Health inspection·October 20, 2022

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) served as the Director of Nursing (DON) and an RN was scheduled and in the facility for at least eight consecutive hours a day, seven days per week when the facility did not have an RN scheduled on 11/15/19 to 10/20/22. The facility did not provide documented evidence of CMS approved waiver for this requirement. This failure resulted in an inadequate RN facility staffing and the potential for residents to have their medical needs to go unrecognized by an RN and the potential for serious medical consequences to occur. Findings: During an interview on 10/18/22, at 9:53 a.m., with Certified Nursing Assistant (CNA) 1, CNA 1 stated the Director of the Skilled Nursing Facility (DIR) was a Licensed Vocational Nurse and was the DON. CNA 1 stated the facility had a part time RN treatment nurse working part time on Mondays and Fridays. During an interview on 10/18/22, at 10:01 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she had been at the facility since August 2022 and the facility did not have a DON or full time RN. LVN 1 stated RNs were necessary when residents needed intravenous (IV) medication or an in-depth assessment. LVN 1 stated she had been told by the facility staff an acute care RN would come to the facility to perform assessments and IV medications if needed. LVN 1 stated she has not needed the acute care RNs since she started. During an interview on 10/18/22, at 10:52 a.m., with the Licensed Vocational Nurse/Audit Nurse (LVNAN), the LVNAN stated the facility did not have a DON. The LVNAN stated she had worked at the facility for 3 years and did not remember the facility ever having a DON. The LVNAN stated RN 1 worked as a part-time treatment nurse on Mondays and Fridays. LVNAN stated RN 1 left after the treatments were completed. LVNAN stated the Minimum Data Set Coordinator RN worked part time for the facility offsite. During a review of RN 1's timesheets titled Employee Timesheet, dated from 7/24/22 to 10/15/22, the timesheets indicated RN 1's total hours were: 7/24/22 to 8/6/22- 16 hours 8/7/22 to 8/22/22- 22 hours (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 055283 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 055283 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/20/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE John C. Fremont Healthcare District Dp/Snf 5189 Hospital Road Mariposa, CA 95338 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)