Health inspection·January 17, 2024

F 0656 Level of Harm - Actual harm Residents Affected - Few pressure], no reading obtained from BP [blood pressure] cuff, no pulse, no chest rise. AMR arrived at approximately 1310. TOD [time of death] pronounced by paramedics x2 from AMR @ 1314. Pt DNR [Do Not Resuscitate], comfort measures. This CN asked CNA what occurred, she stated that she placed meal tray on patients table, was attempting to set up her tray when pt grabbed a handful of food and stuffed it into her mouth and would not open her mouth despite several attempts of CNA asking her to open her mouth, pt then started choking . During an interview on 1/4/2024 at 2:17 p.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 tended to eat her food quickly. LVN 1 stated Resident 1 had an episode of aspiration a month before she died due to eating her food too fast. During an interview 1/5/2024 at 10:19 a.m., with CNA 1, CNA 1 stated Resident 1 would grab whatever food was presented in front of her and Resident 1 would eat very fast and overstuff her mouth. CNA 1 stated Resident 1 had a history of eating fast and overfilling her mouth and staff were aware of these eating behaviors. CNA 1 stated Resident 1 was sent out to the hospital in the past because she choked. CNA 1 stated she did not receive specific instructions on how to monitor Resident 1 during meals. CNA 1 stated Resident 1 could have been considered a choking risk due to her behaviors. CNA 1 stated Resident 1 ate this way from the time of her admission, 10/5/23. During an interview on 1/5/2024 at 10:57 a.m., with the registered dietician (RD), the RD stated she was aware Resident 1 was sent out in the past for aspiration, based on reviewing previous hospitalization documents. The RD stated she was not aware of any feeding behaviors Resident 1 had because she never saw her eat and no one communicated any resident eating concerns to her. The RD stated if she knew about Resident 1's eating behaviors she would have put in a referral for Resident 1 to be seen by the speech pathologist to assess for a possible choking risk. The RD stated she was unaware if Resident 1 was ever seen by a speech pathologist. During an interview on 1/5/2024 at 11:08 a.m., with CNA 2, CNA 2 stated [Resident 1] would grab the trays and shove the food in her mouth, she likes to stuff her mouth. CNA 2 stated Resident 1 would eat very fast and insert large amounts of food into her mouth and staff was aware of her eating behaviors since admission. CNA 2 stated, I thought she would eventually choke one day . CNA 2 stated Resident 1 was a high risk for choking due to her behaviors and being sent out to the hospital for a previous choking incident. CNA 2 stated no specific orders or directions were ever communicated to staff on how to monitor Resident 1's feeding behaviors. CNA 2 stated staff were alerted on Resident 1's eating behavior but the only intervention present was to ensure Resident 1 received the right tray. During an interview on 1/5/2024 at 12:11 p.m., with the director of staff development (DSD), the DSD stated staff did not communicate with her regarding Resident 1's eating behavior. The DSD stated if she had knowledge of these behaviors, she would have created specific training for Resident 1's meals. The DSD stated, I would definitely do a lot of in-service and be hands on with my staff if this was brought to my attention. The DSD stated training would have been important to prevent any incidents of choking. During a concurrent interview and record review on 1/5/2024 at 12:48 p.m., with LVN 1, LVN 1 stated, the choking incident could have been anticipated and avoided. LVN 1 stated Resident 1 went out to the hospital for choking in the past due to eating behaviors. LVN 1 stated Resident 1's eating behaviors were known by the staff. LVN 1 stated due to Resident 1's eating behavior she could have benefited from having a feeder (a staff member who helps resident with all meals) or have had someone monitor her while she ate. LVN 1 stated after Resident 1 returned from the hospital, she had a diagnosis (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055084 If continuation sheet Page 2 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverbank Post-Acute 2649 Topeka Street Riverbank, CA 95367 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Actual harm Residents Affected - Few of dysphagia. LVN 1 stated this diagnosis put her at high risk for choking. LVN 1 stated Resident 1 had no interventions in place to deal with her eating behavior. LVN 1 stated all staff knew about Resident 1's eating behavior. LVN 1 stated she would have considered Resident 1 a high risk for choking due to the way she ate, and her past hospitalization related to choking. LVN 1 concurred there was no documented evidence of a care plan to address her behavior and no interventions in place to deal with her eating behavior. During an interview on 1/5/2024 at 2:13 p.m., with LVN 2, LVN 2 stated before Resident 1 died, she had a previous choking incident in which she was transferred to the acute hospital. LVN 2 stated Resident 1 ate very quickly and fit large portions of food into her mouth. LVN 2 stated staff knew about these eating behaviors because Resident 1 did them every day. LVN 2 stated she was not surprised Resident 1 expired due to choking because she had a previous incident where she choked and was sent out to the hospital. LVN 2 stated Resident 1's dysphagia put her at risk for choking and aspiration. LVN 2 stated a diagnosis of dysphagia means staff should closely monitor consumption of liquids and food. During an interview on 1/5/2024 at 3:30 p.m., with the director of nurses (DON), the DON stated the facility did not think Resident 1's death from choking was an unusual occurrence. The DON stated due to Resident 1's history of CVA and dysphagia the Interdisciplinary Team (IDT – a group of health care professionals with various areas of expertise who work together toward the goals of their residents) and the administrator (ADM) did not consider the incident an unusual occurrence due to Resident 1's known behaviors of trying to consume foods too quickly. The DON stated staff not familiar with Resident 1's behavior would not be aware of her risk for choking. The DON stated there was no choking assessment done and no care plan detailing her risk for choking or aspiration for Resident 1. The DON stated Resident 1 needed a care plan in place regarding aspiration and choking. The DON agreed Resident 1 needed a care plan. The DON stated a care plan is important to make all nurses aware of Resident 1's behaviors. The DON stated Resident 1 was at a high risk for aspiration and a speech therapist should have been involved in her care. The DON stated no speech therapist assessed Resident 1 in the facility. The DON stated the Registered Dietician (RD) was not aware of Resident 1's eating behaviors and since she was not aware, it could have led to negative outcomes for Resident 1. The DON stated staff should have informed the RD about Resident 1's eating behavior if they were aware of it. During an interview on 1/5/2024 at 4:20 p.m., with the ADM, the ADM stated Resident 1's death was not reported because they did not think it was an unusual occurrence. The ADM stated it was not uncommon to have residents die in facilities. During a review of Resident 1's Order Details dated 10/12/2023 at 4:12 p.m., the document indicated Resident 1 had an order for a swallow evaluation with a speech therapist. During a review of Resident 1's Order Details dated 11/29/2023 at 9:03 a.m., the document indicated Resident 1 had a speech therapy evaluation ordered due to swallowing difficulties. During an interview on 1/10/2024 at 10:41 a.m., with the speech pathologist (SP), the SP stated she did not receive any communication regarding Resident 1. The SP stated Resident 1 should have been seen by a speech pathologist. The SP stated there was a failure to communicate regarding Resident 1's speech pathology order which is why it was missed. The SP stated a resident assessment normally occurred within 48 hours of an order. The SP stated Resident 1's first speech therapy consult was ordered on 10/12/23. The SP stated if she had been aware of Resident 1's required speech therapy (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055084 If continuation sheet Page 3 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverbank Post-Acute 2649 Topeka Street Riverbank, CA 95367 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 assessment, the SP would have done it. Level of Harm - Actual harm During a concurrent interview and record review, on 1/10/2024 at 4:52 p.m., with the social services director (SSD), the SSD stated she attended IDT meetings and did not recall Resident 1's eating behaviors being discussed. The SSD stated she heard Resident 1 would try to fit a lot of food in her mouth and Resident 1 once had her whole fist in her mouth to prevent staff from removing the food. The SSD stated a speech therapy evaluation was ordered for Resident 1, but she was unsure if it was done. The SSD stated staff may have forgotten about Resident 1's speech therapy appointment or staff may not have realized she had an appointment. The SD concurred there was no documented evidence of a speech evaluation completed. Residents Affected - Few During an interview on 1/11/24 at 4:30 p.m., with a family member (FM), the FM stated Resident 1 had a diagnosis of bipolar disorder her whole life. The FM stated Resident 1 had trouble speaking and had right sided weakness due to a stroke. The FM stated Resident 1 had a feeding tube due to her inability to swallow at the hospital. The FM stated the facility staff said Resident 1 would receive a swallow evaluation by a speech therapist, but they never told him this was not done. The FM stated Resident 1 tended to eat quickly and he told her [Resident 1] she might choke again due to this behavior. The FM stated he visited Resident 1 regularly and did not observe a feeder or staff member monitoring her while she ate. During a concurrent interview and record review, on 1/5/2024 at 12:48 p.m., with LVN 1, Resident 1's admission nursing assessment, dated 11/23/2023 was reviewed. The readmission form indicated, Resident 1 was readmitted to the facility with a diagnosis of dysphagia. Resident 1 returned after being hospitalized for a choking incident at the facility. LVN 1 stated due to Resident 1's diagnosis and hospitalization, her death from choking could have been anticipated. LVN 1 stated Resident 1's diagnosis of dysphagia means Resident 1 had difficulty swallowing and speaking and the facility should have better monitored her to prevent any future choking incidents. During a review of the facility's policy and procedure (P&P) titled, Care Plans, Comprehensive Person-Centered , dated March 2023, the document indicated, . 11. Assessments of residents are ongoing and care plans are revisedas information about the residents and the residents' condition change. 12. The interdisciplinary team reviewsand updates the care plan: a. when there had been a significant change in the resident's condition . c. when the resident has been readmitted to the facility from a hospital stay . During a review of the facility's policy and procedure titled, Dysphagia -Clinical Protocol , dated September 2017, the document indicated, 1. the staff and physician will identify individuals with a history of swallowing or related diagnosis such as dysphagia, as well as individuals who currently have difficulty chewing or swallowing food . 2. Based on information collected and correlated by various disciplines, the staff and practitioner, in conjunction with the SLP, will define the situation carefully . and whether the situation needs additional evaluation and clarification . Cause Identification 1. It is important to clarify the symptoms and the history in detail to help identify causes, since symptoms related to chewing or swallowing may have modifiable causes . 4. medical and other causes of dysphagia can include the following . f. psychiatric disorders (anxiety, depression, and various personality disorders) . 5 . b (1) examples of situations in which speech therapy interventions may be helpful include individuals who have had a recent stroke with subsequent impaired chewing and swallowing During a review of Resident 1's Certification of Death dated 12/2/23, the Certification of Death (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055084 If continuation sheet Page 4 of 5 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 055084 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/17/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverbank Post-Acute 2649 Topeka Street Riverbank, CA 95367 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete indicated, . 107. CAUSE OF DEATH . (A) IMMEDIATE CAUSE . ACUTE RESPIRATORY FAILURE . sequentially, list conditions, if any, leading to cause . ENTER UNDERLYING CAUSE (disease or injury that initiated the events resulting in death) LAST . (B) ASPHYXIA (C) ASPIRATION (D) STROKE WITH DYSPHAGIA . 123. PLACE OF INJURY OTHER: NURSING HOME .124. DESCRIBE HOW INJURY OCCURRED: CHOKED ON FOOD BOLUS . Event ID: Facility ID: 055084 If continuation sheet Page 5 of 5