Health inspection·August 12, 2025

F 0689 Level of Harm - Actual harm Residents Affected - Few the restroom, and she would ask to go again within minutes of urinating.During an interview on 8/12/25 at 10:27 a.m. with CNA 2, CNA 2 stated she took care of Resident 1 while she was in the facility. CNA 2 stated she would want to toilet all the time. We would take her to the bathroom often, then she would want to go again right away. CNA 2 stated even though staff frequently took Resident 1 to the bathroom, she would try to get up unassisted because she felt like she needed to go again, which increased her fall risk. During a concurrent interview and record review on 8/12/25 at 10:51 a.m., with Licensed Vocational Nurse (LVN) 1, LVN 1 stated she was working when Resident 1 fell on 7/16/25. LVN 1 stated on 7/16/25 around 6:55 a.m., she had just arrived at the facility for her shift and saw Resident 1 in bed. LVN 1 stated she had walked to the nurse's station for report from the night shift and a CNA told her Resident 1 was on the floor. LVN 1 stated she assessed Resident 1 for injuries and Resident 1 complained of pain to her right leg from the back of her knee to her hip. LVN 1 stated Resident 1 appeared to be in pain, so she administered her pain medication . LVN 1 stated Resident 1 was able to move but complained of pain. LVN 1 stated Resident 1 was unable to bear weight on her right leg, so she called hospice and notified them Resident 1 had fallen. LVN 1 stated the hospice nurse came in around 7:30 a.m. for a routine visit and she asked the hospice nurse for an order to X-ray (a painless test that captures images of the structures inside the body) Resident 1's hip but was told to just keep the resident comfortable. LVN 1 stated she was informed by the hospice nurse that because hospice was for end-of-life care, they did not routinely perform X-rays on patients. LVN 1 stated Resident 1's pain continued to worsen, and she had facial grimacing [facial expression that show pain], so they requested an X-ray order from hospice a second time and received an order. Resident 1's X-ray report titled Right Hip, Unilateral [one side] W/ [with] Pelvis, dated 7/16/25 was reviewed, it indicated, . Acute intertrochanteric fracture with impaction [broken ends of a bone are driven into each other] and varus angulation [deviation of the bone towards midline of the body] . Soft tissue swelling [abnormal buildup of fluid] around the right hip. LVN 1 stated the Director of Nursing (DON) had contacted Resident 1's responsible party and they did not want the resident sent to the hospital and requested the resident be kept comfortable at the facility. LVN 1 stated Resident 1 had increased pain, and her morphine sulfate (a powerful pain medication) was changed from as needed to routine for pain control. LVN 1 stated Resident 1 had fallen before the 7/16/25 fall, twice on 5/19/25 and once on 6/16/25. Resident 1's care plan dated 7/16/25 indicated, . at risk for fall related to actual fall on 7/16/2025 . 72-hour alert monitoring . X-ray . Communicated X-ray findings to MD [physician]/hospice/IDT [interdisciplinary team-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident] . Manage resident fall risk through facility red sneaker program . LVN 1 stated the Red Sneaker Program was the facility's fall prevention program and was used for all residents with high fall risk and was not specific to Resident 1. LVN 1 stated Resident 1 needed increased supervision because she had behaviors of getting up to transfer without assistance because she felt like she needed to use the restroom frequently. LVN 1 stated Resident 1 had the urge to urinate frequently causing her to try and transfer herself. LVN was unable to find interventions that addressed urinary frequency and attempts to self-transfer . Resident 1's Fall Risk Assessment, dated 7/3/25, was reviewed. The assessment indicated, . High Risk for Falls . LVN 1 stated Resident 1 fell because she did not have enough supervision and would have required one on one (direct, individualized supervision) to prevent her from falling. During a review of the facility's Red Sneaker Program, the program indicated, . Criteria for Inclusion in the Red Sneaker Program. Resident had had a fall in the last 90 days . has a Fall Risk Assessment Score of above 10 . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 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 056281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few Care Plan Implementation . Anticipate toileting needs of High Risk for Fall Residents . Focus on residents who are High Risk for Falls that may be attempting to ambulate independently . DON and IDT will make sure appropriate individualized CPs [care plans] and interventions are in place .During a concurrent interview and record review on 8/12/25 at 11:33 a.m. with the Minimum Data Set Coordinator (MDSC), Resident 1's MDS Section GG [functional status], dated 7/3/25 was reviewed and indicated, . sit to stand [code 02-substantial/maximal assistance- helper does more than half the effort] . Chair/bed-to-chair transfer [code 02] . Toilet transfer [code 02] . The MDSC stated Resident 1's MDS indicated the resident required the assistance of two people to safely transfer between the bed and chair and the chair to toilet. Resident 1's fall risk care plan dated 3/25/25, was reviewed. The care plan indicated, . functioning deficit related to: Mobility impairment, ROM [range of motion] limitations r/t fracture to right superior/inferior pubis ramus . Interventions . Bed mobility assistance . Call bell within reach . Toileting Assistance . Transfer Assistance . Resident 1's fall care plan dated 5/19/25, was reviewed and it indicated, . At risk for delayed trauma r/t actual fall on 5/19/25 at 12:30 PM 1st and 2nd fall at 5:03 PM . 72 hour alert monitoring . Floor mat next to bed . evaluation of the resident's condition . activity programs . low electric bed . Manage resident fall risk through facility Red Sneaker Program . Resident 1's fall care plan dated 6/17/25 was reviewed and it indicated, . At risk for delayed injury r/t actual fall on 6/16/25 . Assist with toileting q [every] 2 hrs [hours], at bed time and as needed . floor mats to side of bed . level 2 [every 15 minute checks] monitoring x 72 hours . Notify hospice . Encourage activities . Resident 1's fall risk care plan dated 7/16/25, indicated, . At risk for unavoidable falls and related injury . Rt. [right] Hip fracture R/T [related to] Osteoporosis/Diffuse Osteopenia . Resident is on Hospice care . Bed in low position . Fall Mat. Turn and reposition Q [every] 2 hours . The MDSC stated the care plan interventions were not personalized to Resident 1's needs. The MDSC stated rounding on residents and offering to toilet the residents every two hours was standard care and did not specifically address Resident 1's frequent urination or attempts to self-transfer.During a concurrent interview and record review on 8/1/25 at 11:55 a.m. with the DON, the DON stated Resident 1 was at high risk for falls and was admitted with fractures from falling prior to admission. The DON stated Resident 1 was not compliant with care and would try to transfer herself because she felt like she needed to use the restroom frequently. The DON stated Resident 1 was anxious, had behaviors of repeatedly requesting to use the restroom and attempting to self-transfer without assistance because she had urinary urgency, increasing her fall risk. The DON stated the CNAs would take Resident 1 to the bathroom and five minutes later she would get restless and want to go again. The DON stated Resident 1 had been seen by a psychologist (a professional who studies mental processes and behavior) to address the behavior of anxiety causing repeated requests to use the toilet. The DON reviewed Resident 1's electronic medical record and stated Resident 1 did not have a urinalysis (U/A-laboratory test that examines a person's urine to detect and assess various health conditions) to rule out a possible infection as a cause for her urinary urgency. The DON stated a U/A was not tested because Resident 1 was on hospice. The DON reviewed Resident 1's fall care plans and stated the resident sustained four falls while at the facility. The DON was unable to find interventions indicating how the plan of care addressed Resident 1's urinary urgency and frequency and her attempts to self-transfer. Resident 1's General Note, dated 6/17/25, was reviewed. The note indicated, . LATE ENTRY . Writer was notified by staff that resident was sitting on the floor . Resident stated I slid from bed and fell. I wanna go to the bathroom, I need to pee . Resident 1's SBAR [situation, background, assessment, recommendation-a communication tool used by healthcare workers when there is a change of condition among the residents] Post Fall, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 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 056281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few dated 6/16/25 at 11:30 p.m., indicated, . Resident fell in Resident room. Unwitnessed fall . The DON stated the root cause of Resident 1's 6/16/25 fall was the resident's attempt to transfer unassisted because she needed to go to the bathroom. The DON was unable to state if any new, personalized interventions were put into place after the fall on 6/16/25. Resident 1's SBAR Post Fall, dated 7/16/25 at 3:46 p.m. was reviewed and indicated, . Prior to fall resident was Attempt to self transfer . Resident fell in Resident room . Injury . Unwitnessed fall . Fall details: Other Unable to describe . from 7/16/25 was reviewed and indicated, . The DON stated Resident 1's fall was unwitnessed. The DON stated a new intervention was put into place after the fall and Resident 1 was moved into a different room with a CNA assigned in the room for the day and evening shifts. During a review of Resident 1's Psychologist Consultation, dated 6/23/25, . Treatment & compliance . demanding . Affect . Anxious . anxious [with] frequent requests to use restroom .During a review of Resident 1's Post Fall IDT Analysis, Dated 6/19/25, the note indicated, . Fall Date and Time . 6/16/25 . LN was notified by staff that resident was sitting on the floor. LN went to res. room assessed resident, noted this res sitting on the floor leaning her back against the bed .During a review of Resident 1's Psychologist Consultation, dated 7/15/25, . Treatment & compliance . repetitive requests . Affect . Anxious . anxious, forgetful, has frequent requests to use toilet is otherwise cooperative with care & Tx [treatment].During a review of Resident 1's Post Fall IDT Analysis, dated 7/16/25, the IDT note indicated, . Fall Date and Time . 7/16/25 at 06:15 [a.m.] . Immediate interventions post fall . Placed on level 2 monitoring. Hospice Nurse Came New orders for pain meds [medication]. Xray Rt. [right] Leg and Rt. Hip . C/O [complains of] pains Room Change offered for close supervision . At 06:15 AM staff found resident sitting on the floor mat. At 06:05 AM CNA made rounds & res. [resident] was on her bed with her call light within reach. LVN saw res. 10-15 minutes prior to fall. Root cause: Resident was restless and attempted to move from and in her bed and landed on her floor mat .During a review of Resident 1's pain care plan dated 7/16/25, the care plan indicated, . Acute Pain Fracture-Right hip fx [fracture] . Administer Morphine routinely as ordered . Observe for loss of appetite . Utilize non-medication interventions for pain relief . Utilize positioning and relaxation techniques for comfort .During a review of Resident 1's mobility care plan dated 7/16/25, the care plan indicated, . Impaired physical mobility related to acute intertrochanteric fracture of the right hip . Assess for pain regularly . Ensure fracture precautions are communicated . Inspect fracture site for swelling, discoloration or increased tenderness . Maintain toileting schedule .During a review of Resident 1's Order Summary Report [OSR], dated 7/2025, the OSR indicated, . Monitor episode of Anxiety m/b [manifested by] repetitive request to use the restroom despite recently being assisted [Ordered 7/17/25] . Morphine Sulfate (Concentrate) Oral Solution 20 MG/ML (Morphine Sulfate) Give 0.25 ml by mouth every 4 hours as needed for Pain [ordered 3/25/25] . Morphine Sulfate 20 mg/ml . Give 0.25 ml by mouth three times a day for Pain [ordered routinely on 7/17/25] . oxybutynin Chloride Oral Tablet [a medication to treat overactive bladder symptoms include frequency, urgency (sudden, compelling need to urinate), and incontinence (involuntary leakage of urine)] . give 1 tablet by mouth two times a day for overactive bladder for 1 Week over active bladder [ordered 7/17/25] . During a review of the facility's policy and procedure (P&P) titled, Safety and Supervision of Residents, undated, the P&P indicated, . Our facility strives to make the environment as free from accident hazards as possible . Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents . The care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices . Implementing interventions to reduce accident risks . Ensuring that interventions are implemented . Resident supervision (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 056281 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 056281 B. Wing A. Building (X3) DATE SURVEY COMPLETED 08/12/2025 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 0689 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is a core component of the systems approach to safety. The type and frequency of resident supervision is determined by the individual resident's assessed needs .During a review of the facility's P&P titled Falls-Clinical Protocol, dated 9/2012, indicated, . As part of the initial assessment, the physician will help identify individuals with a history of falls and risk factors for subsequent falling . many falls are isolated individual incidents, a significant proportion occur among a few residents . individuals may have a treatable medical disorder or functional disturbances as the underlying cause . After more than one fall, the physician should review the resident's gait, balance, and current medications . staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found. Based on the preceding assessment, the staff and physician will identify pertinent interventions or try to prevent subsequent falls and to address risks of serious consequences of falling . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions based on assessment . until falling reduces or stops or until a reason is identified . (for example, if the individual continues to try to get up and walk without waiting for assistance) . The staff . will follow up on any fall with associated injury until the resident is stable . Frail elderly individuals are often at greater risk for serious adverse consequences of falls . If interventions have been successful in preventing falling, the staff will continue with current approaches or reconsider whether these measures are still needed . If the individual continues to fall, the staff and physician will re-evaluate the situation and consider other possible reasons for the resident's falling . Event ID: Facility ID: 056281 If continuation sheet Page 5 of 5