Health inspection·December 5, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few a progress note about the incident on 11/22/24. LVN 1 stated the facility ' s process for resident appointments was to call the doctor ' s office within two hours to see if the resident ' s appointment was finished and verify transportation back to the facility. During an interview on 12/5/24 at 4:17 p.m. with the scheduler (SCH), the SCH stated on 11/22/24 Resident 1 had a doctor ' s appointment and she had walked with the resident out to the transportation car between 9:30-10:00 a.m. The SCH stated the doctor ' s office called around 12:30 p.m. and notified the SNF Resident 1 was ready to be picked up from his appointment. The SCH stated she forwarded the phone call to the Social Services Director (SSD), and he provided the office with a phone number to call for transportation. During an interview on 12/5/24 at 4:25 p.m. with the SSD, the SSD stated Resident 1 was transported to a doctor ' s office for an appointment in the morning on 11/22/24. The SSD stated transportation to the doctor ' s office had been set up by Resident 1 ' s insurance company. The SSD stated the SCH had given him a phone call from the doctor ' s office in the early afternoon notifying him the resident was finished and ready to be transported back to the SNF. The SSD stated he gave the doctor ' s office the phone number to call for transportation. The SSD stated he had left work at 3:00 p.m. and was unaware Resident 1 had not returned from the doctor ' s office. The SSD stated he did not follow up with the doctor ' s office or Resident 1 to verify the transportation had been taken care of. During a concurrent interview and record review on 12/5/24 at 4:56 p.m. with LVN 2, LVN 2 stated she had started work at 4:00 p.m. on 11/22/24. LVN 2 stated after she had arrived, a Certified Nursing Assistant notified her Resident 1 had not returned from his morning doctor ' s appointment. LVN 2 stated the facility received a phone call after 4:30 p.m. from the doctor ' s office to notify the SNF they were closing soon, and Resident 1 was still waiting at the office. LVN 2 stated she and another nurse left at 5:30 p.m. to pick Resident 1 up from the doctor ' s office. LVN 2 stated when they picked the resident up, he was hungry, so they took him to get some food on their way back to the SNF. LVN 2 stated the incident placed Resident 1 at risk for emotional distress, hunger, and dehydration. LVN 2 stated Resident 1 did not have a jacket with him, and it was cold outside when they picked him up. LVN 2 stated she was not sure why he was left for several hours at the doctor ' s office. During an interview on 12/5/24 at 5:09 p.m. with the Director of Nursing (DON) the DON stated the incident was caused by transportation. The DON denied the facility had any responsibility in making sure the resident returned to the SNF timely. The DON stated, we are ultimately responsible for making sure the resident had something to eat and drink. During a review of Resident 1 ' s General Note, dated 11/22/24 at 12:46 p.m., the note indicated, . At approx. [approximately] 0953 [9:53 a.m.], resident was picked up [name of rideshare service] to be taken to doctor ' s appointment . Resident noted to be alert and oriented and left ambulating [walking] using his walker . During a review of Resident 1 ' s General Note, dated 11/22/24 at 6:22 p.m., the note indicated, . This writer and Receptionist [from SNF] were contacted at 12:50 pm from [name of doctor ' s clinic] and reported that he was done with his appointment . informed the receptionist [at doctor ' s office] . they will need to call [name of insurance transport] to arrange the pickup . informed at 4:45 pm by the Nursing Manager [transport] did not arrive and pick up resident . During a review of the facility ' s document titled Investigation Summary Report for CA00932536, dated 11/22/24, the document indicated, . contacted at 12:50 p.m. from [name of physician ' s clinic] (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 If continuation sheet Page 2 of 3 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 056281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/05/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Countryside Care Center 925 North Cornelia Fresno, CA 93706 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 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few . he was done with his appointment . informed the receptionist . they will need to call [name of insurance] Transport to arrange the pickup . informed at 4:45 pm . [name of insurance] Transport did not arrive and pick up resident . transportation provider that the resident is not a member . Received another call from [name of doctor ' s clinic] representative and stated clinic is closing soon, and resident had been waiting in lobby and had not eaten since lunch . Resident was pick[ed] up at exactly 1733 [5:33 p.m.] . resident returned to facility @ around 1805 [6:05 p.m.] . During a review of the Resident 1 ' s IDT [interdisciplinary team-group of people with different areas of expertise who work together to achieve a common goal] Note, dated 11/22/24 at 9:17 p.m., the note indicated, . Delayed Pick up from [name of doctor ' s clinic] MD [doctor] Appointment . Date and Time . 11/22/24 appointment was at 10:15 AM . IDT meeting was conducted related to delayed pick up . Facility RN & LVN went to pick up resident via private transport . During a review of the facility ' s policy and procedure (P&P) titled Medical and Dental Services Appointments, undated, the P&P indicated, . Routine and emergency medical and dental services are available to meet the resident ' s health services . Social services representatives will assist residents with appointments, transportation arrangements . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 If continuation sheet Page 3 of 3