Health inspection·August 19, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. (evaluation of residents history, current status and predisposing conditions - a factor that increases a person's likelihood of developing a particular health condition, genetic trait, or other characteristic, but it is not the direct or immediate cause) assessments, with date ranges from 2/28/25 to 7/19/25, the Fall Risk Evaluation scores ranged from 17-22 points. The Fall Risk Evaluation of 10 points or higher indicated Resident 1 was a high risk (involving or exposed to a high level of danger) for falls. During a concurrent observation and interview on 8/19/25, at 1:30 p.m. with Resident 1 and her Granddaughter in Resident 1's room, Resident 1 was lying in bed watching television with her granddaughter. Resident 1 had a shoulder sling in place on her left shoulder. Resident 1 stated she wasn't doing too good and pointed in the direction of her sling. Resident 1 stated she did have pain at the time of her fall. Resident 1's granddaughter stated she now requires 1:1 (continuous observation and support by one qualified staff member to one resident) at all times due to her most recent fall on 7/18/25.During an interview on 8/19/25 at 2 p.m., with the Certified Nursing Assistant (CNA) 1, CNA 1 stated she is currently assigned to Resident 1 as a 1:1. CNA 1 stated she re-started the 1:1 care after Resident 1's return from the hospital on 7/19/25. CNA 1 stated 1:1 assignment consists of having a CNA observe, monitor, assist, and help prevent future incidents that could harm the resident. CNA 1 stated she has worked with Resident 1 multiple times prior to this 1:1 assignment and has noticed a change since her last fall. Resident 1 is not as mobile as she used to be. CNA 1 stated it is her responsibility to remain with the resident at all times, provide activities of daily living (ADL- routine tasks such as bathing, dressing and toileting a person performs daily to care for themselves) care including continent care (support for individuals who have difficulty controlling bladder or bowel functions), transfers to and from bed and chair, feeding assistance, dressing assistance, pretty much all ADL care needs. CNA 1 stated Resident 1 is dependent on staff for care. During an interview on 8/19/25 at 2:30 p.m., with CNA 1, CNA 1 stated Resident 1 has had multiple falls throughout her stay in the facility and Resident 1's interventions included bed in low position, call light within reach, pad and chair alarm, and floor mats on both sides of the bed. CNA 1 stated she does not recall any new or different interventions put in place after each of Resident 1's falls. CNA 1 stated nursing staff should let CNAs know what new interventions are supposed to be implemented. CNA 1 does recall Resident 1 having a 1:1 during the months of April through June of 2025. CNA 1 stated Resident 1most recent falls in July 2025 would not have happened if Resident 1 had 1:1 supervision. CNA 1 stated during the time in the facility when Resident 1 did not have a 1:1 assignment all staff tried their best to keep Resident 1 in view. CNA 1 stated Resident 1 was not always in view of staff and that's when she had her falls. CNA 1 stated the only way to keep Resident 1 safe from falls was to continue 1:1 care. During a review of Resident 1's Minimum Data Set Section GG- Functional Abilities Assessment dated 6/1/25, the MDS indicated, .Resident 1 required Supervision or touching assistance for eating abilities indicating staff would provide verbal cues and/or touching/steadying assistance for resident to complete activity.During an interview on 8/19/25 at 2:51 p.m., with Licensed Vocational Nurse (LVN 1), LVN 1 stated Resident 1 had a total of seven falls, witnessed and unwitnessed, since she was admitted to the facility. LVN 1 stated since Resident 1last fall on 7/18/25 she is no longer as active as she used to be, she used to be ambulatory and ambulating throughout the hallways and now she is either in bed or in her wheelchair. LVN 1 stated Resident 1used to be able to feed herself and now she needs feeding assistance. LVN 1 stated Resident 1 had a change of condition since her last fall. LVN 1 stated the 1:1 assigned CNAs are now required to be with the resident at all times and every shift, 1:1 staff assignment for Resident 1 started on 7/21/25. LVN 1 stated 1:1's are responsible for day-to-day care of the resident and maintaining the safety of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055955 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 055955 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727 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 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. resident, any issues have to be communicated to licensed nursing staff to notify the nurse to address the issue. LVN 1 stated Resident 1 is currently on acetaminophen (a drug used to relieve mild or chronic pain) pain medication routinely for pain management and as needed for breakthrough pain.During an interview with LVN 1 on 8/19/25 at 3:17 pm, LVN 1 stated one of Residents 1's care plan interventions was to keep closer observation of the resident after her fall on 3/5/25. LVN 1 stated she interpreted that to mean having increased eyes on the resident and communicating between staff if one staff was not available for someone else to watch Resident 1. LVN 1 stated, .in reality utilizing an intervention of ‘closer observations' is vague and not really measurable. LVN 1 stated the lack of oversight by nursing staff failed to provide Resident 1 with an adequate safe environment to prevent further accidents and falls. LVN 1 stated she does not recall interventions being re-evaluated or communicated that they were re-evaluated. LVN 1 stated they failed to ensure Resident 1's safety. LVN 1 stated it is the facility's expectation all staff follow the plan of care for the residents.During a concurrent interview and record review on 8/19/25, at 3:53 p.m., with the Director of Nurses (DON), Resident 1's Care Plan (CP), dated 3/1/25, was reviewed. The CP indicated, Resident 1 was .At high risk for falls related to confusion (lack of understanding), deconditioning (the decline in physical function), gait/balance problems (difficulty with walking and maintaining stability), hypotension (low blood pressure), repeated falls, weakness, poor cognitive level (problems with a person's ability to think, learn, remember, make judgments, and make decisions), poor safety awareness (inability or failure to recognize, understand, and act on potential hazards and risks) with contributing factors including Alzheimer's , Dementia, and Anxiety Disorder (mental health condition characterized by excessive and persistent worry, fear, and nervousness). The DON stated the interventions associated with the unwitnessed falls on 3/5/25, 3/11/25, 4/15/25, 5/12/25, 7/16/25 and witnessed falls on 7/5/25 and 7/18/25 included 1:1 observation as needed based on the behaviors and needs of the resident. The DON stated Resident 1's bed was in the lowest position to prevent injury and floor mats were placed on both sides of the bed. The DON stated since the 1:1 was as needed a pressure alarm for Resident 1's bed and wheelchair were implemented. The DON stated Resident 1 was placed in a room near the nurse's station, to respond quickly if Resident 1 set off an alarm and to increase observations from nursing staff passing by. The DON stated the falls documented in the medical record for Resident 1, included the Interdisciplinary Team (IDT-which consists of the DON, Assistant Director of Nurses, and the charge nurse) who meet and review each fall, the potential reason for the fall and the current interventions in place. The DON stated this was done after every fall for Resident 1 to ensure the interventions were sufficient for Resident 1. The DON stated when a resident falls the IDT will evaluate the interventions to see what else can be done to prevent future falls and communicate the interventions or updates to staff to implement. The DON stated interventions for residents would have been initiated by the charge nurse at the time of the fall. The DON stated all interventions should be communicated to staff.During a concurrent interview and record review on 8/19/25 at 4:01 p.m., with the DON, Resident 1's Post Fall Evaluation, dated 3/5/25, was reviewed. The Post Fall Evaluation indicated, Resident 1 had her first unwitnessed fall on 3/5/25 with no injuries while in the bathroom alone. During a concurrent interview and record review on 8/19/25 at 4:07 p.m., with the DON, Resident 1's Post Fall Evaluation, dated 3/11/25, was reviewed. The Post Fall Evaluation indicated, Resident 1 had a second unwitnessed fall, in her room on 3/11/25.During a concurrent interview and record review on 8/19/25 at 4:11 p.m., with the DON, Resident 1's Behavior and Unwitnessed Fall Care plan dated 4/3/25 and 4/17/25, were reviewed. The clinical records indicated on 4/3/25 the facility initiated 1:1 care for Resident 1 due to her increased aggressive behaviors and care planned 1:1 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055955 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 055955 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727 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 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. care for unwitnessed fall on 4/15/25.During a concurrent interview and record review on 8/19/25 at 4:15 p.m., with the DON, Resident 1's Post Fall Evaluation dated 4/15/25, was reviewed. The Post Fall Evaluation indicated, Resident 1 had her third unwitnessed fall on 4/15/25 while in her room. The DON stated, when Resident 1 fell on 4/15/25 Resident 1 should have had a 1:1 staff assigned. The DON stated staff were not present at the time of the fall, the CNA was outside the room and the fall was unwitnessed. The DON stated being assigned 1:1 care included 24-hour supervision and observation by staff seven days a week on each shift. During a concurrent interview and record review on 8/19/25 at 4:23 p.m., with the DON, Resident 1's Post Fall Evaluation dated 5/12/25, was reviewed. The Post Fall Evaluation indicated, Resident 1 had her fourth unwitnessed fall on 5/12/25. The DON stated, the .nurse assumed [Resident 1] slid off her wheelchair. The DON stated the CNA staff failed to follow their job assignment as 1:1 staff. The DON stated it was the expectation for all staff to maintain visual observation of the resident at all times and not to leave the residents alone.During a concurrent interview and record review on 8/19/25 at 4:35 p.m., with the DON, Resident 1's Post Fall Evaluation dated 7/5/25, was reviewed. The Post Fall Evaluation indicated, Resident 1 had a witnessed fifth fall on 7/5/25 from her bed to the floor. The DON stated there were no injuries documented. The DON stated Resident 1's 1:1 care was removed on 6/30/25. The DON stated after the fall on 7/5/25, the IDT determined a 1-hour documentation for observation checks would benefit Resident 1. The DON stated the 1-hour documentation was focused on her behaviors and not just her falls. The DON stated due to cost the facility did not provide 1:1 care for Resident 1. The DON stated the facility had implemented fall interventions, but Resident 1 continued to fall so they were not effective enough. During a concurrent interview and record review on 8/19/25 at 4:45 p.m., with the DON, Resident 1's Post Fall Evaluation dated 7/16/25, was reviewed. The Post Fall Evaluation indicated, Resident 1 had an unwitnessed sixth fall on 7/16/25 while in her room. The DON stated the new interventions after her sixth fall included pharmacist review of Resident 1's medications. The DON stated the facility did not place Resident 1 on 1:1 supervision after fall number six. During a concurrent interview and record review on 8/19/25 at 4:55 p.m., with the DON, Resident 1's Post Fall Evaluation dated 7/18/25, was reviewed. The Post Fall Evaluation indicated, on 7/18/25 Resident 1 had a seventh fall. The DON stated Resident 1's record indicated staff heard Resident 1's bed alarm and did not get to Resident 1 in time before she fell to the floor. The DON stated a full body assessment was conducted with no signs of injury, pain or discomfort present. The DON stated if Resident 1's 1:1 care had been re-initiated after the fifth fall on 7/5/25, potentially the resident would not have had the sixth and seventh fall and potentially preventing her injury. During a concurrent interview and record review on 8/19/25 at 5:05 p.m., with the DON, Resident 1's Progress Notes dated 7/19/25 at 6:24 p.m., was reviewed. The Progress Notes indicated, Resident 1 was found with discoloration on her left shoulder during resident care. The DON stated the CNA reported to the charge nurse who completed a full body assessment and documented, that Resident 1 had an area that appeared purplish, tender and painful to touch to left shoulder. Resident 1 was given pain medication, and the primary physician was notified. The DON stated she did not know if the fall on 7/16/25 or 7/18/25 caused Resident 1's bruise. The DON stated documentation indicated new telephone orders were obtained for an in-house x-ray. The DON stated Resident 1's results confirmed a left clavicle fracture. Resident 1's primary physician was notified and provided orders to send the resident out to the general acute care hospital (GACH). Resident 1 was transported on 7/20/25 to the GACH where she was diagnosed with a nondisplaced fracture involving clavicle head of the left shoulder with bruising, limited range of motion due to pain and tenderness to touch. The DON stated Resident 1 returned back to facility on the same day with orders (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055955 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 055955 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727 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 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. for left shoulder sling and follow up with orthopedist (a medical doctor who specializes in the musculoskeletal system including bones, joints, ligaments, tendons, and muscles and treats injuries). During a review of Resident 1's Emergency Department (ED) Provider Note, dated 7/20/25, the ED Provider Note indicated, .[Resident 1] arrived via ambulance with complaint of left shoulder pain and bruising post fall days prior. limited range of motion left shoulder secondary to pain. Tenderness to touch.X-Ray (picture through the body to see bones) of the left shoulder. nondisplaced fracture involving the left clavicle head.recommended left shoulder/arm sling and follow up with Orthopedic in 1-2 week.During an interview with the DON on 8/19/25, at 5:15 p.m., the DON stated at the time of the seventh fall on 7/18/25, the interventions in place failed to maintain the safety of the resident and the facility's lack of action to place Resident 1 back on 1:1 care after the fifth fall on 7/5/25 could have prevented Resident 1's fracture. The DON stated 1:1 care was effective for Resident 1 from 5/13/25 to 6/30/25 because she did not fall during that time, but financially it is difficult to maintain residents on 1:1. During a review of the facility's document titled, Job Description: Licensed Vocational Nurse (LVN), undated, the Job Description for LVN's indicated, . Performing nursing care using sound judgment. Implements physician's orders in a safe and accurate manner.Performs assessment on all changes of conditions and develops appropriate care plans. maintains a safe and clean environment for residents.monitors certified Nursing assistants (CNA's) for proper care, timeliness and quality of care. During a review of the facility's document titled, Job Description: Registered Nurse (RN), undated, the Job Description for RN's indicated, . Performing nursing care using sound judgment. Implements physician's orders in a safe and accurate manner.Performs assessment on all changes of conditions and develops appropriate care plans. Maintains a safe and clean environment for residents.monitors certified Nursing assistants (CNA's) for proper care, timeliness and quality of care. During a review of the facility's document titled, Job Description: Director of Nursing Services (DON), undated, the Job Description for DON indicated, . Essential Functions:. Plans and facilitates meetings and committees to address resident care issues. Manages the Nursing Department with goal of achieving and maintaining the highest quality of care possible.Develops and manages systems to assure clinical competencies.investigate and resolves resident/family/employee concerns.Plans and develops the professional development of nursing staff. Assures that all clinical protocols and nursing policies and procedures are followed. During a review of the facility's policy and procedure (P&P) titled, Care Planning-Interdisciplinary Team, dated March 2022, the P&P indicated, . The interdisciplinary team is responsible for the development of resident care plans. Comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT).physician.registered nurse.nursing assistant.food and nutrition services staff.resident or representative.other staff as appropriate or necessary to meet the needs of the resident.are encouraged to participate in the development of and the revisions of the residents care plan.During a review of the facility's P&P titled, Care Plans, Comprehensive Person-Centered, dated March 2022, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The interdisciplinary team (IDT), in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-centered care plan for each resident. The comprehensive, person-centered care plan: a. includes measurable objectives and timeframes; b. describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including.Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 055955 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 055955 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE California Home for the Aged 6720 E. Kings Canyon Fresno, CA 93727 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 0689 Level of Harm - Actual harm Residents Affected - Few Note: The nursing home is disputing this citation. FORM CMS-2567 (02/99) Previous Versions Obsolete between the resident's problem areas and their causes, and relevant clinical decision making. The interdisciplinary team reviews and updates the care plan: a. when there has been a significant change in the resident's condition; b. when the desired outcome is not met.During a review of the facility's P&P titled, Falls-Clinical Protocol, dated March 2018, the P&P indicated, .Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling.If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions.The staff and physician will monitor and document the individual's response to interventions intended to reduce falling or the consequences of falling.During a review of the facility's P&P titled, Fall Risk Assessment, dated March 2018, the P&P indicated, .The nursing staff, in conjunction with the attending physician, consultant pharmacist, therapy staff and others, will seek to identify and document resident risk factors for falls and establish a resident-centered falls prevention plan based on relevant assessment information. The staff and attending physician will collaborate to identify and address modifiable fall risk factors and interventions to try to minimize the consequences of risk factors that are not modifiable.During a review of the facility's P&P titled, Fall and Fall Risk , Managing dated March 2018, the P&P indicated, .Staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling. Managing Falls and Fall Risk. Staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls. If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. Staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions.The attending physician will help the staff reconsider possible causes that may not previously have been identified.During a review of the facility's P&P titled, Assessing Falls and Their Causes dated March 2018, the P&P indicated, .Provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall. Performing a Post Fall-Fall Evaluation. The IDT will conduct a root cause analysis and initiate interventions accordingly. When a resident fall. Information should be recorded in the resident's medical record regarding incident. Appropriate interventions taken to prevent falls. Event ID: Facility ID: 055955 If continuation sheet Page 6 of 6