Other·April 6, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during an Abbreviated Survey for complaint: CA00564851. Representing the California Department of Public Health-Licensing and Certification: 37312, HFEN, RN. The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint: CA00564851.

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

F684 03/30/2018 § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents' choices. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to ensure timely assessment and treatment of a change of condition for one of three residents, Resident 1, when Resident 1's change of condition was not recognized, assessed or monitored according to 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: WICQ11 Facility ID: CA040001040 If continuation sheet 1 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 professional standards of practice and Resident 1's comprehensive care plan. As a result of this failure, Resident 1 did not benefit from timely recognition and assessment of a decline in physical condition, subsequently developed signs and symptoms of urinary tract infection, was transferred by ambulance to the General Acute Care Hospital (GACH) for treatment where Resident 1 was diagnosed with urosepsis (a life threatening infection resulting from a urinary tract infection) and expired two days later from the effects of urosepsis. Findings: Review of Resident 1's clinical record titled, "Admission Record" (a record which contains resident personal information) indicated Resident 1 was 76 years old and was readmitted to the Skilled Nursing Facility (SNF) on 11/27/17 from the GACH with diagnoses that included a history of urinary tract infection (UTI). Resident 1's clinical record titled, "Minimum Data Set" (MDS) (a resident assessment tool that is used to develop a plan of care) dated 12/4/17, indicated a Brief Interview for Mental Status (BIMS) score (a score that is developed by reviewing the resident's status during the prior seven day period) of 14 points out of 15 possible points which indicated Resident 1 was cognitively (pertaining to memory, judgement and reasoning ability) intact. Review of Resident 1's clinical record titled, "Physician's History and Physical" dated 11/27/17, indicated, "History of Present Illness: Transferred back from the MICU [Medical Intensive Care Unit] at [GACH] after being treated for an acute upper GI [Gastrointestinal] FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 2 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 bleed and fluid overload from heart failure...Patient also had urosepsis ...Past Medical History: 1. Recurrent UTIs...Review of Systems... Genitourinary: No incontinence [involuntary loss of urine from the bladder]...Plan: 76 y/o [year old] female with...urosepsis...2. Will recheck urine and start antibiotics if appropriate." Review of Resident 1's Physician Order dated 11/29/17, indicated "UA [urine analysis, a laboratory test of the urine to determine the presence or absence of a UTI] with C/S [culture and sensitivity, a laboratory test to determine what type of bacteria is present and what antibiotic would be effective to treat the bacteria] if indicated one time only until 11/30/17." Review of Resident 1's UA result dated 11/30/17, indicated "White Blood Cell [WBC, cells that protect the body against infection and increase in numbers during an infection] 6-10 HPF [High Power Field - urine sample was examined under a microscope], reference range [normal range] 0-5 HPF." The UA indicated a WBC count higher than the reference range. The UA indicated the presence of a few bacteria and the reference range indicated there should be no bacteria seen in the urine. The UA indicated the appearance of the urine was "slightly cloudy" and the reference range indicated the normal appearance of urine should be "clear." The UA indicated Leukocyte Esterase (a screening test for WBCs in the urine, a positive result indicates the presence of a UTI) was 1+ (positive) and the reference range indicated the normal result should be negative for Leukocyte Esterase. Review of Resident 1's Progress Notes dated 12/2/17, indicated "Called [Medical Doctor FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 3 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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] made aware of resident's [Resident 1] concern upon urination, dribbling [incontinence of small amounts of urine from the bladder] with burning sensation. Has DX [diagnosis] Chronic UTI, U/A was done, bacteria few...Remains alert and oriented x 3 [knows who she is, where she is and what day it is]. Obtained Pyridium [a medication to relieve dysuria, painful or difficult urination, a symptom of a UTI] 100 MG [milligram] one tablet by mouth x [times] 7 days then reassessed..." Review of Resident 1's Physician order dated 12/2/17, indicated "Phenazopyridine HCl [Hydrochloride] [Generic Name for Pyridium] Tablet 100 MG Give 1 tablet by mouth one time a day for Dysuria x 7 days." Review of Resident 1's care plan dated 12/2/17, indicated "Resident [Resident 1] claimed dribbling with burning sensation upon urination with HX [history] Chronic UTI. Interventions: Medication as ordered, evaluate response to treatment..." Review of Resident 1's urine culture and sensitivity laboratory result dated 12/3/17, indicated " > (greater than) 50,000 colonies of Escherichia coli (a bacteria which can cause UTI)." Review of http://www.glowm.com/lab indicated, "Urine is normally sterile [free of bacteria]. However, in the process of collecting the urine, some contamination from skin bacteria is frequent. For that reason, up to 10,000 colonies of bacteria/ml [per milliliter] are considered normal. Greater than 100,000 colonies/ ml represents urinary tract infection. For counts between 10,000 and 100,000, the culture is indeterminate." On 12/15/17 at 10:09 a.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 4 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 Certified Nursing Assistant (CNA) 1 stated she had provided care for Resident 1 during her stay at the SNF. CNA 1 stated Resident 1 had complained of abdominal pain or bladder pain on 12/2/17 or 12/3/17, but she could not remember the exact date or time. CNA 1 stated Resident 1 usually had a big appetite, but on 12/2/17 or 12/3/17 (could not remember the exact date) she refused her breakfast and just ate soup. CNA 1 stated on that same day, Resident 1 appeared pale. Review of facility's "Census and Nursing Hours Per Patient Day" (NHPPD) dated 12/2/17 and 12/3/17, indicated CNA 1 had provided care for Resident 1 on 12/2/17 and 12/3/17 during the morning shift. Review of Resident 1's clinical record titled "ADL [activities of daily living]" indicated under "meal percentage" Resident 1 ate between 50 percent (%) to 100 % of her meals between 11/28/17 and 12/1/17. The "meal percentage" indicated Resident 1 refused her breakfast, and ate 50 percent of her lunch and 50 percent of her dinner on 12/2/17 and 12/3/17. The "meal percentage" indicated Resident 1 ate 0% of breakfast, lunch and dinner offered on 12/4/17. The "meal percentage" indicated Resident 1 refused her breakfast on 12/5/17. On 12/15/17 at 10:37 a.m., during a concurrent interview and record review, Licensed Nurse (LN) 1 stated she was the day shift nurse caring for Resident 1 on 12/4/17. LN 1 stated, "She [Resident 1] was not doing well. She refused her morning medications." LN 1 stated in the afternoon on 12/4/17, Resident 1's pulse was fast and her blood pressure (BP) was low. LN 1 stated, "She [Resident 1] had a UTI and was placed on Pyridium for dysuria on 12/2/17." LN 1 reviewed Resident 1's "Weights and Vitals [vital signs, a record of blood FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 5 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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, pulse, temperature and respiratory rate] Summary" dated 12/4/17 and noted Resident 1's pulse rate at 10:07 a.m. was 108 beats per minute and Resident 1's blood pressure (B/P) at 3:52 p.m. was 98/51mmHg (millimeters of mercury, a unit measurement of pressure). LN 1 stated, "With the pulse [rate] being high and the BP being low, resident [Resident 1] was dehydrated or had a UTI." LN 1 stated on 12/5/17 Resident 1's physician was in the facility and ordered to send Resident 1 out to the GACH because Resident 1 had increased confusion and "did not look good." Review of professional reference, "Fundamental Nursing Skills and Concepts", Barbara K. Timby, Lippincott, Williams and Wilkins, Philadelphia, c. 2009, indicated the normal range for pulse in adults was 60 to 100 beats per minute and normal blood pressure for adults was 120/80 mmHg. On 12/15/17 at 11:25 a.m., during a concurrent interview and record review, the MD reviewed the "Weights and Vitals Summary." The MD stated she was not informed of Resident 1's change in vital signs on 12/4/17 with a low BP and high pulse rate. The MD stated if she was notified of the change in vital signs along with the dysuria and laboratory results she would have sent the resident to the hospital STAT (right away). The MD stated Resident 1's low blood pressure and high pulse rate along with the laboratory results indicated Resident 1 was septic (overwhelming and life-threatening response to infection that can lead to tissue damage, organ failure, and death). On 12/15/17 at 11:59 a.m., during an interview, LN 1 stated Resident 1's high pulse rate and low BP on 12/4/17 in conjunction with the laboratory result was a change of condition (COC) for Resident 1. LN 1 stated if there was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 6 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE a change of condition for a resident, the following steps should be followed: notify the doctor, notify the family or resident representative (RP), perform a full assessment of the resident, monitor the resident, update the care plan and document the change of condition every shift for 72 hours. LN 1 stated "I did not recognize that it was a change of condition right away. I did not do a care plan. There is no documentation that the doctor or the family was notified of the low BP and high pulse [rate]. I did not recognize the patient was septic by looking at the pulse, a little faster. I just knew that she was not doing well." Review of Resident 1's clinical record titled, "Weights and Vitals Summary" indicated Resident 1's pulse was taken at 10:07 a.m. on 12/4/17 and was recorded as 108 beats per minute and blood pressure was taken at 3:52 p.m. and was recorded at 98/51. There was no record of any other pulse or blood pressure checks for Resident 1 on 12/4/17 after 3:52 p.m. On 12/15/17 at 12:51 p.m., during an interview, the Director of Nursing (DON) stated a change in vital signs (B/P, Pulse, Respiration or Temperature) was a COC if it was outside the resident's usual range for vital signs. The DON stated the following actions were to be done in every COC: reassess the resident, review laboratory results if available, do a medication regimen review (MRR), notify the MD of COC, notify the family, do alert charting (documentation on COC signs and symptoms every shift for 72 hours), and develop a care plan. The DON stated "No care plan was developed for COC regarding vital sign change." On 1/26/18 at 11:06 a.m., during a concurrent interview and record review, the DON stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 7 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1 complained of pain on 12/4/17 and received Tramadol HCl (a pain medication) 50 MG at 4:43 p.m. The DON stated Resident 1's clinical record did not indicate the location of the pain experienced by Resident 1. Review of Resident 1's Medication Administration Record (MAR) dated December 2017 indicated Resident 1 had not requested any pain medication on 12/2/17 or 12/3/17. On 1/26/18 at 11:37 a.m., during an interview, LN 2 stated a "COC is something new/ different that was not there before." LN 2 stated if there was a COC the nurse should: check the resident's vital signs, call the MD, and call the family and inform them of the COC. LN 2 stated the nurse should assess the resident and do alert charting every shift for three days, develop a care plan and evaluate the effectiveness of the care plan. On 1/26/18 at 3:18 p.m., during an interview, LN 3 stated dysuria was a COC. LN 3 stated she assessed Resident 1 on 12/2/17 for complaints of discomfort, dribbling and burning on urination (dysuria). LN 3 stated she called the MD on 12/2/17 and the MD ordered Pyridium. LN 3 stated alert charting should have been done for the COC every shift for three days by the LNs. LN 3 stated the alert charting should have included vital signs (VS), level of consciousness (alert, confused, or increased confusion), presence of dysuria, color and smell of the urine, abdominal pain, temperature, low BP and elevation of pulse rate. LN 3 stated "I do not remember if I did an SBAR [a communication tool to assess and report COC, S - Situation, B - Background, A Assessment, R - Recommendation]." The DON was present during the interview with LN 3. The DON stated there was no SBAR done for Resident 1's symptom of dysuria. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 8 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of facility SBAR Communication Form indicated areas that should be assessed for COC included, "...Vital Signs...Mental status evaluation : decreased level of consciousness, increased confusion...symptoms or signs of delirium [acute change in mental status including increasing confusion]...Cardiovascular evaluation...resting pulse [greater than] 100 or [less than] 50...Abdominal/GI Evaluation...decreased appetite/fluid intake...GI/Urine Evaluation...lower abdominal pain or tenderness...new or worsening incontinence...painful urination...urinating more frequently or urgency with or without other urinary symptoms...Pain..." On 1/26/18 at 3:33 p.m. during a concurrent interview and record review, the DON stated Resident 1's Progress Notes dated 12/2/17 at 4:45 p.m. indicated Resident 1's dysuria was addressed and an order for Pyridium was obtained. The DON stated the Progress Notes had no documentation of LN assessment, no alert charting, of Resident 1's dysuria or COC from 12/2/17 at 4:45 p.m. until the morning of Resident 1's transfer to the GACH on 12/5/17. The DON stated Resident 1's Progress Note dated 12/5/17 at 10:30 a.m. indicated Resident 1 was confused, and had nausea and vomiting and poor intake of food and fluid. On 1/26/18 at 4:02 p.m., during an interview and concurrent record review with the DON and LN 3, LN 3 stated Resident 1's change in blood pressure and pulse on 12/4/17 was a change of condition. LN 3 stated Resident 1's clinical record had no documentation regarding the change of condition. LN 3 stated there was no record of MD notification of the change in Resident 1's blood pressure and pulse, no family notification of a change in Resident 1's condition, no assessment of Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 9 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 and no care plan developed for the change of condition. The DON stated Resident 1's change of condition should have been care planned and the MD should have been notified of Resident 1's change in blood pressure and pulse. The DON stated the MD was not notified of Resident 1's change in blood pressure and pulse and the COC was not care planned. On 1/26/18 at 5:03 p.m., during an interview, LN 4 stated she worked the p.m. shift on 12/4/17 and was assigned to Resident 1. LN 4 stated, "She [Resident 1] was nauseated on 12/4/17 on p.m. shift." LN 4 stated Resident 1 refused her dinner and was "a little confused" on the evening of 12/4/17. LN 4 stated prior to 12/4/17 Resident 1 knew who she was, where she was and what day it was. LN 4 stated on 12/4/17 Resident 1 "didn't know where she was; prior to that she knew where she was." LN 4 stated she did not call the MD regarding the change in Resident 1's mental status. Review of Resident 1's Progress Notes dated 12/4/17 indicated Resident 1 received "Ondanesteron ODT 4 MG TAB RAPDIS [a medication for treatment of nausea and vomiting]" at 1:30 p.m. The Progress Note further indicated, "Patient [Resident 1] feels nauseated." On 3/6/18 at 8:05 a.m., during an interview, the DON stated there was no written policy on SBAR. The DON stated an SBAR was triggered by a COC. The DON provided a few examples of COC; fall, fever, cough, diarrhea, dysuria, consistent change in vital signs, consistent refusal of meals (on consecutive days or refusal of all meals in one day). The DON stated the SBAR should be initiated by the LN and the LN should notify the MD and the resident's family of the COC. The DON stated when an SBAR is initiated, the LN FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 10 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 should continue to monitor and assess the COC every shift for 72 hours. Review of Resident 1's Progress Notes dated 12/5/17 at 10:30 a.m., indicated "patient [Resident 1] alert and oriented to herself, some confusion noted, patient refused her AM medication, waiting for Dr [MD] and her daughter here." Review of Resident 1's clinical record, "Weights and Vital Signs Summary" dated 12/5/17 at 12:26 p.m. indicated Resident 1's B/P was 105/55 and pulse rate was 116 beats per minute. Review of Resident 1's Progress Notes dated 12/5/17 at 12:44 p.m., indicated "Resident noted with increase confusion, weakness, altered mental status, c/o nausea/vomiting, poor PO (by mouth) intake, assessed by MD [name] today...received order send her out to hospital for further eval [evaluation]." Review of Resident 1's Progress Note dated 12/5/17 further indicated at 12:45 p.m., " Picked up [Resident 1] by [name of ambulance company] ambulance to transfer out to [GACH] daughter at bedside." Review of Resident 1's GACH ED (Emergency Department) record dated 12/5/17 at 3:47 p.m., indicated "Chief Complaint: Altered Mental Status, altered mental status since Sunday [12/2/17]...recent dx of uti..." The ED physician notes indicated, "UA consistent with UTI." Review of Resident 1's GACH clinical record titled, "Critical Care Medicine Consult" dated 12/5/17 at 4:48 p.m., indicated, "Patient remains hypotensive [low blood pressure]...will continue IV [intravenous, injected into a vein] fluids (liters 4 and 5)...Will re-evaluate after her FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 11 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 fifth liter...patient's blood glucose (blood sugar) is critically low...patient's blood pressure is currently 92/51...Clinical Impression: UTI, Sepsis, suspect urinary source...delirium, hypoglycemia." Review of Resident 1's GACH clinical record titled, "Critical Care Medicine Consult" dated 12/5/17 at 8:10 p.m., indicated Resident 1 was hypotensive and the reasons for the critical care consultation were "sepsis, urosepsis with hypotension, altered mental status, and hypoglycemia [low blood sugar]. PLAN: The patient is on Levaquin [an antibiotic]. I ordered Vancomycin [an antibiotic] x 1 until the cultures [urine cultures] are back. I also ordered Diflucan [an antifungal]. She has yeast in the urine..." Review of Resident 1's GACH clinical record UA laboratory results dated 12/5/17, indicated Color - amber, appearance - hazy, Leukocyte Esterase 1+ (positive), WBC 82 HPF (reference range 0 to 5 HPF), bacteria occasional, yeast budding -few, and Hyaline cast 79 (reference range: None Seen), Protein 30 mg/dl (milligrams per deciliter, a measurement of protein in the urine) and the reference range indicated there should be no protein in the urine. Review of Resident 1's urine culture results at the GACH dated 12/7/17 at 12:56 p.m., indicated "> 100,000 cfu/ml (colony forming unit per milliliter) of Candida Albicans (a fungal infection)." Review of Resident 1's GACH record dated 12/7/17, indicated "Discharge/Death Note: Date and time of death 12/7/17 @ [at] 14:09 [2:09 p.m.] hours. Cause of death: Sepsis with multiorgan failure due to urinary tract infection. Admitting diagnosis: Septic shock [a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 12 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 widespread infection causing organ failure and dangerously low BP], UTI, metabolic acidosis [too much acid accumulates in the body due to sepsis], lactic acidosis [buildup of lactic acid in the body resulting in an excessively low acid/base balance in the bloodstream which may be fatal] altered mental status - due to septic encephalopathy [a brain dysfunction secondary to infection], acute hyponatremia [low sodium level in the blood], history of atrial fibrillation [irregular heart beat], and acute kidney injury." The facility policy and procedure titled "NSG122 Change in Condition: Notification" dated 11/28/16, indicated "Policy: A Center must immediately inform the patient, consult with patient's physician, and notify, consistent with his/her authority...where there is: A significant change in the patient's physical, mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications)...A need to alter treatment significantly ...or to commence a new form of treatment..." The facility clinical record form titled "Care Path Symptoms of Urinary Tract Infection (UTI)" dated 2014, indicated "Symptoms or Signs of UTI: painful urination, lower abdominal (suprapubic) pain or tenderness, blood in urine, new or worsening urinary urgency, frequency, incontinence." The Care Path indicated if signs and symptoms of UTI were present the nurse should, "Take Vital Signs, Temperature, BP, pulse, apical HR [heart rate], Respiration, Oxygen saturation [level of oxygen in the blood], Finger stick glucose (diabetics). Vital Signs Criteria (any met?): Temp [temperature] > 100.5 degrees Fahrenheit, Apical heart rate >100 or < 50, Respiratory rate >28/min or < 10/min, BP <90 or >200 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 13 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 systolic, Oxygen saturation <90 %, Finger stick glucose <70 or > 300, and Resident unable to eat or drink. If Yes [criteria were met], Notify the MD/NP [Nurse Practitioner]/PA [Physician Assistant]." The facility policy and procedure titled "OPS100 Accidents/Incidents" dated 11/28/16, indicated "Policy:...staff will use the Risk Management System (RMS) to report, review, and investigate all accidents/incidents which occurred, or allegedly occurred...or allegedly involved, a patient who is receiving services...Purpose:...to define the causative/contributing factors and institute preventive measures to avoid further occurrence...Process: 2. Assessment, Medical Assistance, Documentation: 2.1 Patients: 2.1.1 The nurse will examine the patient. 2.1.2 The nurse will notify the physician...and obtain orders as indicated. 2.1.5 The patient's responsible party/family will be notified of the accident/incident...2.1.6 The nurse will: 2.1.6.2 Document the accident/ incident in the patient's chart; Documentation will include all pertinent information, date, time, place, notifications, and initial and ongoing assessments..." Sepsis Symptom Centers for Disease Control titled "Basic Information" dated 3/1/18, at https://www.cdc.gov/sepsis/basic/index.html, indicated "...There is no single symptom of sepsis. Symptoms of sepsis can include confusion or disorientation, shortness of breath, high heart rate, fever, or shivering, or feeling very cold, extreme pain or discomfort, and clammy or sweaty skin..." Review of Professional Reference, "Infection Control and Hospital Epidemiology: Development of Minimum Criteria for the Initiation of Antibiotics in Residents of LongTerm-Care: Results of a Consensus FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 14 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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 Conference" dated 2/2001, indicated "...UTI...1. For residents who do not have an indwelling catheter [a tube placed into the bladder to drain urine], minimum criteria for initiating antibiotics include acute dysuria alone and one of the following: worsening urgency, frequency...or urinary incontinence." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WICQ11 Facility ID: CA040001040 If continuation sheet 15 of 16 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: _______________ 555652 (X3) DATE SURVEY COMPLETED 03/09/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE WILLOW CREEK HEALTHCARE CENTER 650 W Alluvial Ave Clovis, CA 93611 (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: WICQ11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA040001040 (X5) COMPLETE DATE If continuation sheet 16 of 16