Health inspection·November 25, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident's bed, on top of the blanket. LVN 1 checked the resident's blood glucose then took the glucometer out and laid it directly on top of the medication cart. LVN 1 stated, I should not have laid it [the glucometer] directly on the bed. LVN 1 stated the glucometer could spread germs to other residents if it were not properly handled and cleaned. LVN 1 stated the glucometer could spread germs from the resident's environment to the top of the medication cart. LVN 1 stated she should have placed a barrier such as a paper towel under the glucometer on the residents table and the med cart.During a concurrent observation and interview on 11/25/25 at 12:07 p.m. with LVN 3 in front of Resident 7's room, LVN 3 placed a drape on top of the medication cart, then placed the glucometer on top. LVN 3 donned a gown and gloves and stated Resident 7 was on EBPs. LVN 3 placed a paper towel on the overbed table and placed the glucometer, strip, lancet and alcohol swab on top. LVN 3 checked Resident 7's blood glucose then doffed (to take off) his gown, took the strip out of the glucometer, pulled off his gloves and placed the soiled glucometer directly on top of the medication cart. LVN 3 stated he should not have placed the soiled glucometer on top of the medication cart without a barrier because it contaminated the top of the medication cart.During an interview on 11/25/25 at 1:07 p.m. with the Director of Staff Development (DSD), the DSD stated she had done rounds the previous day and noticed the nurses needed an in-service to review the nurse's glucometer infection prevention methods because they needed to improve.During an interview on 11/25/25 at 1:44 p.m. with the Director of Nursing (DON), the DON stated the nurses needed to clean and disinfect the glucometer thoroughly between residents. The DON stated the disinfecting wipes used by the facility had a 2-minute contact time and should be kept wet for 2 minutes to disinfect the glucometer correctly. The DON stated the glucometer should be placed on a barrier such as a paper towel or tissue on top of a flat surface. The DON stated the glucometer needed to be disinfected prior to moving to another resident and a clean barrier should be placed on top of the medication cart prior to placing a soiled glucometer on it. The DON stated the resident's overbed tables could have blood, body fluids or leftover food from meals. The DON stated if the glucometer were moved from the resident's environment to the top of the medication cart without a barrier down, it could transmit germs for all residents receiving medication from the same medication cart.During a review of the facility's P&P titled Blood Sampling-Capillary (Finger Sticks), dated 9/2014, the P&P indicated, . purpose of this procedure is to guide the safe handling of capillary-blood sampling devices to prevent transmission of bloodborne diseases to residents and employees . Always ensure that blood glucose meters intended for reuse are cleaned and disinfected between resident uses . Steps in the Procedure . Wash hands . [NAME] gloves . Place blood glucose monitoring device on clean field [physical barrier to reduce the number of overall germs] . Obtain the blood sample . Following the manufacturer's instructions, clean and disinfect reusable equipment . after each use .During a review of the blood glucose monitor manufacturer guidelines, the guidelines indicated, . The meter should be cleaned and disinfected after use on each patient . cleaning procedure is needed to clean dirt, blood and other bodily fluids off exterior of the meter before performing the disinfecting procedure . disinfecting procedure is needed to prevent the transmission of bloodborne pathogens . each time the cleaning and disinfecting procedure is performed two wipes are needed. One wipe to clean the meter and a second wipe to disinfect the meter . an LTC [long term care] facility establish a program for infection control and identify a key individual responsible for the overall program oversight . program should include addressing the cleaning and disinfecting of blood glucose meters along with other equipment and environmental surfaces .During a review of the facility's policy and procedure (P&P) titled Policies and Practices-Infection Control, dated 10/2023, the P&P indicated, . This facility's infection control policies and practices apply equally to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055084 If continuation sheet Page 2 of 6 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 11/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some all personnel . objectives of our infection control policies and practices are to . prevent, detect, investigate, and control infections in the facility . establish guidelines for implementing isolation precautions, including standard and transmission-based precautions . maintain records of incidents and corrective actions related to infections . 2. During an interview on 11/25/25 at 10:56 a.m. with CNA 1, CNA 1 stated hand hygiene should be done every time a staff member enters or exits a resident's room and before and after contact with the resident or their belongings. CNA 1 stated hand hygiene prevents the spread of disease to other residents.During a concurrent observation and interview on 11/25/25 at 11:31 a.m. with CNA 3, CNA 3 was observed entering room [ROOM NUMBER] without performing hand hygiene and assisted the resident with her bed, touching the resident's environment and left the room without performing hand hygiene. There was an Enhanced Barrier Precautions, sign hanging above the door outside room [ROOM NUMBER], the sign indicated . Everyone must. Clean their hands including before entering and when leaving the room . CNA 3 stated she should have used hand sanitizer prior to entering and exiting the room. CNA 3 stated poor hand hygiene (cleaning hands to prevent the spread of germs by either washing them or using an alcohol-based hand sanitizer) could spread germs to other residents.During an interview on 11/25/25 at 1:07 p.m. with the DSD, the DSD stated the hand hygiene expectations were for staff to use hand sanitizer gel or wash hands, prior to and upon leaving the resident rooms. The DSD stated hand hygiene was important to prevent the spread of disease to the residents and staff.During an interview on 11/25/25 at 1:44 p.m. with the DON, the DON stated hand hygiene was to be performed when entering and exiting resident rooms, prior to moving from resident to resident and before and after administering medication. The DON stated if hand hygiene was not performed correctly, it could transmit infection from resident to resident or from resident to staff.During a review of the facility's P&P titled Handwashing/Hand Hygiene, dated 8/2019, the P&P indicated, . facility considers hand hygiene the primary means to prevent the spread of infections . All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Use an alcohol-based hand rub containing at least 62% alcohol . or, alternatively, soap . and water for the following situations . before and after coming on duty . Before and after direct contact with residents . After contact with a residents' intact skin . After contact with objects in the immediate vicinity of the resident . Before and after entering isolation precaution settings .3. During an observation on 11/25/25 at 10:50 a.m., rooms [ROOM NUMBERS] had Personal Protective Equipment (PPE) carts in front of the room with no signage indicating the reason for the PPE cart or instructions for use of PPE for the necessary precautions.During an interview on 11/25/25 at 10:56 a.m. with CNA 1, CNA 1 stated she was assigned to rooms [ROOM NUMBERS]. CNA 1 stated the PPE carts were in front of the rooms but there were no signs because the residents in those rooms were not on any precautions. CNA 1 stated she had asked the nurses previously and was told the residents in the rooms did not need PPE for precautions. CNA 1 stated EBPs were a type of isolation when the residents had a wound or urinary catheter. CNA 1 stated EBP signage notifies the staff to wear gloves and a gown any time they provide care to the residents.During an observation on 11/25/25 at 11:03 a.m. in front of rooms [ROOM NUMBERS], Enhanced Barrier Precautions signs were hanging above the PPE carts indicating . Everyone must. Clean their hands including before entering and when leaving the room . Wear gloves and a gown for the following High-Contact Resident Care Activities . Dressing. Bathing . transferring . providing hygiene. assisting with toileting . Device care or use. Wound care .During an interview on 11/25/25 at 11:55 a.m. in the hallway in front of rooms 5 & 6, the Director of Staff Development came down the hallway and stated she hung the EBP signs above the PPE carts in front of rooms [ROOM NUMBERS] this morning. The DSD stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055084 If continuation sheet Page 3 of 6 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 11/25/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete signs were missing and should have been on the wall above the PPE carts, so staff were aware of what precautions to take and what PPE to wear.During an interview on 11/25/25 at 11:10 a.m. with the Assistant Director of Nursing (ADON), the ADON stated isolation or precaution signs should hang above the PPE cart to notify staff what type of PPE is needed and the necessary precautions to take when providing care for the residents.During an interview on 11/25/25 at 1:44 p.m. with the Director of Nursing (DON), the DON stated there needed to be a sign hanging above the PPE carts when residents are on any type of isolation or EBP. The DON stated staff and visitors needed to know what types of precautions to use to keep the residents safe and limit the transmission of infectious disease.During a review of the facility's P&P titled Enhanced Barrier Precautions, dated 8/2022, the P&P indicated, . Enhanced barrier precautions (EBPs) are utilized to prevent the spread of multi-drug resistant organisms (MDROs) to residents . used as an infection prevention and control intervention to reduce the spread of multi-drug resistant organisms (MRDOs) to residents . EBPs employ targeted gown and glove use during high contact resident care activities when contact precautions do not otherwise [NAME] . Examples of high-contact resident care activities . dressing bathing/showering . transferring . providing hygiene . changing linens . changing briefs or assisting with toileting . device care or use . wound care . Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required . PPE is available outside of the resident rooms .During a review of a professional reference retrieved from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/faqs.html titled Definition and scope of Enhanced Barrier Precautions, dated 6/28/24, the reference indicated, . Enhanced Barrier Precautions are an infection control intervention designed to reduce transmission of multi-drug resistant organisms (MDROs) in nursing homes . Enhanced Barrier Precautions expand the use of gown and gloves beyond anticipated blood and body fluid exposures . use of gown and gloves during high-contact resident care activities that have been demonstrated to result in the transfer of MDROs to hands and clothing of healthcare personnel . Signs are intended to signal to individuals entering the room the specific actions they should take to protect themselves and the resident. To do this effectively, the sign must contain information about the type of Precautions and the recommended PPE to be worn when caring for the resident. Event ID: Facility ID: 055084 If continuation sheet Page 4 of 6 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 11/25/2025 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure the facility employed an infection preventionist (professionals who works to stop the spread of infections within a healthcare facility) to meet the facility's infection control needs when the facility did not have a trained and certified infection preventionist for over two weeks and the staff failed to follow proper infection control procedures including failing to follow the facility's infection control policy and procedure for performing fingerstick blood glucose, one of three CNA's did not perform hand hygiene when entering and exiting a resident room after touching the residents environment and enhanced barrier precaution signs were not hung by the PPE carts for two rooms.These failures had the potential to have an outbreak of infectious disease throughout the facility. (Cross reference F880)During a concurrent interview on 11/25/25 at 10:30 a.m. with the Administrator (ADM) and the Assistant Director of Nurses (ADON), the ADM stated the facility did not have an Infection Preventionist (IP) because the IP was terminated two weeks prior. The ADM stated there were multiple people covering the IP role including the ADON, DON and DSD. The ADON stated he had been off work for a month and returned today. The ADON was unable to answer how he had performed the IP duties while he was not working.During an interview on 11/25/25 at 10:56 a.m. with CNA 1, CNA 1 stated she had not seen the IP for a month and there were no recent infection prevention in-services provided recently.During an interview on 11/25/25 at 11:12 a.m. with Licensed Vocational Nurse (LVN) 2, LVN 2 stated the facility had an IP but we have not seen her for a few weeks. LVN 2 stated the IP was employed for a short period of time. LVN 2 stated an IP was important to the facility because they were responsible for staff education and to make sure infection control procedures were followed.During a concurrent observation and interview on 11/25/25 at 11:31 a.m. with CNA 3, CNA 3 was observed entering room [ROOM NUMBER], touching the resident's environment and exiting the room without performing hand hygiene. CNA 3 stated she could not remember when the last infection prevention training was provided for the staff. CNA 3 stated she did not know who the IP was now and stated, I don't think we have one.During an interview on 11/25/25 at 11:35 a.m. with LVN 1, LVN 1 stated the facility had not had an IP for a while, but she was not sure of the exact timeframe.During an interview on 11/25/25 at 1:07 p.m. with the DSD, the DSD stated she started working at the facility on 11/3/25. The DSD stated she never met the IP and was told she worked from home. The DSD stated she had been making rounds and had identified infection control issues which she was scheduling in-services for the staff. The DSD stated she did not have an IP certification and had not attended the IP classes. The DSD stated she was not certified to perform the IP duties.During an interview on 11/25/25 at 1:27 p.m. with the ADON, the ADON stated he was IP certified but had been off for about a month. The ADON stated the IP was no longer employed by the facility, but he was not sure when her last day was.During an interview on 11/25/25 at 1:44 p.m. with the DON, the DON stated she was not IP certified. The DON stated there had been no certified IP meeting the facility's infection preventionist duties. The DON stated it was necessary to have an IP employed to meet the regulations and facility's needs. The DON stated she last saw the IP onsite the week of 9/30/25 which was when she had started working at the facility. The DON stated she had not seen the IP onsite for the past three weeks.During a review of an e-mail dated 12/1/25, from the Administrator (ADM), the e-mail indicated the IP's resignation date from the facility was 11/14/25. The ADM indicated the IP's last day onsite at the facility was 10/31/25.During a review of the facility's Job Description: Infection Control Coordinator, undated, the job description indicated, . primary purpose of your job is to plan, organized, develop, coordinate, and direct our (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055084 If continuation sheet Page 5 of 6 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 11/25/2025 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 0882 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete infection control program and its activities in accordance with current federal, state, and local standards, guideline, and regulations. Coordinate the development and monitoring of our facility's established infection prevention and control policies and practices. Plan, develop, organize, implement, evaluate, and director our infection control program. Monitor infection control practices and procedures to ensure that all personnel are implementing our standard operating procedures. Make rounds to nursing units for the purpose of case findings, review of environmental sanitation procedures, and supervision of isolation precautions/practices. Orient new employees to the importance of infection control policies and procedures. Ensure that all nursing service personnel follow established isolation precautions and aseptic technique to include universal precautions . Make rounds. Monitor medication passes and treatments to ensure that appropriate hand washing techniques are being followed in the handling and administering of drugs, medications, and treatments. Develop and participate in the planning, conducting, and scheduling of timely in-service training classes and educational programs that provide instructions on how to do the job.During a professional reference review titled State Operations Manual [SOM], Appendix PP, dated 7/23/25, the SOM, indicated, . Infection preventionist . The facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility's IPCP [infection prevention and control plan]. The IP must . Be qualified by education, training, experience or certification . Work at least part-time at the facility . Have completed specialized training in infection prevention and control. The IP must physically work onsite in the facility. He/she cannot be an off-site consultant or perform the IP work at a separate location .An IP must have obtained specialized IPC [infection prevention and control] training beyond initial professional training or education prior to assuming the role. Event ID: Facility ID: 055084 If continuation sheet Page 6 of 6