist, thumb side in, just above the person's navel (belly button), Grasp the fist tightly with your other hand, make quick, upward and inward thrusts with your fist. If the person is lying on his or her back, straddle the person facing the head. Pushed your grasped fist upward and inward ... You may need to repeat the procedure several times before the object is dislodged. If repeated attempts do not free the airway, call 911 ..." On 1/4/19 at 9:22 a.m., during a telephone interview, the Registered Dietitian (RD) stated she was not informed by the facility that Resident 56 had tooth extractions and dental procedures. The RD stated, "I would refer [Resident 56] to speech [pathologist] or check with him how he is eating and doing on his current diet. We can do a downgrade [of Resident 56's diet] if needed. Downgrading [a diet] is easier and safer than upgrading [a diet]." On 1/4/19 at 10:59 a.m., during an interview, LN 2 stated when Resident 56 started choking, she ran out to the nurse's station to ask for help. LN 2 stated there was a CNA in the room and at the time Resident 56 was choking, the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 31 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 CNA continued feeding Resident 56's roommate. LN 2 stated she found LN 3 at the nurse's station and asked for help to respond to Resident 56. LN 2 stated LN 3 performed four abdominal thrusts on Resident 56 and Resident 56 was still choking. LN 2 stated she went outside Resident 56's room to go to the nurse's station. LN 2 stated, "After four [abdominal thrusts], I'm going to call [Number and Name of Ambulance Company]." LN 2 stated after calling the Ambulance Company's main phone line, she went back to Resident 56's room and brought the emergency crash cart in case it was needed. LN 2 stated she was not aware that she needed to call 911 in an emergency life threatening situation. LN 2 stated, "I should have responded to [Resident 56] when he was choking. I was so scared ..." LN 2 stated she knew Resident 56 had missing teeth. LN 2 stated, "I think I remember, [Resident 56] was getting his tooth extracted to be fitted with partial [dentures]. I heard it from another nurse. I did not refer [Resident 56] to RD and SP." LN 2 stated it was important to assess Resident 56 after he came back from a dental procedure or when he had tooth extractions to monitor for pain, bleeding and assess if he could tolerate his current mechanical soft diet. The facility policy and procedure titled, "Change in Condition Assessment" dated 11/24/17, indicated, "Policy: It is the policy of this facility that residents who experience a change of condition will be assessed promptly and follow up action will be taken as indicated and in a timely manner ... Procedure ... 7. When emergency issues occur ... shortness of breath ... the physician will be called Stat [right away] ... b. If the resident deteriorates, the licensed nurse is to call 911 for transport to the hospital ... 12. The licensed nurse is to discuss the resident's change with the physician. Discussion should include interventions that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 32 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 can be carried out by the nursing staff in the facility. Every effort should be taken to treat the resident's condition in house before sending the resident to the acute hospital, if at all possible. All conversations with the physician are to be documented in the resident's medical record, in the nursing notes. 13. Treatments and interventions are to be carried out per the physician orders. 14. The licensed nurse who completed the resident assessment is to document the assessment in the nurse's note. An accurate assessment may require additional tools to be used to assist the licensed nurse. Tools available to the nurse include ... c. Pain assessment, f. SBAR [Situation, Background, Assessment and Recommendation- is a structured form of communication that provides a systematic approach for nurses to assess and record change in a resident's status] Tool ... 15. Alert (72 Hour) Charting is to be initiated for any resident who experiences a change in condition. Documentation is to address the resident's status and effect of any new orders. Shift to shift reports should include the resident's change, current status and any new interventions started during a shift. It is important to communicate and document changes that occur from shift to shift ... 17. The Director of Nursing (DON) is to be notified of any resident experiencing changes in condition. The DON is to monitor the resident's changes and ensure that the attending physician is updated ..." The facility policy and procedure titled, "Life Threatening Medical Emergency Response" dated 11/24/17, indicated, "Purpose: To assure prompt response to a medical emergency... Policy: It is a policy of this facility to respond to any emergency which activates the facility's medical emergency response... 7. The emergency lead will communicate with the paramedics, update them on the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 33 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 code status, diagnoses, recent medications administered..." Review of the facility document titled, "Emergency Operations Plan" dated 11/17, indicated, "... Rapid Response Guides... Follow these steps if you recognize a potential or actual emergency that may threaten or impact the health and safety of occupants including residents... Step 1... Call 9-1-1 for emergency response..." The facility policy and procedure titled, "Documentation, Nursing" dated 11/24/17, indicated, "... Purpose... To improve resident care by ensuring that nursing assessments, treatments and observations are documented in the medical record and easily accessible to all health care professionals involved in the resident's care... Policy... Documentation is to be clear, legible and reflect the plan of care..." The facility policy and procedure 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... Policy... The care plan is to be updated when the resident experiences acute... changes in their medical... and functional condition... Procedure: Based on comprehensive assessment the interdisciplinary team (IDT) is to develop a quantifiable objectives for the highest level of functioning the resident may be expected to attain, as well as the resident's goals and preferences... The Interdisciplinary Team includes: Attending Physician, Licensed Nurse, Nursing Assistant, Resident, Resident's Representative, Dietitian and/or Food and Nutritional Service Director, Social Service Designee, Activities Designee... 3. The care plan is to be reviewed and revised by the IDT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 34 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 after the resident's initial assessment, quarterly and more often as warranted by the change in a resident's condition. 4. The resident's care plan is to be updated as changes occur... 6. The focus/problem list is to identify those areas that the resident has actual or potential risk for injury, illness or other impairments. 7. Each goal is to be realistic, measurable, directed towards the focus and individualized to the resident. The goal is to build upon the resident's strength... 8. Interventions are those services, items and approaches that specific staff is to carry out to aid the resident in attaining and maintaining their highest functional level and preventing further decline..." Review of Resident 56's death certificate dated 11/29/18 obtained on [Name of County] on 1/3/19 indicated, " ... Cause of Death: Asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death, suffocation) by Choking on Food Bolus (Tortilla) ... Choked on Food Bolus (Tortilla) ..."

F684 SS=E Quality of Care CFR(s): 483.25

F684 07/27/2022 § 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 35 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 by: 2. Resident 56's face sheet (a document containing resident profile information) indicated Resident 56 was 70 years of age, admitted to the facility on 4/7/17 with diagnoses which included dysphagia (difficulty in swallowing) and muscle weakness. Resident 56's Minimum Data Set assessment (MDS) (a resident assessment tool used to identify resident cognitive and physical function) assessment, dated 10/4/18 indicated the following for Resident 56: Brief Interview for Mental Status (BIMS- assessment of cognitive status for memory and judgement) score of 9 of 15 points (moderate cognitive impairment)required supervision (oversight, encouragement or cueing) with setup assistance for meals and had no problems or difficulty with swallowing. On 12/5/18 at 8:30 a.m., during an interview, Certified Nursing Assistant (CNA) 1 stated, "I have been working in the facility for 17 years. I took care of [Resident 56] for 1 year. He eats breakfast in his room. I open the lid of his tray and he would feed himself. That's all I do for him and he will eat by himself, then I would get his tray back [once resident was finished with his meal]." CNA 1 stated on 11/29/18 while in the room giving Resident 56's roommate his breakfast tray, he heard Resident 56 cough. CNA 1 stated, "I went over [to Resident 56], he was sitting upright, he just nodded, he didn't say anything. I told the charge nurse [Resident 56] might be aspirating [breathing foreign objects into airways]. That was the only time I heard [Resident 56] cough like that." On 12/5/18 at 9:16 a.m., during an interview, Licensed Nurse (LN) 2 stated, "A CNA came to me [on 11/29/18] and told me [Resident 56] might be aspirating. [Resident 56] didn't talk. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 36 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 told him to lift up his head, I looked into his mouth and I saw a white drool mixed with food. I ran out to the nurses' station [calling out] that I need help [Resident 56] is choking. I called [Name of Ambulance Company] at around 7:25 a.m. [11/29/18] that I need an emergency transport, a resident is choking. I told them to send an ambulance with lights and sirens. I need emergency transfer now." LN 2 pointed at a paper written with the name and number of the ambulance company located at the nurses station and stated that was the number she used to call for the ambulance. LN 2 stated, "I came back to the nurses station and [the time] was 7:55 a.m. I was angry. Where are [the paramedics]. I see them out there parked at the front door [located across the street from the facility]. I asked them are you guys the lights and siren guys and he said yeah that's how busy we are. I told them I think our patient just passed away and they said what room... I don't understand what took them so long. They could have saved him. They are well equipped. They didn't even come with the lights and sirens on. I would have heard it but I didn't hear it. I never have to send a resident on a real emergency. Usually it's planned and [paramedics] respond right away but this time, I don't know why they didn't come right away." Review of Resident 56's progress note dated 11/29/18 indicated, "... This writer [LN 2] was notified at 0725 [a.m.] by CNA [1] that [Resident 56] may be possibly choking on breakfast, immediately went to assess resident and [Resident 56] was found sitting up in bed with a tray in front of him containing a freshly served breakfast that included a partially eaten tortilla. Resident pulse at 65, SpO2 sat (oxygen saturation- level of oxygen in the blood) is only 65% on RA [room air], asked resident if he was choking and no response was given, had resident sit more upright and looked in his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 37 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 mouth and could see nothing, immediately went to nurses station to get help from NOC [night nurse], returned to resident with NOC nurse and he [NOC nurse] immediately began to do abdominal thrusts after quick assessment and attempting a finger sweep with no success because resident would not open his mouth and partially clenching his teeth, after NOC nurse gave approximately 4 abd [abdomen] trust [thrusts]with no success [LN 1] ran back to nurses station to call for emergency assistance from [name of Ambulance Company]... dispatcher states that she will send ambulance with lights and sirens due to patient's inability to breathe... at 7:45 [LN 1] went back to desk and called resident's emergency contact ... and notified them of situation [choking] ... returned to resident's bedside, abd thrust still are ineffective ... however resident still has strong pulse 65-68 and Sp02 in 60's, resident suddenly went limp, cyanotic [turned blue in color] and without a pulse at [7:55 a.m.] ..." Resident 56's progress note dated 11/29/18 at 8 a.m., indicated [name of Ambulance Company] arrived at [approximately] 0758 [a.m.] ... resident was no longer breathing ... time of death announced [sic] at [7:55 a.m., by [RN] ..." On 12/5/18 at 3:06 p.m., during an interview, Resident 17 stated she was Resident 56's sister. Resident 17 stated, "I just don't understand, they knew he had problems with swallowing. He needed to have supervision while eating. Somebody should have been there watching him. Nobody supervised him. They just put his tray and leave. My sister comes in on Monday, Wednesday and Friday. We eat lunch together. When we eat together, he coughs a lot that's why he needed some supervision. My sister was not here every day to watch for him. Somebody with that problem FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 38 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 shouldn't be left alone in the room while eating. We shouldn't have to be mourning his death if they would have supervised him." On 12/5/18 at 3:46 p.m., during a concurrent interview and record review, the Speech Pathologist (SP) reviewed Resident 56's speech therapy notes and plan of care dated 4/10/17 which indicated the facility referred Resident 56 to SP for a swallow evaluation due to reports from caregivers of Resident 56 having swallowing difficulties during meals. The SP stated he performed the initial swallow evaluation on 4/10/17 and documented Resident 56 was having difficulty masticating [chewing] foods, and was observed with occasional coughing during meals. The SP stated Resident 56 and the family report intermittent [swallowing] difficulty. The SP stated Resident 56 was at risk for aspiration on liquids and required intermittent supervision. The SP stated, "He [Resident 56] was admitted on mechanical soft diet (is a diet that includes soft and easy to chew foods for people who have difficulty chewing and swallowing), honey thick liquids. When I discharged him [on 5/5/17], he did not require cueing and supervision with mechanical soft texture. He was safe to eat by himself. I told him to take small sips, small bites and he was able to demonstrate it safely." The SP note dated 5/8/17 indicated, "The [Resident 56] wishes to remain on current mechanical soft texture diet with nectar thick liquids to minimize risk of aspiration ... Precautions: ...Aspiration ... [Resident 56] and family report intermittent [swallowing] difficulty]. The SP stated it was a team effort that involved Licensed Nurses and CNA's to observe him and supervise him while eating. The SP stated, "[The facility] would have to let me know if [Resident 56] had any problems and would make a referral for me to do another swallow [evaluation]." SP stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 39 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 facility did not request a second referral for Resident 56 to receive a swallowing evaluation. On 12/5/18 at 4:26 p.m., during a telephone interview, Family Member (FM) 1 stated she took Resident 56 to an appointment with Neurologist (Neuro- brain and spinal cord Medical Doctor [Neuro MD]) on 4/18/18 and Resident 56 was diagnosed with PSP. FM 1 stated she took Resident 56 to the neuro MD because Resident 56 began to have difficulty speaking and was falling frequently. FM 1 stated Resident 56's voice was, "Very soft spoken that you could hardly hear his voice or understand him." FM 1 stated she was concerned and wanted to know what was wrong with him. FM 1 stated she wanted to know if Resident 56 had Parkinson disease (a progressive disease of the nervous system marked by tremor, muscular stiffness, and slow, rough movement). FM 1 stated, "[Resident 56] got diagnosed last April [2018] with Progressive Supranuclear Palsy. It was paralysis in the muscles. It affected his speech, walking and swallowing. The [Neuro MD] told me it's a progressive disease." FM 1 stated she comes to the facility every Monday, Wednesday and Friday to visit Resident 56 and Resident 17 and they would have lunch together. FM 1 stated, "One time, we had lunch and something got stuck in his throat. I took [Resident 56] out to the nurses' station and told the nurse something got stuck in his throat. I told a [Licensed Nurse] and she just gave him a pudding. I cut [Resident 56's] food in small pieces when I am there. He needs supervision while eating. He coughs up a lot ... I wouldn't want it to happen to anybody else." Review of Resident 56's clinical record fax to physician dated 6/13/17, indicated, "[Attention] ... [Name of PCP] ... Problem, [Resident 56] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 40 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 [FM] want [Resident 56] referred to Neurology. [FM] states [Resident 56] has slurred speech, swallowing problems (on thickened liquids) ... gait imbalance ..." The clinical record indicated Resident 56's PCP ordered a referral to a Neuro MD. On 12/6/18 at 9:10 a.m., during an interview, CNA 2 stated she had been working in the facility for 26 years and took care of Resident 56. CNA 2 stated Resident 56 was observed to decline for the past months. CNA 2 stated Resident 56's voice changed to a very low tone and was at times difficult to understand. CNA 2 stated Resident 56 was becoming weaker and began to fall more often. CNA 2 stated she was unaware if he had swallowing issues because she would only set-up the meal tray for Resident 56 to eat his meal in his room and was not present while Resident 56 was eating. CNA 2 stated Resident 56 was not supervised during his meals. On 12/6/18 at 9:47 a.m., during a concurrent interview and record review, LN 4 reviewed Resident 56's Neuro MD progress notes dated 4/18/18 indicating, "... Had PSP (Progressive Supranuclear Palsy) with degeneration... need to be monitored closely..." LN 4 stated she was the LN assigned to Resident 56 when he returned from his appointment with the Neuro MD. LN 4 stated Resident 56 returned with a doctor progress note indicating Resident 56 was newly diagnosed with PSP. LN 4 stated, "I just gave the document to medical records and it would be filed [away from the clinical record] by medical records." LN 4 stated she did not know what PSP meant for Resident 56's care and did not inform the Unit Manager (UM), Director of Nursing (DON) or the IDT team about the new diagnosis. LN 4 stated she should have informed the UM and DON in order to communicate and plan Resident 56's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 41 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 care and needs especially with a new diagnosis that she was not familiar with. LN 4 reviewed Resident 56's clinical record and was not able to find a care plan for his new diagnosis of PSP and how to address his care needs. LN 4 stated, "I have never done a care plan. It should be care planned so the nursing team would communicate and take care of his needs. It should also be [added] in his diagnosis but I don't see it included in his diagnoses. When I received the document after his appointment I should have documented it [in the clinical record]. I just wrote "no new orders" and no new diagnosis. I should not have done that. It made it look like I didn't do it. I didn't put it in the electronic health care record (EHR). I should have put it (in the EHR). That is what we were trained as nurses." LN 4 stated Resident 56's Primary Care Physician (PCP) should have been informed of his new diagnosis but she did not communicate this to him. LN 4 stated, "If we noticed that residents are having problems with swallowing we get a referral for a speech therapist [evaluation]. He had no problems with eating and swallowing. Sometimes I see him when I pass meds [medications] and he was okay." The facility document titled, "Job Description LVN" undated, indicated, "... As LVN... you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties... Assist in developing methods for coordinating nursing services with other patient services to ensure the continuity of the patients' total regimen of care... Participate in the development of a written plan of care (preliminary and comprehensive) for each patient that identifies the problems/needs of the patient, indicates the care to be given, goals to be accomplished, and which professional service is responsible for each element of care..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 42 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/6/18 at 9:59 a.m., during a concurrent interview and record review, the UM reviewed Resident 56's Neuro MD progress notes dated 4/18/18 indicating, "... Had PSP (Progressive Supranuclear Palsy) with degeneration... need to be monitored closely..." The UM stated she was not aware of Resident 56's new diagnosis of PSP when he went to his Neuro appointment. The UM stated, "It should have been communicated with all staff. It was not care planned and it should have been care planned. If I was the one doing the care plan, I would put it under ADL's [Activities of Daily Living] and to monitor for decreased ADL functions such as difficulty in swallowing, to monitor how he eats, decreased in mobility function and to monitor for falls. [Resident 56] does not have a progressive disease like Parkinson's [progressive nervous system disorder that affects movement] before but now that he has a diagnosis of a progressive disease with degeneration, it should have been communicated with staff in order to plan care and anticipate the residents' needs." The UM stated the SP and PCP should have been notified about his newly diagnosed condition but was not informed by the nursing staff. On 12/6/18 at 10:05 a.m., during a concurrent interview and record review, the DON reviewed Resident 56's Neuro MD progress notes dated 4/18/18 and indicated, "... Had PSP (Progressive Supranuclear Palsy) with degeneration... need to be monitored closely..." The DON stated she was not familiar with PSP or what it meant for Resident 56's care needs. The DON stated, "I did not know that [Resident 56] had that diagnosis. The healthcare team should have been notified about the diagnosis. If it got worst, we would have to send him back to the doctor. A referral to Speech [Pathologist] should have been made with the new FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 43 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 diagnosis. It is important to monitor his swallowing if it got worse." The DON reviewed Resident 56's clinical record and was unable to find a care plan addressing his needs with his new diagnosed condition of PSP. The DON was unable to find Resident 56's PSP diagnosis added to his list of diagnoses. The DON stated, "It should be included in the diagnosis and it should be care planned to better plan for his care especially with a new diagnosis. The supervision [how he eats and level of assistance when eating] for [Resident 56] might have been different if the facility was aware of the new diagnosed condition." The DON reviewed the Neuro progress note with the PSP diagnosis and stated LN 4 was aware of the diagnosis and failed to communicate the condition to all facility team members. On 12/6/18 at 11:44 a.m., during a telephone interview, the SP stated he was not aware of Resident 56's diagnosis of PSP. The SP stated, "That's the first time I've heard of that diagnosis. Unfortunately I wasn't aware. It would have warranted a [speech therapy] screen..." The SP stated a speech therapy screening was not requested by the facility. On 12/6/18 at 1:39 p.m., during a telephone interview, the PCP stated the new diagnosis of PSP for Resident 56 was not communicated to him by the nursing staff. The PCP stated, "I'm looking at [internet search engine name] right now for the meaning of PSP. It means the resident will have swallowing problems... [The facility] has my direct number. They can call me anytime but I was not informed about the new diagnosis. It's a progressive disease so all the symptoms he was having will get worse over time [swallowing problems]. The nurses need to monitor his swallowing, the food and diet texture is a big thing..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 44 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/7/18 at 8:46 a.m., during a telephone interview, the Neuro MD stated, "I saw [Resident 56] last April 2018 and I diagnosed him with PSP. It means the patient cannot swallow, [he] will fall more. It's like a death sentence for the patient. With a swallow eval [evaluation] it may prolong his life... The facility should have known he had PSP. I wrote monitoring but [the facility] has their own speech therapist. They should have made a referral with the speech therapist when they saw the diagnosis that he had PSP. A speech evaluation should have been made. The resident needs supervision with eating and walking because [he] will have more difficulty with swallowing and walking as the disease progresses. It's a simple job they need to do. They need to look at the diagnosis and find out what the best care to give the patient. That's why nursing homes are there to provide the best care for the patient. They should not just file the paper with the diagnosis. They should read it and find out about it and what it means to the patient's care. That's what nursing care is for, to be able to provide a better care for the patient and their needs. [The facility] has a speech therapist that should work with him." Professional reference titled, "Progressive Supranuclear Palsy (PSP) information" undated, (found at www.movementdisorders.ufhealth.org) indicated, "... Treating speech and swallow impairments is equally important... Choking or swallow difficulty is very common in PSP and another potential hazard. Aspiration of food, liquids or saliva can result in death. As such, formal swallow evaluation is strongly recommended and should include regular follow-up exams..." On 12/7/18 at 9:14 a.m., during an interview, LN 5 stated she has been working in the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 45 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 for 6 years. LN 5 stated, "If [residents] are choking or having a stroke, I start the Heimlich maneuver... I would call 911 first because it's an emergency situation. I never had to send somebody out on an emergency. The most recent one I sent out was a resident had a [Urinary Tract Infection- infection of the bladder] so I called [Name of Ambulance Company] but if it's an emergency I would call 911. On 12/7/18 at 9:25 a.m., during an interview, LN 1 stated she would call 911 in a life and death situation such as when a resident was choking. LN 1 stated she would call the [name of Ambulance Company] for non-threatening situations. On 12/7/18 9:49 a.m., during an interview, CNA 3 stated, "I notify the nurse if I came across a resident that needs emergency attention, and after that the nurse takes over. I would call 911 for an emergency situation..." On 12/7/18 10:04 a.m., during an interview, CNA 4 stated, "For emergency situation, I call code blue from the nurses station. The nurses will do whatever they need to do for the resident and if delegated to me to call the ambulance, I will call 911. We have a different ambulance [phone number] for non-emergent situation. I will call 911 whether outside, home or in the facility for emergency situation." On 12/7/18 at 10:01 a.m., during a telephone interview, LN 2 stated, "We call [Name of Ambulance Company] for everything, for emergency and non-emergency... I will not call 911. That's what [licensed nurses] were trained when I got hired and that's what I did." On 12/7/18 at 9:35 a.m., during an interview, the CNO stated, "For both emergency and nonFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 46 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 emergency, nurses are supposed to call [Name of Ambulance Company]. If it is an emergency, we specify lights and sirens. It will not make any difference if we call 911 because there's only one Ambulance Company in this area." The CNO stated new hires and current staff are given in-service training for unusual occurrence such as fall prevention program, skin integrity and choking. On 12/7/18 at 9:45 a.m., during an interview, the DON stated, "...If I am in that situation, I could have handled it differently. I would have called 911 directly since they will come immediately and 911 would have dispatched the fire department to respond competently in an emergency situation." The DON stated the facility does not have a specific policy for responding in an emergency situation. The DON stated it was included in the LN's Basic Life Support (BLS) training that they knew how to respond to an emergency like choking and how to perform the Heimlich maneuver. On 12/7/18 9:55 a.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated the LN's are in-serviced annually on how to respond to an emergency situation like choking prevention. The DSD was not able to provide a specific policy on how the facility responds to an emergency situation like choking. The DSD stated the facility does not have a specific policy on how to respond when a resident was choking. The DSD stated LN's are supposed to call 911 for an emergency situation. The DSD provided a facility document titled, "CPR [Cardiopulmonary Resuscitation- an emergency life-saving procedure performed when someone's breathing or heartbeat has stopped]" undated, indicated "... First Aid for the Choking Victim: The Heimlich maneuver... [the manual application of sudden upward FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 47 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 pressure on the upper abdomen of a choking victim to force a foreign object from the trachea] Choking is caused by an obstructed airway and is one of the leading causes of death. Everyone should know how to help a person who is choking, and as medical professionals, all CNAs are required to know how to assist someone with an obstructed airway caused by a foreign body... It is sensible to have someone call 911. The Heimlich maneuver may be successful. But it may not work and it is much, much better to have emergency personnel on the way then wait until the person loses consciousness and then call for help... Always call 911 or have someone call for help..." The DSD stated she goes over this document when she performs her annual in-service training on choking with the Licensed Nurses. On 12/7/18 at 10:16 a.m., during an interview, LN 6 stated, "If it's an emergency, I would immediately call 911. If it's a non-emergency situation, I would assess the resident and I would call the PCP. If the PCP says to send resident out then I would call the ambulance which is [Name of Ambulance Company] but if they are having a heart attack or choking, I would definitely call 911 because it's an emergency. The nurses on the floor trained me what to do in case of an emergency situation and they told me to call 911." On 12/7/18 at 10:43 a.m., during a telephone interview, [Ambulance Company] representative stated, "[The facility] usually gets a hold of us through 911 or by calling us directly. Sometimes it depends on the situation... but I would think if it's a real emergency situation [staff] would call 911 as far as I know." On 12/7/18 at 12:16 p.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 48 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 interview and record review, LN 7 opened a facility binder located at the nurse's station and pointed at the [Name of Ambulance Company] number and stated, "I would call [name of Ambulance Company] for any emergency situation. I was trained on orientation to call direct line [name of Ambulance Company] for all emergencies." On 12/10/18 at 9:40 a.m., during an interview, the DSD stated she would call 911 for an emergency situation such as when a resident was choking. The DSD stated she would call [Name of Ambulance Company] for nonemergency situations such as when a resident will be transferred out of the facility to General Acute Care Hospital (GACH) for a procedure. On 12/10/18 at 9:50 a.m., during an interview, LN 8 stated she would call 911 for every emergency situation such as when a resident was choking or having chest pain. LN 8 stated she would call [Name of Ambulance Company] for non-emergency situations and if residents were stable enough to be transferred to GACH for an evaluation. LN 8 stated, "The difference between calling 911 and the [name of Ambulance Company] is that, 911 can dispatch an ambulance that is available right away." On 12/10/18 at 10:41 a.m., during an interview, LN 2 stated she was not sure if anybody checked to see if the ambulance arrived to the facility while Resident 56 was still choking. LN 2 stated she did not call the paramedics to ask if they were on the way to the facility. On 12/10/18 at 10:53 a.m., during an interview, the DON stated nobody from the facility staff checked to see if the ambulance arrived at the facility while Resident 56 was still choking. The DON stated, "Someone should have called [the ambulance to [ask] when they are arriving to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 49 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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]. The [facility staff] should call 911..." On 12/27/18 at 9:17 a.m., during a telephone interview, [Ambulance Company] Compliance Officer stated, "If the facility needs emergency transport, they should call 911. They should not be calling for the ambulance number. The ambulance number is different from 911." The Ambulance Compliance Officer stated 911 was used for emergency situations and the ambulance direct phone number was used for non-emergency situations. On 1/3/19 at 8:20 a.m., during a telephone interview, FM 1 stated, "[Resident 56] was having a lot of problems with speech, swallowing and walking. That's why I wanted him seen by a neurologist. [The facility staff] were saying [Resident 56] was high functioning. I was trying to get my brother more help." FM stated Resident 56 was admitted to the facility on April 2017 FM stated, "[Resident 56's] voice was not clear enough. I have to tell him to speak louder and he told me he couldn't. I requested another appointment to a neurologist and the reason for the referral was his speech problem so he could communicate better and other things that needs to be addressed like swallowing." On 1/3/19 at 9:28 a.m., during a concurrent interview and record review at the nurse's station, LN 4 reviewed the appointment calendar and stated Resident 56 went to dental appointments on 4/18/18, 5/4/18, 5/23/18, 6/5/18, 6/15/18, 7/19/18, 7/24/18, 9/17/18 and 11/21/18. LN 4 stated, "I don't know why [Resident 56] went to the dentist." LN 4 stated she was not aware Resident 56 had tooth extractions whenever he would go to his dental appointments or what procedure was performed by the dentist on Resident 56. LN 4 stated, "[Resident 56] has never had any tooth FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 50 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 extractions, not that I am aware of." LN 4 reviewed Resident 56's progress notes in the computer and was unable to find documented assessment for the reason Resident 56 went to multiple dental appointments. LN 4 stated, "It should be documented in the progress notes. It should have been documented when the [dental] appointment was made so [Licensed Nurses] knew why [Resident 56] was going to the [dentist]. It should be documented in case it doesn't get passed on [to the next shift]." LN 4 stated it was important Licensed Nurses assessed and documented in the nurse's progress notes every time Resident 56 went to his dental appointment and after Resident 56 comes back from his dental appointment to ensure continuity of care and provide his care needs. LN 4 stated Resident 56 has a low tone voice and it was difficult for staff to understand him at times. LN 4 stated, " ... In the morning, [Resident 56's] voice would be louder, it varies, but that would be his usual [tone of voice]. LN 4 stated, the facility would call the PCP to get an order for a referral to SP but a referral to SP was not made. LN 4 stated, "It should have been referred to the [SP]. [Resident 56] should have been evaluated [by SP]." LN 4 stated she did not inform the PCP on Resident 56's change of voice. LN 4 stated, "For me [Resident 56] has always been that way [difficult to understand speech]." On 1/3/19 at 10:24 a.m., during a telephone interview, FM stated Resident 56 was having dental pain and had tooth extractions. FM stated, "I do not know how many teeth [the dentist] pulled. He was complaining about tooth pain for about a year and the dentist was working with him for one year. I do not remember how many teeth [were extracted]. The facility should have notes from the dentist." On 1/3/19 at 12:03 p.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 51 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 interview and record review, the DON reviewed Resident 56's dental consultation notes dated 1/11/18, indicated, " ... Treatment (Tx) Recommendation ... # (number) 27 [tooth] sharp edge... # 27 painful- cuts tongue [with] sharp edge ..." The DON stated the dental consultation notes should have been given to the Licensed Nurse for a follow up after the dentist evaluated Resident 56. The DON was unable to find a documented nurse's assessment or follow up in Resident 56's clinical record. The DON stated, "It would be painful for a resident when they are eating. If you have a cut in the tongue, it makes [the resident] not want to eat. It will hurt more with spices [on the food] ..." On 1/3/19 at 12:09 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 3/23/18, indicated, " ... Tx Recommendation ... [Extraction] # 21 [tooth] ..." The DON was unable to find documented nurse's assessment in Resident 56's clinical record, Licensed Nurses followed up after Resident 56 was evaluated by the dentist. The DON stated, "Social Service gets [the consultation notes] and files them away." On 1/3/19 at 12:10 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 4/10/18, and indicated, " ... Referred for Extraction of Teeth ... [#] 6, [#] 21 ..." The DON stated, "For taking a tooth out, [facility] would monitor [the resident] for 72 hours, every shift." The DON was unable to find documented nurse's notes, documentation the Licensed Nurses performed an assessment on Resident 56 after his dental appointment. The DON stated the facility reviewed all the residents medical records once a month. The DON stated when a resident goes out on an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 52 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 appointment, the facility does not verify if the consultation notes or referral was followed up by the Licensed Nurses or if a documentation or follow up assessment was completed. On 1/3/19 at 12:12 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's x-ray results of the teeth dated 5/23/18 and stated she did not see a lot of teeth left. The DON stated, "I would have referred him to speech [pathologist]. As nurses, we can downgrade (a process when a SP changes a resident's diet to a consistency that is safe for residents to swallow) [a diet] but not upgrade [a diet]. Nurses are not getting the [dental consultation notes] so they will not be able to downgrade [Resident 56's diet]." On 1/3/19 at 12:13 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 6/5/18, indicated, " ... MD Progress Note ... #6 [tooth], # 21 [tooth] extracted without complications ... MD New Orders ... Soft foods only for at least 3 days ..." The DON reviewed Resident 56's clinical record and was unable to find a documented assessment performed by Licensed Nurses after Resident 56's tooth extraction. The DON stated the facility should monitor Resident 56 and document every shift for 72 hours if there was any change in condition such as bleeding or pain. On 1/3/19 at 12:14 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 5/23/18, indicated, " ... MD new orders ... [follow up] for extraction with [oral] sedation ... Date/Time of Next Appointment ... 6/15/18 [at] 9 a.m. ... procedure appointment ..." The DON reviewed Resident 56's nurse's progress notes dated 5/23/18 and stated the facility should document what the follow up dental FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 53 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 appointment is for. The DON stated it was important to document in Resident 56's nurse's progress notes the reason why he went to the dentist and any procedures that would be done. On 1/3/19 at 12:20 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 6/15/18, indicated, " ... Tooth # 7, 22, 14 ... Pain ... Please evaluate and render appropriate treatment ..." The DON reviewed Resident 56's clinical record and was unable to find documented assessment Licensed Nurses evaluated Resident 56 for pain after his dental appointment. The DON stated, "There should be a nurse's note. They should be putting [Resident 56] on documentation making sure [Licensed Nurses are] addressing the pain in his mouth and making sure he can eat his meals properly and safely or if it's too much pain to downgrade [Resident 56's diet] for the time being." On 1/3/19 at 12:41 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 7/24/18, indicated, " ... MD Progress Note ... [Resident 56] has multiple missing Permanent teeth, needs replacement with upper and lower partial [dentures ... MD New Diagnosis: tooth # 14 has [dental] caries (tooth decay) ... MD New Orders ... filling [plus] partials [dentures] ..." The licensed nurse did not note at the bottom of the dental consult note there was a new order from the dentist. The DON reviewed Resident 56's clinical record and was unable to find documentation of the new order after Resident 56 was seen by the dentist. The DON stated the Licensed Nurse did not document any new orders from the dentist. The DON stated, "It needs to be clarified as an actual order." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 54 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 1/3/19 at 12:54 p.m., during a concurrent interview and record review, the DON reviewed Resident 56's dental consultation notes dated 11/21/18, indicated, " ... 2 x-rays taken for #7 [tooth], # 25 [tooth]. [Resident 56] is partially edentulous (lacking teeth), needs [Partial Upper Dentures] ..." The DON reviewed Resident 56's clinical record and was unable to find documentation Licensed Nurses referred Resident 56 to the SP to evaluate his swallowing abilities after the tooth extractions. The DON stated, "[Resident 56's] diet was not downgraded and remained the same diet after the tooth extraction." The DON stated Resident 56 should have been referred to the SP and the Licensed Nurses should have assessed and documented how Resident 56 tolerates the mechanical soft diet. On 1/3/19 at 1:27 p.m., during an interview, the DON stated in the event of a life threatening emergency, the facility could call the main line of [name of Ambulance Company]. The DON stated, "Nurses can call that number [name of Ambulance Company] for emergency and nonemergency situations." Because of the actual harm to Resident 56 that resulted in a choking episode which led to Resident 56's death, an IJ situation was called on 1/3/19 at 3:29 p.m. with the Administrator and Director of Operations. The facility submitted an Action Plan to address the IJ situation which included providing education to all staff members on how to recognize and respond to a life threatening emergency. The Licensed Nurses were also provided an inservice education on assessment and documentation when a resident returns from an appointment, has a new diagnosis that required special needs or supervision and a change in condition. The Action Plan was accepted on 1/3/19 at 6:47 p.m. The interventions to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 55 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 address the IJ situation on the Action Plan were fully implemented and the IJ was removed on 1/4/19 at 12:23 p.m. On 1/4/19 at 7:18 a.m., during a concurrent observation and interview, LN 3 demonstrated how he performed the Heimlich maneuver on Resident 56. LN 3 stated LN 2 went out of Resident 56's room on 11/29/18 and informed him Resident 56 was choking. LN 3 stated he went inside Resident 56's room, went to the right side of the bed and Resident 56's right side rail was up. LN 3 stated he did not put the right side rail down as he was preparing to perform the Heimlich maneuver. LN 3 stated he positioned Resident 56's on the left side of the bed. LN 3 stated he placed his hands on the xiphoid process (lower part of the breast bone) and began abdominal thrusts. LN 3 stated, the Heimlich maneuver was not working and Resident 56 was still choking. LN 3 stated, "The ambulance took a long time to arrive because we didn't call 9-1-1." LN 3 stated LN 2 should have not left Resident 56's room when she found him choking but should have started the Heimlich maneuver right away. LN 3 stated he performed a finger sweep (a technique for clearing a mechanical obstruction from the upper airway. The rescuer opens the victim's mouth by grasping the lower jaw and tongue between the thumb and fingers. The rescuer then attempts to sweep the foreign object out of the victim's mouth with a finger) on Resident 56 to clear his airway. LN 3 stated, "I saw something in his mouth. I tried to [perform a finger sweep] but he bit me so I don't want to make [Resident 56] more nervous. It might dislodge [the food bolus] further down if you do a finger sweep." Professional reference titled, "Abdominal Thrusts" dated 12/17/18, (found at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 56 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 https://medlineplusgov/ency/article/000047 .htm) indicated, " ... If the person is choking, perform abdominal thrusts as follows ... Place your fist, thumb side in, just above the person's navel (belly button), Grasp the fist tightly with your other hand, make quick, upward and inward thrusts with your fist. If the person is lying on his or her back, straddle the person facing the head. Pushed your grasped fist upward and inward ... You may need to repeat the procedure several times before the object is dislodged. If repeated attempts do not free the airway, call 911 ..." On 1/4/19 at 9:22 a.m., during a telephone interview, the Registered Dietitian (RD) stated she was not informed by the facility that Resident 56 had tooth extractions and dental procedures. The RD stated, "I would refer [Resident 56] to speech [pathologist] or check with him how he is eating and doing on his current diet. We can do a downgrade [of Resident 56's diet] if needed. Downgrading [a diet] is easier and safer than upgrading [a diet]." On 1/4/19 at 10:59 a.m., during an interview, LN 2 stated when Resident 56 started choking, she ran out to the nurse's station to ask for help. LN 2 stated there was a CNA in the room and at the time Resident 56 was choking, the CNA continued feeding Resident 56's roommate. LN 2 stated she found LN 3 at the nurse's station and asked for help to respond to Resident 56. LN 2 stated LN 3 performed four abdominal thrusts on Resident 56 and Resident 56 was still choking. LN 2 stated she went outside Resident 56's room to go to the nurse's station. LN 2 stated, "After four [abdominal thrusts], I'm going to call [Number and Name of Ambulance Company]." LN 2 stated after calling the Ambulance Company's main phone line, she went back to Resident 56's room and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 57 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 brought the emergency crash cart in case it was needed. LN 2 stated she was not aware that she needed to call 911 in an emergency life threatening situation. LN 2 stated, "I should have responded to [Resident 56] when he was choking. I was so scared ..." LN 2 stated she knew Resident 56 had missing teeth. LN 2 stated, "I think I remember, [Resident 56] was getting his tooth extracted to be fitted with partial [dentures]. I heard it from another nurse. I did not refer [Resident 56] to RD and SP." LN 2 stated it was important to assess Resident 56 after he came back from a dental procedure or when he had tooth extractions to monitor for pain, bleeding and assess if he could tolerate his current mechanical soft diet. The facility policy and procedure titled, "Change in Condition Assessment" dated 11/24/17, indicated, "Policy: It is the policy of this facility that residents who experience a change of condition will be assessed promptly and follow up action will be taken as indicated and in a timely manner ... Procedure ... 7. When emergency issues occur ... shortness of breath ... the physician will be called Stat [right away] ... b. If the resident deteriorates, the licensed nurse is to call 911 for transport to the hospital ... 12. The licensed nurse is to discuss the resident's change with the physician. Discussion should include interventions that can be carried out by the nursing staff in the facility. Every effort should be taken to treat the resident's condition in house before sending the resident to the acute hospital, if at all possible. All conversations with the physician are to be documented in the resident's medical record, in the nursing notes. 13. Treatments and interventions are to be carried out per the physician orders. 14. The licensed nurse who completed the resident assessment is to document the assessment in the nurse's note. An accurate assessment may require additional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 58 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 tools to be used to assist the licensed nurse. Tools available to the nurse include ... c. Pain assessment, f. SBAR [Situation, Background, Assessment and Recommendation- is a structured form of communication that provides a systematic approach for nurses to assess and record change in a resident's status] Tool ... 15. Alert (72 Hour) Charting is to be initiated for any resident who experiences a change in condition. Documentation is to address the resident's status and effect of any new orders. Shift to shift reports should include the resident's change, current status and any new interventions started during a shift. It is important to communicate and document changes that occur from shift to shift ... 17. The Director of Nursing (DON) is to be notified of any resident experiencing changes in condition. The DON is to monitor the resident's changes and ensure that the attending physician is updated ..." The facility policy and procedure titled, "Life Threatening Medical Emergency Response" dated 11/24/17, indicated, "Purpose: To assure prompt response to a medical emergency... Policy: It is a policy of this facility to respond to any emergency which activates the facility's medical emergency response... 7. The emergency lead will communicate with the paramedics, update them on the resident's code status, diagnoses, recent medications administered..." Review of the facility document titled, "Emergency Operations Plan" dated 11/17, indicated, "... Rapid Response Guides... Follow these steps if you recognize a potential or actual emergency that may threaten or impact the health and safety of occupants including residents... Step 1... Call 9-1-1 for emergency response..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 59 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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, "Documentation, Nursing" dated 11/24/17, indicated, "... Purpose... To improve resident care by ensuring that nursing assessments, treatments and observations are documented in the medical record and easily accessible to all health care professionals involved in the resident's care... Policy... Documentation is to be clear, legible and reflect the plan of care..." The facility policy and procedure 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... Policy... The care plan is to be updated when the resident experiences acute... changes in their medical... and functional condition... Procedure: Based on comprehensive assessment the interdisciplinary team (IDT) is to develop a quantifiable objectives for the highest level of functioning the resident may be expected to attain, as well as the resident's goals and preferences... The Interdisciplinary Team includes: Attending Physician, Licensed Nurse, Nursing Assistant, Resident, Resident's Representative, Dietitian and/or Food and Nutritional Service Director, Social Service Designee, Activities Designee... 3. The care plan is to be reviewed and revised by the IDT after the resident's initial assessment, quarterly and more often as warranted by the change in a resident's condition. 4. The resident's care plan is to be updated as changes occur... 6. The focus/problem list is to identify those areas that the resident has actual or potential risk for injury, illness or other impairments. 7. Each goal is to be realistic, measurable, directed towards the focus and individualized to the resident. The goal is to build upon the resident's strength... 8. Interventions are those services, items and approaches that specific FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 60 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 staff is to carry out to aid the resident in attaining and maintaining their highest functional level and preventing further decline..." Review of Resident 56's death certificate dated 11/29/18 obtained on [Name of County] on 1/3/19 indicated, " ... Cause of Death: Asphyxia (a condition arising when the body is deprived of oxygen, causing unconsciousness or death, suffocation) by Choking on Food Bolus (Tortilla) ... Choked on Food Bolus (Tortilla) ..."Based on observation, interview, and record review, the facility failed to ensure two of 40 sampled residents (Resident 70 and Resident 56) received treatment and care in accordance with professional standards of practice, comprehensive person centered care and the residents' choices to enable residents to maintain their highest practicable level when: 1a. The facility failed to ensure the bed's dimension were appropriate for Resident 70's size and weight prior to the installation of the side rails. There were no appropriate alternatives prior to installation of side rails for Resident 70. The facility failed to assess the risk of entrapment prior to the use of the side rail for Resident 70, when Resident 70 was observed with four bed rails up and his legs between the gap of the bed rails almost touching the ground. 1b. Resident 70 was assessed as a high risk for falls on 4/26/18 and experienced 10 falls between 6/25/18 and 12/3/18, including a fall in which his right arm was caught between the side rail and the mattress on 11/15/18. The fall assessment and interventions following each fall did not address resident behaviors and possible triggers to the falls. 1c. The facility failed to appropriately assess FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 61 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 70's needs and preferences for activities. 1d. The facility failed to assess Resident 70 for duplicate therapy (prescribing multiple medications for the same medical indication) when resident was receiving both Ambien and Trazodone and did not follow Pharmacy Consultant recommendations to discontinue one of the medications. 1e. Resident 70 was prescribed and administered multiple psychotropic medications and the Pharmacy Consultant (PHARM) recommended a reduction or elimination of drugs to comply with standards of practice. 1f. Resident 70 was admitted on Keppra (a medication used to treat seizures) without seizure diagnosis and evaluation by the Primary Care Physician (PCP) to determine the need to continue the medication. Resident 70 did not have seizure episode since admission to the facility. The facility failed to follow up with Resident 70's PCP and evaluate if Resident 70 had a seizure diagnosis. These failures resulted in the potential harm of not meeting the needs of the resident and not keeping the resident safe. 2. Resident 56 experienced a choking episode while eating a meal unsupervised in his room in bed on 11/29/18 and staff did not recognize the emergent situation and delayed calling emergency services or 9-1-1. Resident 56 was diagnosed with Progressive Supranuclear Palsy (PSP - a brain disorder that affects the ability to swallow and affects the ability to walk with a steady gait, balance and speech) on 4/18/18. Resident 56's diagnosis of PSP was not communicated to the Primary Care Physician and Interdisciplinary team (IDT- a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 62 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 group of health care professionals from diverse fields who work in a coordinated fashion toward a common goal for the patient). Based on this new diagnosis and high risk for choking there was no updated care plan and no intervention in place. Resident 56 had multiple teeth extractions and there was no documented assessment performed by Licensed Nurses after Resident 56 returned from his dental appointments. Resident 56's multiple teeth extractions could have placed the resident at a higher risk of choking affecting his chewing and swallowing ability. These facts were not communicated to the Speech Pathologist for a swallow evaluation to be done. These failures resulted in Resident 56 not receiving the care needed for a diagnosis of PSP, such as swallow evaluation, possible supervision during meals, modified meals and other services required for PSP. Findings: 1a. Resident 70's face sheet (a document containing resident profile information) indicated Resident 70 was admitted to the facility on 4/19/18 with diagnoses which included cerebral infarction (a portion of the brain that has restricted blood supply), muscle weakness, dementia (memory loss) with behavior disturbance, epilepsy (abnormal electrical activity in the brain), insomnia (difficulty in sleeping), bipolar disorder (mental illness characterized by episodes of mood swings), major depressive disorder (mental illness characterized by feelings of prolonged sadness) and peripheral vascular disease (reduced blood flow to the extremities). Review of Resident 70's Minimum Data Set (MDS- an assessment of healthcare and functional needs) assessment dated 4/26/18, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 63 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 70's Brief Interview for Mental Status (BIMS- assessment of cognitive status) score of 3 of 15 points which indicated Resident 70 was severely cognitively impaired. Section "G" indicated Resident 70 was totally dependent on staff members to transfer from one surface to another. Section P "Restraints and Alarms" "Bed rail" and "Other" coded as "0" (Not used); MDS dated 7/19/18 section P indicated "Bed rail" coded as "0" (Not used) and Alarms "2" (Bed alarm); MDS dated 10/17/18 section "P" indicated "Bed rail" coded as "0" (Not used and "2" (Used daily) for Bed alarm, floor mat alarm, and Motion sensor alarm. MDS dated 11/9/18, indicated "Bed rail" or "Other" coded as "0" (Not used). On 12/7/18 at 8:30 a.m., during an observation, Resident 70 was in his bed lying on his right side with his legs over the side of the bed. The bed had four side rails in the up position and Resident 70's legs were positioned in the gap between the right upper side rail and the right lower side rail. The call light cord was looped on a hook on the wall at the head of the bed and out of reach from Resident 70. Resident 70 was in his room alone without staff to assist him. On 12/7/18 at 8:31 a.m., during a concurrent observation and interview, LN 5 observed the position of Resident 70's legs dangling off the bed in the gap between the lower and upper side rails on the right side. LN 5 immediately repositioned Resident 70 so his legs were on the bed and no longer in the gap between the upper and lower side rails. LN 5 then called CNA 8 to assist in repositioning the resident up on the bed and attempted to lower the side rails. LN 5 was unable to lower the side rail on the lower left side of the bed. The left side rail was left in the up position. The bed rail on the lower right side was lowered by the LN 5 with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 64 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 ease. LN 5 stated the call light was not where it should be. On 12/7/18 at 9:45 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed with three side rails up. LN 5 stated there were three side rails up and only the right lower side rail was down. LN 5 stated, "I'm pretty sure the right bottom side rail was up [during the 8:31 a.m. observation]." On 12/7/18 at 9:48 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed, resting and there were three side rails in the up position (right and left upper and left lower). Certified Nursing Assistant (CNA) 8 stated he had worked with Resident 70 for several months and was assigned to Resident 70 since six a.m. on 12/7/18. CNA 8 stated, "We [Facility staff] were told not to use the bottom side rails and I don't know how they got in the upper position. I overlooked that four side rails were up." CNA 8 stated he did not know why the call light cord was on the wall and out of the reach of Resident 70. On 12/7/18 at 10:00 a.m., during an interview, LN 5 stated she understood there was an order to use only the upper right and upper left side rails. LN 5 stated she did not know who put the lower side rails in the up position. On 12/10/18 at 10:55 a.m., during an interview, the Director of Nursing (DON) stated, "Yes, all four side rails would be considered a restraint. It could be for safety, but the consent does not include all four side rails." On 12/17/18 at 4:55 p.m., during a concurrent interview and record review, the DON stated a side rails assessment was completed on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 65 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 4/19/18 but did not include alternative measures tried prior to the decision to use side rails. The DON stated, "The CNAs and nurses are responsible to see that a bed assessment is completed. The bed already came with side rails. He is dead weight; he is non-ambulatory; he came as a LTC [Long Term Care] resident. A Hoyer lift [mechanical lift to assist a resident to transfer who is unable to assist in self transfer] is used due to dead weight [115.8 pounds]." The DON stated a reassessment of the side rails was not done in July and started reassessment in October. The DON stated no one admitted who put up the lower side rails. The DON emphasized staff were aware they were not to put all four rails in the up position. The DON stated Resident 70 could have injured himself while the four rails were up. The DON stated, "[Resident 70] could be at risk for entrapment, but with all the side rails up he could still get through." The DON stated, "We do not consider this (meaning side rails up) a restraint if used for mobility." The DON stated there was no monitoring plan to make sure the use of the side rails was safe. Resident 70's "Resident Bed Rail Consent Form" dated 4/19/18, indicated, "... Mobility Assist...Can enable [Resident 70] to independently reposition self in bed, or to assist caregivers to reposition him/herself in bed, from side to side, move closer to the head of the bed, or to move from a lying to sitting to lying position...Medical Safety...can be a safety measure identified in the resident's care plan by preventing [Resident 70] from slipping or rolling out of bed due to seizures...It is the policy of this facility to use bed rails only after evaluation and care planning deemed it is appropriate to treat the resident's medical symptoms and assist the resident in maintaining his/her highest practicable physical and psychosocial FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 66 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 wellbeing...Recommendations...Type of rail (s)... 1/4 partial rail, left upper, right upper...Frequency...Rail(s) are to be used at all times when [Resident 70] is in bed...Bed rail (s) are to be released PRN [as needed] to allow the resident to move in and out of bed, exercising his/her extremities... Benefits [versus] Risk" indicated, "... Area of concern... [Resident 70] side rails... Benefits...Securityfeel safe, mobility assist from side to side, move from a lying to sitting to lying position, help with transferring, medical safety... Risks related to Noncompliance [sic] ... skin tears, possible Fall [with] injury, bruising, strangulation, suffocation, caught between rail [and] mattress..." Resident 70's physician orders dated 4/20/18, indicated, "...May use side rails for assist in mobility, repositioning, and assist with ADL [Activities of Daily Living] ..." The physician orders did not specify how many side rails could be used. Resident 70's "Progress note" dated 4/19/18 at 4:50 p.m., indicated, "Fall Score: 12, fall category: Moderate Risk..." Resident 70's "Progress note" dated 4/26/18 at 1:26 p.m., indicated, "Fall Score: 18, fall category: High Risk ..." Residents 70's care plan dated 4/20/18 indicated "[Resident 70] uses side rails r/t [related to] assisting with physical functioning such as for mobility to independently reposition self or to assist or to assist caregivers to reposition ...type of rails: ½ Partial Rail Left Upper and Right Upper [side rail informed consent dated 4/19/18 indicated ¼ side rails were to be used not 1/2] ...Evaluate the resident's side rail use PRN [as needed]: Evaluate/record continuing risks/benefits of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 67 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 side rails, alternatives to the use of side rails, need for ongoing use, reason for side rail use ...Discuss and educate with the resident/family/caregivers, the risks and benefits of side rails, when the side rails should/will be applied, and an concerns or issues regarding side rail use ..." On 12/18/18 at 3:10 p.m., during a concurrent observation and interview, the Maintenance Man (MM) 1 took off the lower side rails from the bed. MM 1 stated he had been instructed by the ADM to take the side rails off so they could no longer be used. On 12/19/18 at 8:05 a.m., during an interview, the Administrator (ADM) stated it had been a mistake that the bottom side rails were used. The ADM stated, "They should have already been removed; just like all the rest of the beds in the facility. I don't know why that one was different. It appears that one was missed. I wish we could have seen it before. The maintenance man has removed them [side rails]." The ADM stated there was no way to know if the lower side rails had been used before [the observation of 12/7/18 were Resident 70 was dangling off his bed with legs between the side rails]. The ADM stated the survey had prompted them to look at all side rails in the facility. The ADM stated, "My goal is to never let it happen again." The facility document titled "Quarterly Maintenance Inspection Check List" for "New equipment inspection (Bed)" dated 12/20/18 indicated a check mark for Resident 70's "Bedrails" and "Beds Operations". The "Preventative Maintenance-Resident's Rooms" log dated 11/14/18 indicated Resident 70's bed had been checked, but does not indicate what parts had been checked or if repairs were needed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 68 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 1b. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the Unit Manager (UM) reviewed Resident 70's progress notes dated 6/25/18 for Fall number 1 which indicated "... Author heard [Resident 70] yell out, looked in the room and saw [Resident 70] with legs hanging from the bed and [Resident 70] slipping to the floor....[Resident 70] noted to have hit his head on the foot of the bed on the plastic foot rail that was down... [Resident 70] said he was leaving and that he had purposely thrown himself to the floor. [Resident 70] stated he knew what he was doing and that he would continue to do it..." The UM reviewed Resident 70's care plan dated 6/25/18 which indicated, " ... Added floor mats ..." Resident 70's progress notes dated 6/26/18 indicated, "IDT [Interdisciplinary Team] met including DON, DSD [Director of Staff Development], SSA [Social Service Assistant], Unit Manager, MDS Coordinator, RD [Registered Dietician], ADM regarding [Resident 70] episode of throwing himself on the floor. Floor mats and bed alarm added. Staff will continue to monitor and re-direct. Patient teaching was done as well ..." The IDT did not contain documentation evidence of Resident 70's behavior or approaches for the behaviors. The IDT was aware Resident 70 had a BIMS of less than 3 and did not address whether resident education or patient teaching was appropriately understood by resident due severe cognitive impairment. The UM stated, Resident 70 was not on the falling star program (system used by the facility to identify residents who are high risks for falls). Resident 70's care plan dated 4/20/18, indicated "[Resident 70] has impaired cognitive function due to Dementia, CVAs, BIMS score 0.0 [severe cognitive impairment] ...Interventions ...Ask simple yes/no questions FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 69 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 in order to determine the resident's needs ...Assure the resident understands consistent, simple, directive sentences. Provide the resident with necessary cues ..." On 12/17/18 at 10:48 a.m., during an interview, CNA 8 stated the falling star program (residents identified at high risk for falls) was implemented just two months ago. CNA 8 stated, "We do one on one with [Resident 70] when he is in his chair because he will try to throw himself out [of the wheelchair onto the floor] ..." Resident 70's "Progress Note" dated 6/25/18 at 9:30 a.m., indicated "Fall Score: 20.0 Fall Category: High Risk." On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 7/1/18, for fall number 2 which indicated, "...nurse walked in [room number] to find [Resident 70] on floor on top of the mat, head by foot of bed, [Resident 70] was supporting himself on [right] side arm..." The UM reviewed Resident 70's care plan dated 7/2/18, indicated "...Shower resident daily..." The UM stated she put daily showers as an intervention to prevent Resident 70 from falling. The UM stated the showers helped him to calm him, but Resident 70's response varied whether or not it calmed him. The UM stated showers were used to prevent Resident 70 from falling. The UM was unable to state how the showers would prevent Resident 70 from falling. On 12/17/18 at 1:13 p.m., during a concurrent interview and record review, LN 4 stated, "We give him a shower every day, it helps him relax for a couple of hours then he starts yelling again. I'm familiar with the resident since admission. He doesn't use the call light. He FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 70 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 curses in Spanish, screams and yells. He will ask to be changed even if he is dry and ask to get up even after we just placed him back to bed." LN 4 was unable to state how the showers would prevent Resident 70 from falling. Resident 70's "Progress Note" dated 7/1/18 at 9 p.m., indicated "Fall Score: 19.0 Fall Category: High Risk." On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 8/11/18 at 7:50 a.m. for Fall number 3, indicated " ... [Resident 70] noted on knees, on floor mat, between the bed and sliding glass door ..." Resident 70's care plan dated 8/11/18, indicated " ... [Provide Resident 70 with] Frequent reminders to ask for help [due to] safety ..." Resident 70's progress notes dated 8/13/18, indicated "...IDT met ...regarding [Resident 70] episode of falling. Resident is non-compliant, attempts to get out of bed, makes repetitive statements, and yells out most of the time. He has alarms, floor mats, is on [every 2] hours for bladder incontinence, and is on daily shower schedule. Staff will continue to monitor and educate." The UM stated she added a new intervention in Resident 70's fall care plan to remind Resident 70 to ask for assistance. The UM stated, "[Resident 70] does not make sense with his repetitive behavior of yelling out." The UM was unable to explain how the new intervention will address Resident 70's behavior and prevent further falls. The UM was unable to stated how Resident 70 would understand the education provided with his severe cognitive impairment. Resident 70's "Progress Note" dated 8/11/18 at 7:30 a.m., indicated "Fall Score: 25.0 Fall Category: High Risk." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 71 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 10/15/18 at 3 p.m. for Fall number 4 which indicated, " ... [Resident 70 sliding off the bed, [bed alarm] turned on. Resident was holding onto the side rail and bed sheets...Resident had left foot on the floor and right foot bent at 90 degrees ...Resident stated "I was looking for something to clean my mouth..." Resident 70's care plan dated 10/15/18 indicated "...Staff to anticipate needs. Educate staff on residents' oral care needs ..." The facility document titled, "Interdisciplinary (IDT) Meeting Summary" dated 10/16/18 at 9:18 a.m., indicated " ... Root Cause/Contributing Factors [Resident 70's fall] ... Resident noted with behavior issues, resident is impulsive, seeking attention, resident wanted his mouth clean, however did not ask for assistance ...IDT Recommendations ...Resident is on falling star program. resident is up for daily showers. staff to anticipate his needs, and educate staff on residents' oral care needs..." The UM stated the recommended intervention was to provide oral care. The UM was unable to state how the recommended intervention to provide oral care would prevent Resident 70 from falling. Resident 70's "Progress Note" dated 10/15/18 at 3 p.m., indicated "Fall Score: 23.0 Fall Category: High Risk." On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress notes dated 10/26/18 at 5:45 p.m. for Fall number 5 which indicated, " ... [Resident 70's] alarm went off ... [Resident 70] in a sitting position on the floor mats ..." Resident 70's care plan dated 10/26/18 indicated, " ... Toilet every 2 hours with routine care for incontinence ...". The UM stated they FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 72 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 provided a radio/CD (computer disc) to play Spanish music. The UM was unable to state how the radio/CD (computer disc) playing Spanish music would prevent Resident 70 from falling. Resident 70 "Progress Note" dated 10/26/18 at 5:45 p.m. indicated "Fall Score: 28.0 Fall Category: High Risk." On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note 11/7/18 at 8:30 a.m. for Fall number 6 which indicated "[Resident 70] was noted to be on the floor, on the floor mat ...near the foot of the bed leaning on his right side/elbow/hip with his feet towards the door ...stated he wanted a shower and was trying to get up and go ..." The facility document titled, "Interdisciplinary (IDT) Meeting Summary" dated 11/8/18 at 9:44 a.m. indicated, "...Root Cause/Contributing Factors...resident was noted to be yelling out staff names earlier in the morning, however did not yell out for shower. resident stated he was getting up to take shower ...resident is aware of daily showers. resident is noted to be impulsive and can be hard to redirect at times... IDT Recommendations...provided resident with digital wall clock and dry erase board to be able to direct resident as to when showers will be given to provide resident with a time frame to aid with a visual for the resident ..." The UM was unable to explain if Resident 70 was able to understand these instructions. The UM was unable to stated how a digital wall clock and dry erase board would prevent Resident 70 from falling. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note dated 11/15/18 at 5:35 p.m. for Fall number 7 which indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 73 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 RT [right] arm was caught between the right side rail and the bed..." The IDT Summary dated 11/15/18 at 10:00 a.m. indicated, "The IDT discussed resident and current safety/fall interventions. BIMS 0 ...on the falling star program...has daily showers, new clock provided ...and a white board to let resident know when his showers will be...cd player in room to play music to calm resident ... resident has alarms and will stay in place at this time ..." The UM stated the environment should have been checked for potential hazards. The UM stated no education was provided on measuring the gap between side rails and mattress. The UM stated a side rail assessment should had been done after the fall when Resident 70's arm was caught in between the side rail and the mattress and that was not done. Resident 70's "Progress Note" dated 11/15/18 at 8:35 p.m., indicated "Fall Score: 29.0 Fall Category: High Risk." On 12/17/18 at 3:36 p.m., during an interview and record review, the DON stated the interventions for the falls worked to a degree. The DON stated Resident 70 needed more supervision than every hour to provide care and repositioning. The DON stated the alarms are not going to prevent a fall but to alert staff when Resident 70 was on the floor. The DON stated that even when staff sat with Resident 70, he was still agitated and wanted to get up. The DON stated she would check on him more often if she was assigned as the nurse to the residents. The DON stated she was unable to show documentation for every two hour check and it was the responsibility of all staff to help when Resident 70 called. On 12/18/18 at 9:14 a.m., during an interview, CNA 10 stated she remembered the fall event FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 74 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 11/15/18] when Resident 70's leg was hanging from the right side of the bed and his arm was caught between the side rail and the mattress. CNA 10 stated, "Two upper side rails were up that day. The side rails help him roll to the side during care. Most of the time he was not able to use the side rails, maybe 15% of the time." CNA 10 stated, "The side rails I think for him is to help him prevent from falling, because he can't even use the side rails, he is total care. CNA stated she could not remember receiving education from the DSD on side rail use, but recalled there was a huddle for the bed alarms to alert staff. CNA 10 stated, "The interventions with side rails and bed alarms are not helping him because he still falling." On 12/18/18 at 9:44 a.m., during an interview, LN 10 stated Resident 70 had fallen a lot of times, and recalled the incident on 11/15/18 when it looked like Resident 70 slid off the right side of his bed. LN 10 stated LN 9 saw part of his arm caught between the side rails and the mattress. LN 10 stated, "The chance of the resident getting caught in the side rails is high. He is full care but I know he can hold onto the side rails." LN 10 stated Resident 70 always yelled out and he needed more one on one supervision. LN 10 stated, "Yes, the side rail is preventing him from moving so it is considered a restraint. Despite the side rail and bed alarm he is still falling." On 12/18/18 at 11:08 a.m. during a telephone interview, CNA 11 stated she recalled the incident on 11/15/18 when Resident 70's feet were on the floor and his arm was caught in the space between the right upper side rail and mattress. CNA 11 stated another CNA then helped Resident 70 get back onto the bed. On 12/18/18 at 11:38 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 75 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 LN 9 stated she was at the nurses' desk when Resident 70 yelled out at the time of the fall on 11/15/18. LN 9 stated she went to Resident 70's room across from the nurses' desk and saw Resident 70 sitting on the floor with his arm up between the side rail and the mattress. LN 9 stated, "That's why we have the risk versus [as opposed to] benefit statement but [the rails] also help with mobility and he helps by using the side rails during care." LN 9 stated the side rails could be a potential hazard. LN 9 stated Resident 70 should have been on the RNA (restorative nurse assistant) program and the nurse was responsible to do an evaluation at the time of a fall. On 12/18/18 at 12:17 p.m., during a concurrent interview and record review, the DON and ADM reviewed the progress notes for the fall on 11/15/18 which indicated Resident 70's arm was caught between the upper right side rail and the mattress. The ADM stated, "We brainstorm every single time; our immediate intervention is based on discussion of falls. It doesn't mean they don't have a right to fall." The ADM stated they considered a low bed but a low bed was not used. The DON stated, "I don't see how more supervision could have been provided. These falls are not contributing to anything PT [Physical Therapy] could help with." The DON stated, "Side rails can help and they can hurt." The ADM stated they had followed their policy for fall prevention. On 12/19/18 at 11:41 a.m., during a concurrent observation and interview, LN 1 measured the gap between mattress and upper right and left side rail on Resident 70's bed. The gap for both sides of the bed was a space of 1.5 inches. On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note of Fall number 8 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 76 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 dated 11/16/18 at 5:52 a.m. which indicated "...witnessed fall... [Resident 70] sitting on the floor mat next to the right side of bed while holding to the rail to get out of bed while holding to the rail..." The facility document titled, "Interdisciplinary (IDT) Meeting Summary" dated 11/16/18 at 9:32 a.m., indicated "... Root Cause/Contributing Factors ...Resident noted to be more agitated and restless lately since return from acute... IDT Recommendations... Immediate intervention was that nursing called family to come in and see resident. MD to review medications and request labs..." The UM stated staff provided one on one supervision when resident was in a high back wheelchair. Resident 70's "Progress Note" dated 11/16/18 at 2:30 a.m., indicated "Fall Score: 29.0 Fall Category: High Risk." On 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note for Fall number 9 dated 11/16/18 at 11a.m. which indicated " ... [Resident 70] ... yell[ed] out "HELP HELP"...Pt was on the floor on the left side of the bed, near the foot of the bed...leaning on his right elbow and hip with his legs towards the sink...noted with abrasion to right elbow ...Pt continues with 1:1 supervision ..." The UM stated the intervention of one on one supervision started on 11/19/18 but was not documented on the care plan. The UM stated the staff use the high back wheel chair to take Resident 70 around the inside and outside of the building after his shower. The UM was unable to stated why the one on one intervention was not part of the plan of care. Resident 70's "Progress Note" dated 11/16/18 at 11:05 a.m., indicated "Fall Score: 20.0 Fall Category: High Risk." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 77 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/17/18 at 1:36 p.m., during a concurrent interview and record review, the UM reviewed Resident 70's progress note for Fall number 10 dated 12/3/18 at 8:40 a.m. which indicated "...pt. was on the floor...right ...of the bed, facing the sliding door, with legs stretched in front of him and his right arm still holding onto the side of the bed...sitting upright on his bottom on the floor mat ..." The UM stated the new intervention was a Psychologist consultation for Resident 70 to review the prescribed psychotropic medications. The UM was unable to state how the Psychologist consultation would prevent Resident 70 from falling. Resident 70's "Progress Note" dated 12/3/18 at 8:40 a.m., indicated "Fall Score: 24.0 Fall Category: High Risk." On 12/17/18 at 10:48 a.m., during an interview, CNA 8 stated Resident 70 needed total assistance to transfer and a Hoyer lift was used. On 12/17/18 at 12:47 p.m., during a concurrent interview and record review, the MDS Coordinator reviewed Resident 70's MDS assessment section P (restraint and alarms) dated 10/17/18 and stated the side rails were coded "0" (not used). On 12/17/18 at 3:36 p.m., during a concurrent interview record review, the DON stated interventions to prevent falls worked to some degree. The DON stated, "We don't have a scheduled time to check on residents who is a high fall risk." The DON stated the CNAs did hygiene care every two hours. The DON stated, "The documentation is not accurate. The CNAs sometime document it late, they don't document at the time the intervention was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 78 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 done." The DON stated, "We have staff that does one on one with him, but it is not something we do with him every day, only if his behavior becomes out of control." On 12/18/18 at 9:20 during an interview, the Director of Rehabilitation (DOR) stated, Resident 70 had frequent falls and used a motion alarm to alert the staff when resident was attempting to get out of his bed. DOR stated the motion is activated "When a resident has a fall, it sets off an alarm." The DOR reviewed resident 70 clinical record and stated, "With that many falls [10 since June 2018] he [Resident 70] should be in our study [for QAPI quality assurance prevention and intervention] and should be reviewed for intervention. We should be asking the questions how to keep him safe." The DOR stated the facility does not involve her department with assessments for side rail safety. (DOR) stated she had been working for 17 years with the facility and the DON or ADM would let her know if someone had a mobility decline, falls or a need for therapy services. The DOR stated Resident 70 was not referred to receive therapy services each time he had a fall and would benefit from these services with his safety risk. The DOR stated the process of referral depended upon the nurses to inform the therapy department of the need and change of condition. On 12/18/18 at 10:30 a.m., during an interview, the Restorative Nursing Assistant (RNA) 1 stated anybody could make a referral for therapy for the RNA program. The RNA stated there was no referral for Resident 70. 1c. Resident 70's "Activity Program Profile" dated 4/26/18 at 7:01 a.m., indicated "Source of Information for this Assessment... [Resident 70] ...likes to play bingo...Orientation [to]person...place...time...situation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 79 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 Speech...clear...Diet Order NPO (nothing by mouth)...Mood...Pleasant..." Resident 70's "Activity Participation Review" dated 7/19/18 at 4:55 p.m., indicated "...Resident prefers independent activities...likes to watch t.v. and visit with daughter...He likes bingo, and has attended bingo with daughter...Activity Plan Review...remain appropriate/current as per care plan..." Resident 70's "Activity Participation Review" dated 10/17/18 at 2:19 p.m., indicated "... [Resident 70] chooses independent activities, he has participate[d] a couple times in bingo with daughter...Activities follows up with room checks...activities continue to encourage him to participate in an activity of choice." On 12/18/18 at 9:14 a.m., during an interview, CNA 10 stated one on one care would help keep Resident 70 occupied with television, movie, and radio, and the staff member would get him up if he wanted to get up on the wheelchair. CNA 10 stated, "He stays up for a while once every two days [per week] on morning shift. I have not seen him go to an activity. The activity lady used to bring a newspaper in his room, but I don't think he is able to read the magazines." On 12/18/18 at 11:50 a.m., during a concurrent interview and record review, the Activity Assistant (AA) stated the activity log showed Resident 70 was in his room when visited by the activity personnel or volunteers. The AA was unable to provide documented evidence of activities offered Resident 70 in or out of his room. On 12/18/18 at 12:17 p.m., during a concurrent interview with the ADM and DON, the ADM FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 80 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 it was Resident 70's choice to do his own activities. The DON stated, "[Resident 70's] care plan describes what those activities are." The DON was unable to provide documentation of what activities were offered Resident 70 and participated in. On 12/18/18 at 5:24 p.m., during a telephone interview, the Family Member (FM) stated, "[Resident 70] doesn't want to be in that bed most of the time, he wants to be up on the chair, but they keep him on the bed most of the time." The FM stated, "[My Dad] loves bingo, even hearing people playing bingo makes him happy." The FM stated when Resident 70 was admitted to the facility he loved to go outside, watch the birds, play bingo, poker and other card games. The FM stated she requested PT for Resident 70 's legs but the staff did not provide it. The FM stated, "I always get the answer from the facility that he didn't want to go bingo, but when I ask him he said he loves bingo; he wants to go. It takes a lot of their time to take him to bingo; maybe that's why they don't take him to bingo." The FM stated she was concerned about the side rail. The FM stated, "He just lies in bed most of the time and I feel they just forget about him." The FM stated Resident 70 was calm when he saw more people in the hallway. The FM stated, "He likes to have the Bible read to him; he is a Christian. I never saw anybody read the Bible to him." The FM stated her father never had seizures that she was aware of. The FM stated, "He is alert, he can answer questions." On 12/18/18 at 5:31 p.m., during a concurrent observation and interview in Resident 70's room, CNA 8 was at bedside and provided one on one supervision. Resident 70 was lying on his bed and responded to question of bingo, "I love bingo!" Resident 70 was informed that today was bingo day and responded, "Nobody FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 81 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 told me today was bingo day. I love bingo. I guess I missed it. I don't feel too good about it. Nobody tells me anything. They just leave me lying down in my bed all day. If I had known that today was bingo, I would have attended, but they never tell me anything." CNA 8 stated, "I didn't know he liked bingo; this is the first time I heard he likes bingo." On 12/19/18 9:45 a.m., during a concurrent interview and record review, the ADM reviewed the activity admission assessment dated 4/26/18 and the quarterly activity assessments dated 7/19/18 and 10/27/18. The ADM stated this survey brought to light the lack of documentation for person-centered activities for Resident 70. The ADM stated she had seen the word "sleeping" recorded by a staff member on the log which showed a possible attempt to offer an activity. The ADM stated there needed to be more of an effort to provide Resident 70 his choices of activities during room visits according to preferences listed on the assessment. The ADM stated she would like to have seen documentation that clearly showed the staff attempted but Resident 70 did not participate. The ADM stated the form is not thorough enough and a continuous effort to document was needed. The ADM stated it was unfortunate Resident 70 did not attend bingo on 12/18/18 and did not know if the activities staff asked Resident 70 to participate or offered to take him to the religious service on 12/18/18. The ADM stated they needed to continually try to offer activities and do a better job of documentation. The ADM stated her expectation was for more documentation to show what they are doing for Resident 70. Resident 70's Care plan dated 4/27/18, indicated "[Resident 70] will participate in an activity of choice three times a week...Activities will make sure a volunteer staff member brings FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 82 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 him to bingo if he chooses to attend, and all music programs...If unable to attend an activity Activities will follow up with social visit..." The facility documentation of the room check log (staff check on Resident 70) dated 8/30/18, 9/11/18, 10/2/18, 10/31/18, 11/5/18, and 11/27/18 indicated Resident 70 was "sleeping" and on 10/10/18 indicated "no response." The facility was unable to provide documentation for other days. 1d. The facility documents titled "Monthly Behavior Talley" dated 5/9/18 at 1:59 p.m., indicated 28 episodes of behavior classified as "inability to relax" while treated with Trazodone (medication to treat depression) and Xanax (anxiety medication). Resident 70's "Monthly Behavior Talley" dated 6/20/18 at 10:39 a.m., indicated 226 episodes of behavior classified as "inability to relax" while treated with Risperdal (antipsychotic medication to change effects of chemicals in the brain), Trazodone, and Xanax, and 228 episodes of "...constant yelling, repetitive statements." Resident 70's "Monthly Behavior Talley" dated 7/13/18 at 4:34 p.m., indicated "...Behavior ...aggression towards staff and others 5 episodes, constant yelling 108 episodes, constant repetitive yelling, 197 episodes, sleeplessness 18 episodes" while treated with Risperdal (medication to treat mental illness), Depakote (medication to treat seizure disorders), and Trazodone. On 12/20/18 at 4:12 p.m., during a telephone interview, the PCP stated Resident 70 was not confused and had witnessed Resident 70's agitated behavior many times while he sat at the desk. The PCP stated Resident 70 should FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 83 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 be on one to one supervision at all times to observe his needs. The PCP stated, "I need more information on his behaviors ...he needs one on one to observe what is wrong for at least two weeks to a month ...no one goes in there much because he hits or throws something." The PCP stated the facility should do standard nursing care to manage Resident 70. The PCP stated a neurologist should be consulted because of the seizure medication prescribed but Resident 70 would not be cooperative with an EEG (electroencephalogram - a test that detects electrical activity in brain). On 12/18/18 AT 9:30 a.m., during a concurrent interview and record review, the DON reviewed the MAR (Medication Administration Record) and stated the Ambien (medication for difficulty sleeping) was given on 12/2/18 at 2:52 p.m., 12/3/18 at 10:48p.m., 12/7/18 11:31 p.m., 12/8/18 at 11:45 p.m., 12/9/18 at 11:45 p.m., 12/11/18 at 12:06 a.m., 12/11/18 at 11:42 p.m., 12/12/18 at 11:17 p.m., 12/17/18 at 11:48 p.m., and 12/18/18 at 11:48 p.m. The DON stated these were appropriate times to give hypnotic sleeping medications, as it depended on when the resident wanted to go to bed and not when the medication would be the most beneficial. Resident 70's Pharmacist recommendation dated 4/23/2018 indicated Pharmacist recommended Renal Function test for Keppra (seizure medication). The facility was unable to provide documentation that the recommendation was followed. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 4/23/2018 and 5/31/2018 indicated "Resident receives Carafate ... [anti-ulcer medication], which has the potential to alter the absorption of several drugs. Recommend administering Carafate 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 84 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 hours before or 2 hours after other medications if possible. it should also be given on an empty stomach..." On 12/19/18 at 9:30 a.m., during a concurrent interview and record review, the DON stated she didn't think it was a problem to administer the medication Carafate together because he would never have an empty stomach since he received bolus tube (method of using a syringe to deliver through a tube in the stomach) feeding. The DON reviewed the Medication Administration Record (MAR) which indicated it was being given with other medications. The DON stated she did not see a need to provide education to the nursing staff and that she would just notify them of the recommendation PCP. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 7/2/18 indicated "The patient has experienced a recent fall and is currently taking Amlodipine [medication to treat high blood pressure], Loratadine [medication to treat allergy symptoms], Enalapril [medication to treat high blood pressure], Tramadol [pain reliever], Levetiracetam [Keppra, medication to treat seizures], Finasteride [medication to treat enlarged prostrate], Gabapentin [to treat nerve pain or seizures], Januvia [prevents high blood sugar], Depakote, Risperdal, Trazodone, and Novolog [insulin to treat high blood sugar] which increase fall risk. Please reevaluate these medications for dose reduction/discontinuation, if clinically indicated, to decrease the patient's fall risk..." The facility failed to provide documentation of follow up of these recommendations. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 8/1/18, indicated "The patient is currently receiving a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 85 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 PRN psychotropic drug, Ambien. Please provide clinical rational and duration of therapy, required by CMS (Centers for Medicare & Medicaid Services), for this PRN psychotropic order to be active longer than 14 days..." The DON was unable to provide documented evidence of the MD's (Medical Doctor) rationale for continued use and rationale for Ambien PRN (as needed) for continued use. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 9/9/18 indicated "Ambien 5 mg Via Peg-tube q 24h PRN insomnia ... RECOMMENDATION: Please discontinue the above order. If the order is to be continued beyond 14 days, please specify a specific duration of use (with an extended stop date up to 6 months from date written) and provide clinical rationale below..." On 9/19/18 the PCP documented "Continue please." Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 10/12/18, indicated "Trazadone 50mg via PEG-Tube at bedtime since May 2018 Currently this resident has both Ambien and Trazodone for sleeplessness. This might be considered duplicate therapy...RECOMMENDATION: Please consider a trial dose reduction to: Trazodone 25 mg via PEG-Tube QHS." If a gradual dose reduction is contraindicated at this time, please document the clinical rationale below. On 10/22/18 the PCP documented "Continue." Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 8/9/18, indicated "Risperdal 0.5mg via g-tube BID for behavioral and psychological symptoms of dementia...RECOMMENDATION: Please consider a dose reduction to [50% of current dose] with the goal of discontinuation..." On FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 86 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 9/2/18 the PCP documented "Continue" without rational for the decision to continue the medication. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 9/9/18, indicated, "Risperdal 0.5 mg via g-tube BID (twice daily) for behavioral and psychological symptoms of dementia...This medication has the potential to cause agitation... RECOMMENDATION: Please consider a dose reduction to [50% of current dose] with the goal of discontinuation." The physician documented "Continue please" on 9/17/18 without rational for the decision to continue the medication. The facility failed to provide documentation of assessment. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 10/12/18, indicated, "Risperdal 0.5 mg via PEG-Tube BID since May 2018. RECOMMENDATION: Please consider reducing the current medication dose to: Risperdal 0.25 mg via PEG-Tube BID...If a GDR (gradual dose reduction) is clinically contraindicated at this time, please document the clinical rationale. This must address the reason(s) why an attempted dose reduction would likely impair function..." The physician documented "Continue" on 10/22/18 without rational for the decision to continue the medication. Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 11/16/18, indicated "Change of condition: Falls (1/15/18 17:35: 11/16/18 02:30 & 11:00)...Risperdal...Monitor for sedation dizziness, drowsiness, headache and orthostatic hypotension (low blood pressure with position changes); instability due to pseudoparkinsonism (rigidity, stiffness, walking disorder), akathisia (a state of agitation, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 87 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 distress, and restlessness), tremor, fatigue...Resident has a diagnosis of CKD (chronic kidney disease...Please assess patient's renal function (i.e. Cr - creatinine - a blood test for kidney function) and evaluate the following medications for possible renal dose adjustment if appropriate: Levaquin (medication to treat infection), Pepcid and MOM (Milk of Magnesium- to treat constipation)." Resident 70's "Consultant Pharmacist's Medication Regimen Review" dated 11/9/18, indicated "Ambien is ordered for this patient with a history of falls...The only dose of this medication was given on the date of his fall at 3:50 am and his fall was at 8:30 am the same morning. Per nursing note the resident wanted a shower but was confused. This medication can cause a lot of sedation and confusion and should only be given at bedtime...RECOMMENDATION: Working with the nursing team to explain that this medication needs to be given at bedtime or it cannot be given due to the potential side effects...Having the doctor D/C (discontinue) this medication and change the dose of Trazadone if needed...Also, please ensure that nursing is monitoring for these potential safe effects and that appropriate fall prevention measures are in place for this patient." Resident 70's "Pharmacy recommendation" dated 12/5/18 indicated "Order a trial discontinue of Risperidone and Xanax and change Temazepam 15mg QHS. Side note: "Xanax new order, psych order, review medications." The DON stated, "The pharmacist initiates the recommendation for the gradual dose reduction. We fax the Pharmacist's recommendations to the doctor." The DON stated the doctor does not assessed resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 88 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 for gradual dose reductions. The DON stated, "On all monthly Pharmacist's Medication Regimen Reviews dating back from 4/23/18 there is a recommendation for a gradual dose reduction to be done." The DON was unable to find documented evidence showing that a GDR was initiated or done. On 12/19/18 at 4:55 p.m., during a concurrent phone interview and record review, the Pharmacist (PHARM) stated she reviewed documentation monthly with the DON for nurse's notes, behavior assessment sheets, and the medication administration record (MAR). The PHARM stated the facility receives feedback from the physician. The PHARM stated she received one response from the physician regarding the medication Risperdal and told him antipsychotic medications should not be given for dementia. The PHARM stated the physician evaluated Resident 70's diagnosis and changed it to bipolar disorder. The PHARM stated Risperdal had potential to cause anxiety in16% of patient, and Risperdal might have caused the anxiety in Resident 70. The PHARM stated the medication combination could cause extreme drowsiness and the best time to administer Ambien (medication to help with sleep) would be an hour or half hour before bedtime around nine or ten in the evening or it would cause drowsiness throughout the day. The PHARM stated the medication would take eight hours to clear the system.

F700 SS=J Bedrails CFR(s): 483.25(n)(1)-(4)

F700 07/27/2022 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 89 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to assess one of 40 sampled residents (Resident 70) for the risk of entrapment (resident caught, trapped, or entangled in the space in or about the bed and side rail) from bed (side) rails (adjustable metal or rigid plastic bars that attach to the bed), prior to installation and failed to ensure safety standards were met for the installation of bed rails when Resident 70 was observed with four bed rails up and his legs entrapped between the gap of the bed and side rails almost touching the ground . The Guidance for Industry and FDA Staff: Hospital Bed System Dimensional and Assessment Guidance to Reduce Entrapment", issued on 3/10/06, indicated that entrapment may occur in flat or articulated (raised) bed positions. To reduce the risk of head entrapment, rail perimeter openings should not be greater than four and three quarter inch. To reduce the risk of neck entrapment the gap FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 90 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 between the mattress and under the rail should be less than four and three quarter inches. The recommendation also indicated the dimension limits for the open space within the perimeter of the rail should be small enough to prevent the head from entering. The recommended space should be less than four and three-quarter inches..." This failure resulted in bed (side) rail entrapment for Resident 70 (bed user's legs were entrapped within openings of the two side rails and between the bed mattress) and place Resident 70 at potential risk for serious harm, injury or death. Because of the serious potential harm related to the use of side rails used without proper assessment of the size of the bed, the weight of the resident, and without an intervention to prevent entrapment an Immediate Jeopardy (IJ) situation was called on 12/19/18 at 1:45 p.m. with the Administrator, Director of Nursing, Chief Nursing Officer and Director of Operations. Findings: Resident 70's "Order Summary Report" dated 4/19/18 indicated, "Admit to [facility] on 4/19/2018 under care of [physician name] for skilled nursing services with the diagnoses of [deconditioning secondary to multiple CVA's cerebral vascular accident (poor blood flow to brain results in cell death)] ...all meds [medications] via [by way of] peg-tube ... (Percutaneous Esophageal Tube-surgically placed for administration of medications or feeding)." Resident 70's "Progress Notes" undated, indicated, "[Resident 70] was admitted on 4/19/18 to room [number of room] via stretcher FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 91 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 from [Acute Care Hospital] with a diagnosis of deconditioning secondary to multiple CVA...Resident was oriented to the facility including the use of the call light and bed controls [bed with four side rails] ... Pt [patient] A&O x2 (alert and oriented to person and time), able to make needs known, calm and cooperative with staff and care pt is 1-2 person assist..." Resident 70's physician order dated 4/20/18, indicated, "[Resident 70] May use Side rails for assist in mobility, repositioning, and in assist with ADL (activities of daily living) care." On 12/7/18 at 8:30 a.m., during an observation, Resident 70 was in his bed lying on his right side with his legs over the side of the bed. The bed had four side rails in the up position and Resident 70's legs were dangling off the bed entrapped in the gap between the right upper side rail and the right lower side rail. The call light cord was looped on a hook on the wall at the head of the bed and out of reach from Resident 70. During the observation Resident 70 was alone in his room with no staff available to provide assistance to Resident 70. On 12/7/18 at 8:31 a.m., during a concurrent observation and interview, Licensed Nurse (LN) 5 observed the position of Resident 70's legs dangling off the bed entrapped in the gap between the bed and upper and lower side rails on the right side. LN 5 immediately attempted to repositioned Resident 70 so his legs were on the bed and no longer entrapped in the gap between the upper and lower side rails. LN 5 then called CNA 8 to assist in repositioning Resident 70 up on the bed because she was unable to reposition his without another staff member's assistance and attempted to lower the side rails. LN 5 was unable to lower the side rail on the lower left side of the bed and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 92 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 left the lower left side rail in the up position. The side rail on the lower right side was lowered by the LN 5 with ease. LN 5 stated the call light was not where it should be. On 12/7/18 at 9:45 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed with three side rails up. LN 5 stated there were three side rails up and only the right lower side rail was down. LN 5 stated, "I'm pretty sure the right bottom side rail was up [during the 8:31 a.m. observation]." On 12/7/18 at 9:48 a.m., during a concurrent observation and interview in Resident 70's room, Resident 70 laid in bed, resting and there were three side rails in the up position (right and left upper and left lower). Certified Nursing Assistant (CNA) 8 stated he had worked with Resident 70 for several months and was assigned to Resident 70 since 6 a.m. on 12/7/18. CNA 8 stated, "We [Facility staff] were told not to use the bottom side rails and I don't know how they got in the upper position. I overlooked that four side rails were up." CNA 8 stated he did not know why the call light cord was on the wall and out of the reach of Resident 70. On 12/7/18 at 10:00 a.m., during an interview, LN 5 stated she understood there was an order to use only the upper right and upper left side rails. LN 5 stated she did not know who put the lower side rails in the up position. On 12/10/18 at 10:55 a.m., during an interview, the Director of Nursing (DON) stated, "Yes, all four side rails would be considered a restraint. It could be for safety, but the consent does not include [consent to use] all four side rails." On 12/17/18 at 1:36 p.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 93 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 interview and record review, the UM reviewed Resident 70's progress note dated 11/15/18 at 5:35 p.m. for Resident 70's fall number 7 which indicated "...Residents RT [right] arm was caught between the right side rail and the bed..." The IDT Summary dated 11/15/18 at 10:00 a.m. indicated, "The IDT discussed resident and current safety/fall interventions. BIMS 0 ...on the falling star program...has daily showers, new clock provided ...and a white board to let resident know when his showers will be...cd player in room to play music to calm resident ... resident has alarms and will stay in place at this time ..." The UM stated the environment should have been checked for potential hazards. The UM stated no education was provided on measuring the gap between side rails and mattress. The UM stated a side rail assessment should had been done after the fall when Resident 70's arm was caught in between the side rail and the mattress and that was not done. On 12/17/18 at 4:55 p.m., during a concurrent interview and record review, the DON stated a side rails assessment was completed on 4/19/18 but did not include alternative measures tried prior to the decision to use side rails or a risk of entrapment assessment. The DON reviewed side rail informed consent and stated the informed consent had documented risk of Resident 70 side rail entrapment. The DON stated, "The CNAs and nurses are responsible to see that a bed assessment is completed. The bed already came with side rails. He is dead weight; he is non-ambulatory; he came as a LTC [Long Term Care] resident. A Hoyer lift [mechanical lift to assist a resident to transfer who is unable to assist in self transfer] is used due to dead weight [115.8 pounds]." The DON stated a reassessment of the side rails was not done in July and started reassessment in October. The DON stated no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 94 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 one admitted who put up the lower side rails. The DON emphasized staff were aware they were not to put all four rails in the up position. The DON stated Resident 70 could have injured himself while the four rails were up. The DON stated, "[Resident 70] could be at risk for entrapment, but with all the side rails up he could still get through." The DON stated, "We do not consider this (meaning side rails up) a restraint if used for mobility." The DON stated there was no monitoring plan to make sure the use of the side rails was safe. Resident 70's "Resident Bed Rail Consent Form" dated 4/19/18, indicated, "... Mobility Assist...Can enable [Resident 70] to independently reposition self in bed, or to assist caregivers to reposition him/herself in bed, from side to side, move closer to the head of the bed, or to move from a lying to sitting to lying position...Medical Safety...can be a safety measure identified in the resident's care plan by preventing [Resident 70] from slipping or rolling out of bed due to seizures...It is the policy of this facility to use bed rails only after evaluation and care planning deemed it is appropriate to treat the resident's medical symptoms and assist the resident in maintaining his/her highest practicable physical and psychosocial wellbeing...Recommendations...Type of rail (s)... 1/4 partial rail, left upper, right upper... Frequency... Rail(s) are to be used at all times when [Resident 70] is in bed... Bed rail (s) are to be released PRN [as needed] to allow the resident to move in and out of bed, exercising his/her extremities ... Benefits [versus] Risk" indicated, "... Area of concern ... [Resident 70] side rails ... Benefits ...Security-feel safe, mobility assist from side to side, move from a lying to sitting to lying position, help with transferring, medical safety... Risks related to Noncompliance [sic] ... skin tears, possible Fall FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 95 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 [with] injury, bruising, strangulation, suffocation, caught between rail [and] mattress..." Review of the clinical record indicated Resident 70 did not have a seizure diagnosis. UM confirmed that Resident 70 did not have documented diagnosis of seizures. On 12/17/18 at 4:52 p.m., during a concurrent interview and record review, the DON stated side rails were ordered on 4/20/18 and a side rail consent was obtained on 4/19/18 and side rails were in use as of 4/19/18 [day of admission]. Fall risk assessment dated 4/19/18 indicated Resident 70 was a "Moderate risk" for falling. The DON stated there was no documentation for side rail alternative for least restrictive intervention used before side rails were implemented. The DON stated, "All staff is responsible to assess if the side rails are working properly and will notify maintenance if there is something wrong with the side rails." The DON stated the side rails were determined necessary for Resident 70 by an assessment and speaking with RP (responsible person). The DON was unable to find documentation of a seizure diagnosis. The DON stated a Hoyer lift (hydraulically operated device used to enable caregiver to transfer a resident from the bed to wheelchair) was the safest way to transfer Resident 70 because he could not bear weight or help with transfer from bed to chair. The DON stated the process to wean residents off from side rail use was for nurses to reassess [for side rail need] every three months. The DON stated the side rails would not impede Resident 70 from doing anything. The DON stated resident was able to move out of bed and had been found on the floor multiple times. The DON stated, "I can't tell you why the four side rails were up. The nurses didn't tell me. They should not have been up." The DON stated the risk for entrapment and injury was high with four side rails up. The DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 96 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 70 was able to move himself out of his bed which increased the risk of entrapment when the four side rails were in the up position. On 12/18/18 at 9:20 during an interview, the Director of Rehabilitation (DOR) stated, Resident 70 had frequent falls and used a motion alarm to alert the staff when resident was attempting to get out of his bed. DOR stated the motion is activated "When a resident has a fall, it sets off an alarm." The DOR reviewed resident 70 clinical record and stated, "With that many falls [10 since June 2018] he [Resident 70] should be in our study [for QAPI quality assurance prevention and intervention] and should be reviewed for intervention. We should be asking the questions how to keep him safe." The DOR stated the facility does not involve her department with assessments for side rail safety. (DOR) stated she had been working for 17 years with the facility and the DON or ADM would let her know if someone had a mobility decline, falls or a need for therapy services. The DOR stated Resident 70 was not referred to receive therapy services each time he had a fall and would benefit from these services with his safety risk. The DOR stated the process of referral depended upon the nurses to inform the therapy department of the need and change of condition. On 12/18/18 at 10:26 a.m., during a concurrent interview and record review with the DON and ADM, the DON stated she was unable to find documentation of the incident [dated 12/7/18 when Resident 70 was observed dangling off the bed with his legs between the side rails]. The ADM stated, "We have called it a mistake." On 12/18/18 at 12:00 p.m., during a concurrent interview and record review, the Social Service Assistant (SSA) stated she had worked at the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 97 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 facility for one year and had taken the lead position one week ago. The SSA stated the side rail assessment was not addressed in IDT meetings and it would require another IDT (interdisciplinary team - a group of healthcare providers from different fields who work together or toward the same goal to provide the best care or best patient outcomes) meeting to assess for the need of the side rails. The SSA reviewed the records and was unable to find documented evidence where Resident 70 had been referred to RNA (restorative nursing therapy services) or PT (Physical Therapy) because of his climbing out of bed and falling. The SSA stated she knew staff had been performing one on one supervision for resident 70 because of his high risk of falling but the one on one was only performed on as needed bases. The SSA stated she was not involved with the assessment or when the decision was made to place Resident 70 on a one on one supervision. The SSA stated, "I am still learning his needs. I do IDT notes and always attend IDT meetings." On 12/18/18 at 3:29 p.m., during a concurrent interview and record review, the Director of Staff Development (DSD) stated she was not involved in any assessment of side rails and had no knowledge of any alternative or reassessment of side rails. The DSD stated, "If I'm not present during the IDT meeting there is no way for me to get the information that was discussed." The DSD stated Resident 70 would have benefited from a restorative nurse assistant (RNA) program to provide range of motion exercise for Resident 70. The DSD stated, "The side rails pose more of a threat or a hazard to him if the staff was not present." The DSD stated keeping the side rails up was not preventing Resident 70 from falling "Because he was still falling, even with the side rails." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 98 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/18/18 at 5:18 p.m., during a telephone interview, the family member (FM) stated, "At the time [Resident 70] was admitted, the consent for side rails was not filled out when they gave it to me. They told me to sign it and they would fill it in later." The FM stated she did not want the side rails all the time and was told the side rails were going to be on the right side of the bed to help with his mobility. FM stated the facility did not attempt alternatives prior to implementing the side rails on the day of admission. On 12/18/18 at 5:45 p.m., during a concurrent observation and interview, the DON stated she did not know how the right lower side rail worked. The DON stated, "Usually the CNAs know better. The DON called for a CNA who had difficulty finding the release lever and putting the lower rails up or down. On 12/19/18 at 8:05 a.m., during an interview in the ADM's office, the ADM stated it was a mistake for the staff to have used the bottom two side rails on 12/7/18. The ADM stated the lower two side rails should have already been removed, just like all the rest of the beds in the facility. The ADM stated the maintenance staff had removed the lower side rails on Resident 70's bed on 12/18/18. The ADM stated she did not know why Resident 70's bed had four side rails and it appeared his bed had been missed when they checked all the beds for removal of lower end side rails. The ADM stated there was no way to know if the lower side rails had been used before the observation of Resident 70 dangling off the bed with his legs between the side rails. On 12/19/18 at 9:19 a.m., during a telephone interview, LN 5 stated on the day of 12/7/18 the two upper side rails were up and the right lower FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 99 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 side rail was up on Resident 70's bed. LN 5 stated the lower left side rail was up and even with the bed mattress. LN 5 stated, "I didn't even know where the lever was to put it down." LN 5 stated the left lower side rails remained in the up position because she did not know how to release the side rail. LN 5 stated her understanding was that a restraint was something that prevented movement and she did not consider the side rails as a risk for Resident 70 because Resident 70 could move in bed. On 12/19/18 at 9:23 a.m., during a telephone interview, CNA 8 stated, "I'm pretty sure all four side rails were up [on 12/7/18] ... I was a little late that day, and I was rushing..." CNA 8 stated that all four side rails would be considered a restraint according to nursing home regulations. On 12/19/18 at 11:05 a.m., during a concurrent interview and record review, the DON stated she was unable to find documentation of the incident where Resident 70 was dangling off the bed with his legs between the side rails on 12/7/18. The DON stated the only way to identify delayed injuries as a result of the incident dated 12/7/18 was for the nurses to document. The DON stated, "The nurse does weekly skin assessments and would see if there had been [delayed] bruising." The DON stated she had asked the Chief Nurse Executive (CNE) if there should be documentation and was told by the CNE she would not view it as a fall so no documentation was necessary. The facility policy and procedure titled, "Physical Restraints," dated, 11/24/17, indicated, "...physical restraints are to be only when there is a physician's order...the 'restraint' is based on the effect...of restricting freedom of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 100 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 movement or normal access to one's body...Alarms that prevent the resident the freedom to move around, or cause fear in the resident who attempts to move independently, are considered restraints..." The facility policy and procedure titled, "Fall Program" dated 11/24/17, indicated "...a licensed nurse is to complete the Fall Risk Assessment...upon admission to determine the resident's risk factors associated with the potential for falls...is to then be completed...after any actual fall...The higher a resident's risk for falls is, the more individualized interventions should be considered...Bed in low position...Medication review by the pharmacist. Eliminate or reduce medications when appropriate...Restorative program to improve mobility, lower extremity strengthening and/or coordination..."

F757 SS=D Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 01/28/2019 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 101 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 40 sampled residents (Resident 36) was free from unnecessary medication when Ipratropium/Albuterol Duoneb (inhalation medication to increase air flow to lungs) was administered for an excessive duration and without adequate indication for use from 9/19/18 to 12/5/18 four times daily for the diagnosis of pneumonia (lung inflammation caused by bacterial or viral infection) and was not re-evaluated when symptoms of pneumonia had resolved. This failure resulted in Resident 36 receiving multiple doses of medication that had the potential to cause symptoms of cardiac distress. Findings: On 12/6/18 at 12:30 p.m., during a concurrent medication pass observation and interview, Licensed Nurse (LN) 2 prepared to administer Ipratropium Duoneb inhaler to Resident 36. LN 2 stated Resident 36 had an order for Ipratropium Duoneb inhaler to be administered every six hours for pneumonia. LN 2 stated she did not know if Resident 36 had pneumonia currently, but she was aware he had been treated for it in the past. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 102 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/7/18 at 3:50 p.m., during a concurrent interview and record review, the Director of Nursing (DON) reviewed Resident 36's clinical record and stated there was no documented indication for Resident 36 to have continued on Duoneb medication. The DON stated she would have called the physician to clarify the order and ask if this medication should be given on a PRN (as needed) basis. The DON stated sometimes the physician followed up with a chest x-ray to evaluate if pneumonia had resolved. Resident 36's clinical record from General Acute Care Hospital (GACH) dated 9/18/18, indicated, "......Resident was admitted with a diagnosis of PNA...". Resident 36's Care Plan dated 9/19/18 for "Respiratory illness" indicated revision on 10/21/18 and 11/18/18, but the care plan had no updated assessment or intervention for absence of pneumonia to what do you mean by this exactly indicate the need for DuoNeb Solution. Resident 36's Physician Orders dated 9/18/18, indicated, "... DuoNeb Solution 0.5-2.5 (3) milligrams (mg- a unit of measurement ) [per] 3 millimeter (ml- a unit of measurement) [Ipratropium-Albuterol] 1 applicatorful inhale orally every 2 hours as needed for SOB/wheezing AND 1 applicatorful inhale orally every 6 hours for [pneumonia]..." Resident 36's clinical record titled, "RADIOLOGY REPORT" dated 11/25/18, indicated "...no acute alveolar/interstitial infiltrates, consolidation, CHF[congestive heart failure], mass or pneumothorax...". Resident 36's September Medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 103 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 Administration Record (MAR) indicated DuoNeb Solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol) was given every six hours from 9/19/2018 to 9/30/18 for pneumonia. Resident 36's October MAR indicated the DuoNeb Solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol) was given every six hours from 10/1/18 to 10/31/18. Resident 36's November MAR indicated the Duoneb Solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol) was given every six hours from 11/1/18 to 11/30/18. Resident 36's December MAR indicated the Duoneb Solution 0.5-2.5 (3) mg/3 ml (Ipratropium-Albuterol) was given every six hours from 12/1/18 to 12/6/18. Was there a record review/interview validation by staff of the MARs?

F802 SS=E Sufficient Dietary Support Personnel CFR(s): 483.60(a)(3)(b)

F802 01/28/2019 §483.60(a) Staffing The facility must employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required at §483.70(e). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 104 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 §483.60(a)(3) Support staff. The facility must provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. §483.60(b) A member of the Food and Nutrition Services staff must participate on the interdisciplinary team as required in § 483.21(b)(2)(ii). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the competency of staff to carry out the function of the food and nutrition services when a Dietary Aide (DA) was unable to describe or demonstrate the appropriate procedure for washing and sanitizing kitchen ware such as pots and pans using the two compartment sink. This failure had the potential for a highly susceptible population of 97 residents who received food from the kitchen to be at high risk for foodborne illness. Findings: On 12/05/18 at 2:38 p.m., during a concurrent observation and interview in the kitchen, the DA stated the kitchenware was washed in the first compartment of the sink, then sanitized in the second compartment, then all the kitchenware was placed on a table to be air dried. The DA stated the sanitizer used was the quaternary ammonia sanitizer that was distributed from a hose that went into the second sink. The DA took the temperature of the water with the facility's thermometer and stated that's how she checked if the sanitizer was the correct strength. The DA stated she could not remember how long the items had to be in the sanitizer. The DA looked for it on the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 105 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 directions posted above the sink and stated she could not find it. The DA stated, "I guess it was 45 to 60 seconds." The DA stated she would not do anything else to test the sanitizer. The facility policy and procedure titled, "Warewashing" dated 5/16, indicated, "Purpose: To properly clean and sanitize dishware and utensils when a dish machine is not available ... It is the policy of this facility to initiate manual dish washing procedures when the dish machine is not working properly. The facility will implement a two (2) compartment procedure for manual washing ... PROCEDURE: ... 4. Rinse, scrape or soak all items before washing, if needed. 5. The first compartment is for washing ... 6. The second compartment is for rinsing ... 7. Complete washing and rinsing process. Drain and clean the second sink. Then use the cleaned second sink to sanitize the items ..." The procedures also described the quaternary ammonia chemical sanitizer had to be mixed to the proper concentration of 200 ppm (parts per million; a unit of measurement) or per manufacturer's recommendation. Also, each item was required to be immersed in the sanitizing solution for two minutes. Review of the undated document titled, "(the name of the sanitizer solution)" indicated a test strip was used to test the sanitizer strength and was dipped into the sanitizer solution for 10 seconds and the test strip should indicate the solution was between 150 ppm and 400 ppm. On 12/6/18 at 9:15 a.m., during an interview, the Registered Dietician (RD) stated the daily process for washing pots and pans was with the 2-compartment sink and the dishmachine combined. The RD stated all staff were expected to know how to clean kitchen ware if FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 106 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 dishmachine was not in service. The RD stated she was not present during the "washing of the pots and pans" in-service training and was unable to state if a training included warewashing when the dishmachine was out of service. A review of the document titled, "Inservice Program" showed an inservice was provided on "Washing Pots and Pans - PP [Policy and Procedure]" on 6/30/17. The documentation provided did not indicate if warewashing when the dishmachine was not in service was included in the inservice. The facility did not provide any documentation to show that a supervisor conducted an assessment for staff competency in relation to job duties for the DA. The facility provided a document that included a 12 question test titled, "Competency Test for Cooks and FNS (Food and Nutrition Service Staff) completed by DA on 11/21/18. There was no indication on the exam about who reviewed it and there were no questions regarding cleaning kitchen ware in the 2-compartment sink.

F808 SS=E Therapeutic Diet Prescribed by Physician CFR(s): 483.60(e)(1)(2)

F808 01/28/2019 §483.60(e) Therapeutic Diets §483.60(e)(1) Therapeutic diets must be prescribed by the attending physician. §483.60(e)(2) The attending physician may delegate to a registered or licensed dietitian the task of prescribing a resident's diet, including a therapeutic diet, to the extent allowed by State law. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 107 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 by: Based on observation, interview and record review the facility failed to follow the menu when diets were not fortified according to the fortification schedule for 20 of 97 residents who had a physician's order for a fortified diet. This failure had the potential for residents to receive fewer calories than the fortified schedule indicated, which could affect resident's weight and further compromise their medical status. Findings: On 12/5/18 at 11:40 a.m., during a concurrent observation and interview in the kitchen, Cook 1 stated they were supposed to receive melted butter for the fortified diets. Cook 1 stated she did not provide extra butter in accordance with the fortification menu. On 12/5/18 at 11:50 a.m., during a concurrent observation and interview in the kitchen during tray line service, Resident 80 had a turkey sandwich as an alternate diet for lunch. Resident 80's tray ticket indicated a fortified diet. The Registered Dietician (RD) stated the turkey sandwich should of had an extra mayonnaise packet to make it fortified. The RD stated there was no extra mayonnaise on Resident 80's food tray. On 12/7/18 at 8:59 a.m., during an interview, the RD confirmed fortified diets were a physician's order. Review of the fortified menu titled, "Fall Week" dated 1/18 indicated, for lunch on 12/5/18 an extra ½ ounce of melted margarine was added to the noodles and ½ ounce of melted margarine was added to the spinach. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 108 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 document titled, "FORTIFIED DIET" dated 2015, indicated, "... Description: The fortified diet is designed for residents who cannot consume adequate amounts of calories and/or protein to maintain their weight or nutritional status... Nutritional Breakdown: The goal is to increase the calorie density of the foods commonly consumed by the resident. The amount of calories should be approximately 300-500 per day... Foods: Examples of adding calories may include- Extra margarine or butter to food items such a vegetables, potatoes, hot cereal, bread, toast, pancakes, waffles, rice, pasta, etc... Extra mayonnaise added to sandwiches and mayonnaise based salads..."

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 01/28/2019 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 109 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when: 1.The hamburger patties were not verified to be cooked to a safe temperature. 2. Clean pans used to serve food were stored and stacked wet. 3. There were no air gaps for essential equipment. These failures had the potential to cause food borne illness to a highly susceptible population of 97 who received food from the kitchen. Findings: 1. On 12/5/18 at 11:30 a.m., during a trayline observation in the kitchen, Cook 2 removed two hamburger patties from the grill without taking the temperature of the patties and placed the two hamburger patties in the tray line. On 12/5/18 at 11:35 a.m., during a trayline observation in the kitchen, Cook 1 measured the temperature of a hamburger patty with a calibrated thermometer. Cook 1 stated the temperature for the [hamburger] patty was 153.8 degrees Fahrenheit (F- unit of measurement for temperature). On 12/5/18 at 11:38 a.m., during a concurrent interview with Cook 1 and Cook 2, Cook 2 stated she did not take the temperature of the hamburger patties after cooking them on the grill and then placing them on the trayline to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 110 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 served. Cook 1 stated she did not know what temperature hamburger patties should be cooked to and that 153.8 degrees F was "okay." Cook 1 stated the hamburger patties were an alternate entrée for resident lunches that day. On 12/5/18 at 11:40 a.m., during an interview, the Registered Dietitian (RD) stated the hamburger patties had to be cooked to 155 degrees F. The Federal Food Code (2017) indicated the standard of practice was for mechanically tenderized and/or comminuted (meats that are mixed with different pieces of meat) meats as ground beef was to be cooked to an internal temperature of 155 degrees F for 17 seconds. 2. On 12/5/18 at 7:47 a.m., during a concurrent observation and interview in the kitchen, there were 24 pans of various sizes stored on a shelf. The pans with varied sizes were stacked inside one another and were wet. Cook 1 stated the pans were used to hold food served to residents and should be air dried before being stored on the shelf. Review of the facility Policy and Procedure titled, "Pots and Pans" dated 4/30/17, indicated the purpose of the policy was to ensure proper cleaning and sanitation of pots and pans. The procedure revealed, "All items are to be air dried until no water droplets are present." 3. On 12/5/18 at 10:32 a.m., during an observation in the kitchen, there was a plastic drainpipe from the food preparation sink area immersed into a floorsink (a drain that drops below the floor level) and one metal drainpipe was immersed in a floorsink located under the dishmachine counter. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 111 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/5/18 at 10:43 a.m., during an interview, the PM (plant manager) stated there was no air gap (a space between the drainpipe and the floor drain) for the food preparation sink drainpipe. The PM stated there should be at least a one-inch air gap. The PM stated the drainpipe located underneath the dishmachine counter was from the walk-in refrigerator or the walk-in freezer and stated there was no air gap for the drainpipe. According to the Federal Food Code (2013), an air gap between the water supply inlet and the flood level rim of the plumbing fixture shall be at least twice the diameter of the water supply inlet and may not be less than 1 inch.

F813 SS=E Personal Food Policy CFR(s): 483.60(i)(3)

F813 02/07/2019 §483.60(i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to: 1. Store resident's food brought from outside sources that would require reheating for safe consumption or for the residents' preference. 2. Ensure nursing staff stored food brought in from outside sources for up to 72 hours as per the facility policy and procedure on food storage. These failures had the potential to affect residents' choice to consume food that was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 112 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 brought in from outside the facility and potentially could limit resident food consumption. Findings: On 12/6/18 at 12:03 p.m., during an observation in nurse station 2, there was a resident refrigerator for food and snacks. The refrigerator had a sign which indicated, "ATTENTION ALL STAFF... ANY FOOD AFTER 72 HOURS/3 DAYS MUST BE DISCARDED..." On 12/6/18 at 12:05 p.m., during an interview, CNA 7 (Certified Nursing Assistant) stated, "[Facility staff] can store resident's food if it fits in the fridge and up to 48 hours." On 12/6/18 at 12:12 p.m., during an interview, Licensed Nurse (LN 4) stated, "[Facility staff] can store resident's food for 24 hours in the fridge and only if it fits, if not we tell them we can't store it here." On 12/6/18 at 12:39 p.m., during an interview, the DSD (Director of Staff Development) stated facility staff were not allowed to reheat food brought from the outside. The DSD stated there was no documentation to show nursing staff was trained on the policy for food brought in from outside sources. On 12/6/18 at 12:50 p.m., during an interview, the ADM (Administrator) stated the facility did not currently reheat food for residents food brought in from outside or store food for residents brought in from outside that would require reheating. The ADM stated large portions of food brought in from outside could not be stored due to the refrigerator being small. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 113 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/6/18 at 3:35 p.m., during an interview, the RD (Registered Dietitian) stated, "I realized it is the resident's right to have food brought in from outside reheated, currently we are not accepting food that would need to be reheated." The facility policy and procedure titled, "Food from Outside source" dated, 5/16, indicated, ..." To enhance the resident's nutritional status by ensuring that food brought in from outside of the facility meets sanitation regulations and handling... 5. Food brought in from home should be precooked. Facility staff are not allowed to reheat food. 6. Food that does not have a manufacturer's printed date must be thrown out 72 hours from the time it was brought in the facility or opened..."

F867 SS=F QAPI/QAA Improvement Activities CFR(s): 483.75(g)(2)(ii)

F867 01/28/2019 §483.75(g) Quality assessment and assurance. §483.75(g)(2) The quality assessment and assurance committee must: (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to have an effective Quality Assessment and Performance Improvement (QAPI- a program that enables the facility to evaluate and improve the quality of resident care and services through data collection, staff input, and other information) program when: 1. Quality of care issues were not identified with appropriate plans of actions developed to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 114 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 correct the identified deficient practice (cross reference F600, F604, F 684, F 700). 2. Nine of 11 staff: Certified Nursing Assistant (CNA) 9, CNA 5, CNA 6, Licensed Nurse (LN) 1, LN 2, LN 8, Housekeeping (HK)1 and HK 2 were unable to identify the purpose of QAPI or the current facility QAPI projects. These failures resulted in an ineffective QAPI program necessary to improve quality of care provided to residents and ensure adequate staff knowledge of the facility QAPI program and QAPI project improvements plans. Findings: 1. On 12/10/18 at 11:51 a.m., during an interview, the Administrator (ADM) stated QAPI projects were identified through resident council meetings, complaints and concerns brought from the staff members and department managers. The ADM stated the current QAPI projects the facility was currently working on were fall prevention, making sure nourishments are passed and offered, infection control and hand sanitation during medication pass, making sure care plans were specific and resident centered and reducing urinary tract infections (UTI- infection of the bladder, kidneys). The ADM did not list any QAPI projects in relation to Quality of Care issues such as LN's communicating to the Interdisciplinary Team (IDT- a professional group consisting of a nurse, dietitian, social service person, therapist, and physician who meet to plan resident care) any change in condition with the residents care.[reference F 684 and F 600]. The ADM did not list any QAPI projects in relation to side rail assessment and side rail re-evaluation to justify the need for the side rail. [reference F 604, F 684 and F 700]. The ADM did not list any QAPI projects to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 115 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 ensure the pharmacy recommendations were followed and coordinated with the Primary Care Physician (PCP) [reference F 684]. 2. On 12/10/18 at 12:05 p.m., during an interview, CNA 9 stated he was not aware what QAPI was and the current QAPI projects the facility was working on. CNA 9 stated, "I am not aware of other quality improvement processes." On 12/10/18 at 12:06 p.m., during an interview, LN 1 stated, "I don't have an idea about QAPI." On 12/10/18 at 12:07 p.m., during an interview, CNA 5 stated, "I don't know anything about QAPI." On 12/10/18 at 12:08 p.m., during an interview, LN 2 stated she heard about QAPI in her previous employment. LN 2 stated, "Should I know this project? Is this facility doing that? I would like to know and be informed." On 12/10/18 at 12:09 p.m., during an interview, HK 1 stated, "I have not heard about [QAPI]. I just go room to room and clean." On 12/10/18 at 12:10 p.m., during an interview, LN 8 stated she was not aware what QAPI was and the current QAPI projects the facility is working on. On 12/10/18 at 12:11 p.m., during an interview, CNA 6 stated she was not aware what QAPI was and the current QAPI projects the facility is working on. On 12/10/18 at 12:12 p.m., during an interview, HK 2 stated she was not aware what QAPI was and the current QAPI projects the facility was working on. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 116 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 12/10/18 at 12:13 p.m., during an interview, HK 3 stated she was not aware what QAPI was and the current QAPI projects the facility was working on. On 12/21/18 at 11:30 a.m., during an interview, the ADM stated facility staff needed to put an intervention in the resident's care plan that was specific and measurable. The ADM stated fall prevention was very important and the facility had to identify the root cause of every fall. The ADM stated QAPI issues needed to be proactive not reactive. The ADM stated LNs needed to be aware of every pharmacy recommendation for each resident and to inform the PCP of any changes or recommendations with the residents medications. The facility policy and procedure titled, "Quality Assurance Performance Improvement" dated 12/30/17, indicated, "Purpose: To integrate a team approach to improving quality of care. The purpose of this policy is to outline the facility's commitment to continuous quality improvement... Policy: It is the policy of this facility to develop, implement and maintain an effective, ongoing, facility wide and data driven, quality assurance and performance improvement QAPI) program that reflects the quality of care and quality of life provided to residents in the facility. The QAPI plan outlines the facility's proactive approach to continuous improvement in the care and engagement of residents, staff and other partners. The success of the QAPI plan is based on the involvement of all employees..."

F880 Infection Prevention & Control FORM CMS-2567(02-99) Previous Versions Obsolete

F880 Event ID: S70D11 01/28/2019 Facility ID: CA040000225 If continuation sheet 117 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) SS=D CFR(s): 483.80(a)(1)(2)(4)(e)(f) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 118 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to implement and maintain an infection control program for one of 40 sampled residents [Resident 17] when the oxygen tubing for Resident 17 was undated and exposed to the open air. These failures had the potential to place Resident 17 at risk for cross contamination and exposure to infectious organisms. Findings: On 12/6/18 at 11:30 a.m., during a concurrent FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 119 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (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 observation and interview, Licensed Nurse (LN) 2 stated the oxygen tubing and humidifier bottles were changed and each one dated weekly on Sunday evenings. LN 2 stated, "The night shift changes the tubing and the bottle on Sunday night. The cannula (tubing) should be in a bag. There is usually a bag hanging and the bag should be dated. We cannot assume that it was changed." LN 2 stated she had not noticed the undated tubing which hung just over the mattress at the right side of the bed and not in use by Resident 17 during the observation. On 12/7/18 at 4:15 p.m., during an interview, the Director of Nursing (DON) stated, "Our policy is to change the tubing and bottle weekly and date it." The DON stated the tubing was also to be placed in a bag, dated, and changed as needed. The DON stated the risk of not having the tubing and bottle dated was not knowing how old it was and possibly infected with bacteria. Resident 17's "Order Summary Report" dated 6/2/17 indicated, "Oxygen @ 2L/min via n/c [nasal cannula], prn [as needed], to keep sats [oxygen saturation in circulating blood] at or above 93% as needed...Oxygen: Change humidifier Q [every] 7 days if used. Document date changed on bottle, every night shift very Sun[day]...Oxygen: Change oxygen tubing Q7 days if used. Document date changed on tubing, every night shift every Sun." The facility policy and procedure titled "Oxygen Administration" dated 11/24/17, indicated "...If oxygen is used periodically, the humidifier bottle should be changed weekly. Nasal cannulas are to be changed weekly. The date and initials of the nurse who changed these items is to be marked with a black sharpie..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: S70D11 Facility ID: CA040000225 If continuation sheet 120 of 121 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: _______________ 555244 (X3) DATE SURVEY COMPLETED 01/04/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE ANBERRY NURSING AND REHABILITATION CENTER 1685 Shaffer Rd Atwater, CA 95301 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: S70D11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA040000225 (X5) COMPLETE DATE If continuation sheet 121 of 121