Other·January 10, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public HealthLicensing and Certification during an abbreviated survey for complaint CA 00552396. Representing the California Department of Public Health: 36476 RN, HFEN. The abbreviated survey was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint CA 00552396. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 1 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: NY3511 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA030000026 (X5) COMPLETE DATE If continuation sheet 2 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG

F309 PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.24, 483.25(k)(l)

F309 SS=G PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 01/12/2018 483.24 Quality of life Quality of life is a fundamental principle that applies to all care and services provided to facility residents. Each resident must receive and the facility must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident’s comprehensive assessment and plan of care. 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive personcentered care plan, and the residents’ choices, including but not limited to the following: (k) Pain Management. The facility must ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. (l) Dialysis. The facility must ensure that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 3 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents’ goals and preferences. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure one of three sampled residents, Resident 1, received necessary dialysis (treatment for kidney failure using an artificial kidney to filter wastes, salts and fluids from the blood) services in accordance with professional standards of practice, based upon a comprehensive assessment, and as indicated in the resident's care plan when: 1. Necessary assessments of Resident 1's condition were not completed as required by the facility policies. 2. Resident 1 did not receive dialysis treatments as indicated in the care plan. 3. Resident 1's physician was not notified of the missed dialysis treatments. These failures resulted in missed dialysis treatments for Resident 1, worsening of Resident 1's medical condition, and transfer to the general acute care hospital (GACH) for emergent (needed immediately) dialysis and inpatient treatment. Findings: 1. Review of Resident 1's clinical record titled, "Admission Record" (document containing resident personal information) indicated Resident 1 was 53 years old and was readmitted to the skilled nursing facility (SNF) on 8/23/17 with diagnoses that included acute pulmonary edema (excess fluid in the lungs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 4 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE which may interfere with ability to breathe), atherosclerosis (build-up of plaque in the arteries), acquired absence of right upper limb below the elbow (surgical removal of the limb), congestive heart failure (heart failure causing build-up of fluid in the lungs and surrounding body tissues), cardiac pacemaker (small device placed in the chest to control abnormal heart beats), primary pulmonary hypertension ( high blood pressure in the arteries of the lungs resulting in heart failure), end stage renal disease (ESRD, kidney failure requiring treatment with an artificial kidney or kidney transplant in order to maintain life). Review of Resident 1's "Online Referral" transfer form from the GACH to the SNF dated 8/21/17, indicated, "Nephrology [kidney disease specialist] Progress Note: Assessment: ESRD due to malignant hypertension [very high and difficult to control blood pressure] on maintenance [regularly scheduled treatments] hemodialysis [a machine filters wastes, salts, and fluids from the blood through an artificial kidney in order to maintain life when the kidneys no longer work]." Review of Resident 1's clinical record titled, "Progress Notes" dated 8/23/17 indicated, "PT [patient] admitted to facility alert and oriented X [times] 3 [knows who he is, where he is and what date it is] at 1600 [4 p.m.] via [by way of] ambulance gurney, transferred from [GACH], no c/o [complaints of] pain, no respiratory distress [no difficulty breathing], pt. placed on 2 L (liters, a measurement of volume] of O 2 [oxygen], sutures [stitches] clean and dry and intact to right wrist amputation [surgical removal], no drainage noted. AV [arteriovenous] fistula [an artery and a vein are surgically connected to create a large blood vessel which can deliver a high flow of blood] to left arm, bruit [whooshing sound made as the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 5 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE blood flows through the fistula] and thrill [buzzing felt over the fistula indicating that the fistula is working] present, no drainage noted. PT is own RP [responsible party], consent to treat and POLST [document indicating resident wishes for end of life care] signed by pt. list of medications faxed to pharmacy and [Medical Director, MDR] and [MDR] made aware of admission, noted orders for PT [physical therapy], OT [occupational therapy] ST [speech therapy] RD [registered dietician], Pt educated about room and call light placed within reach." The progress note was electronically signed by Licensed Nurse (LN) 12. Review of Resident 1's care plan dated 8/23/17 indicated, "Focus, The resident needs hemodialysis. The resident will have immediate intervention should any s/sx [signs or symptoms] of complications from dialysis occur through the review date. Interventions/Tasks, AV fistula to left arm, Check and change dressing daily at access site. Document. Monitor intake and output. Monitor labs and report to doctor as needed. Pt uses [name and address of dialysis clinic] tues [Tuesday], thurs [Thursday], sat [Saturday] at 7:30 a.m. chair time [time scheduled to be at the clinic and ready for dialysis]. [Name, address and phone number of transportation company] will pick up. Date initiated: 8/23/17." On 12/5/17 during an interview, the Director of Nursing (DON) stated LN 9 was the nurse assigned to Resident 1 during the day shift on 8/24/17, 8/25/17 and 8/26/17. On 12/5/17 at 10:15 a.m. a telephone call was placed to LN 9 to clarify the manner in which he had assessed Resident 1 during his stay between 8/24/17 and 8/26/17. The call was not answered and the request for a return call was not honored. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 6 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 12/5/17 at 11:16 a.m., during an interview, LN 12 stated she was the nurse that admitted Resident 1 to the SNF on 8/23/17. LN 12 stated, "When the resident is admitted I do a quick assessment. Social Services makes the arrangements for dialysis. I don't remember arranging anything about his dialysis, I just passed on [to the on-coming shift] what I assessed and what I know about the patient's orders." LN 12 stated she had not contacted anyone regarding Resident 1's scheduled dialysis times or days. On 12/5/17 at 11:38 a.m., during an interview and concurrent record review, the DON stated the expectation was the admitting nurse would do a complete head to toe assessment on the admission or re-admission of a resident. The DON stated for a dialysis resident the assessment should include the "Admission Assessment" packet, a head to toe assessment, status of the dialysis AV fistula, lung sounds and presence of edema (build-up of fluid in the body). The DON stated the nurse assigned to the resident should know what care the resident required. The DON reviewed Resident 1's "Admission Assessment" dated 8/23/17. The DON stated the assessment was incomplete; it did not include the "Admit/Readmit Screener," a document that included a head to toe assessment, special equipment required, language spoken and other resident specific information. The DON reviewed the "Progress Notes" dated from 8/23/17 through 8/26/17. The DON stated the Progress Notes were not complete. The DON stated the nurse assigned to Resident 1 should have done a complete head to toe assessment at the beginning of each shift and documented the assessment in the progress notes and that had not been done. The DON stated after the initial admission entry on 8/23/17 there was no FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 7 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE further assessment of Resident 1's dialysis status, AV fistula, presence of edema or lung sounds documented in Resident 1's record. Review of facility document titled, "Licensed Practical/Vocational Nurse Job Description" dated revised 5/20/16, indicated, "Duties and Responsibilities. 1. Responsibilities to the Patient. A. Participates in an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient through interview, observation and physical examination...H. Provides nursing care to meet patient needs: a. Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools..." Review of facility document titled, "Registered Nurse (SNF) Job Description" dated revised 5/12/16, indicated, "Duties and Responsibilities. 1. Responsibilities to the Patient. A. Participates in an on-going systematic assessment of the physical, emotional, social, educational, and functional needs of the patient through interview, observation and physical examination. 1. Receives admissions and/or transfers to the unit. 2. Completes nursing admission notes within 24 hours...J. Provides nursing care to meet patient needs: a. Performs a complete head-to-toe assessment of each assigned patient per shift using proper documentation tools..." Review of facility document titled, "Care of the Dialysis Resident" dated 8/1/15, indicated, "1. Check shunt [dialysis access such as AV fistula] for bruit every 4 hours for the first 24 hours post dialysis...and then once per shift." 2. Review of Resident 1's care plan dated 8/23/17 indicated, "Focus, The resident needs FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 8 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE hemodialysis. The resident will have immediate intervention should any s/sx of complications from dialysis occur through the review date. Interventions/Tasks, AV fistula to left arm, Check and change dressing daily at access site. Document. Monitor intake and output. Monitor labs and report to doctor as needed. Pt uses [name and address of dialysis clinic] tues [Tuesday], thurs [Thursday], sat [Saturday] at 7:30 a.m. chair time [time scheduled to be at the clinic and ready for dialysis]. [Name, address and phone number of transportation company] will pick up. Date initiated: 8/23/17." Review of Resident 1's Interdisciplinary Team ( IDT, a team of healthcare providers including nurses, social services staff, dietary staff, activities staff and physicians) Note dated 8/24/17 at 8:47 a.m., indicated, "1. Pertinent Diagnosis, Acute pulmonary edema, coronary artery bypass [surgery to bypass an obstructed heart artery], ESRD. 2. Problem ... Hemodialysis with AV shunt [fistula] to left arm. 2A. IDT recommendations, Continue orders per MD [physician]. HD [hemodialysis] on scheduled days. C. IDT attendees: C1. Attendees: DON, MDS [Minimum Data Set, a resident assessment tool used to plan resident care] nurse, DSD [Director of Staff Development], SSD [Social Services Director], DSM [Dietary Services Manager]. The IDT note was electronically signed by the DON. Review of Resident 1's clinical record titled, Progress Note" dated, "Late entry, Effective Date 8/25/17 at 8:40 a.m." indicated, "Resident [Resident 1] arrived to the facility late in the evening on the 23rd [Wednesday, August 23, 2017]. When social services arrived to the facility on the 24 [Thursday August 24, 2017], social services was informed that resident had dialysis on Thursday and was supposed to be there at 7:15 a.m. Social services called FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 9 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dialysis center to see if they could accept the resident. The dialysis center could accept the resident at 3:15 p.m. that day...Social services called the dialysis center and informed them that we could not find transportation for this resident at 3:15. So the dialysis center was able to have the resident come in on Friday the 25 at 11:30...On Friday the 25 [transportation company] called the facility at 10:30 and stated they would not be able to pick the resident up and canceled the transportation...Social services called the dialysis center and informed them that we couldn't find any last minute transportation...[transportation company] said that they could transport the resident to and from dialysis starting on Saturday the 26...They would be here at 7 a.m. to pick resident up and transport him to dialysis on Saturday the 26..." The Progress Note was electronically signed by the SSD. On 9/13/17 at 12:31 p.m., during an interview, the SSD stated she had attempted to schedule Resident 1's dialysis (hemodialysis) treatments on 8/24/17, 8/25/17 and 8/26/17 but had difficulties with obtaining transportation to the dialysis unit. The SSD stated she was unable to find a company who could provide transportation on 8/24/17 and the company scheduled for 8/25/17 called that morning and canceled their transportation appointment. The SSD stated on 8/26/17 a transportation company arrived to take Resident 1 to dialysis but was informed by a nurse that he required transportation by gurney, which they were unable to provide, and they left the SNF. The SSD stated Resident 1 did not receive his dialysis treatment on 8/24/17, 8/25/17 or 8/26/17. On 9/13/17 at 1:57 p.m., during an interview, LN 7 stated it was very important to for residents to receive dialysis treatments as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 10 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE scheduled. LN 7 stated, "If there is a problem getting the resident dialyzed for whatever reason, I report that to my DON and call the medical doctor to see if he wants the resident to go to acute care [GACH]." On 9/13/17 at 2:48 p.m., during a telephone interview, LN 2 stated she had worked at the SNF during Resident 1's stay at the facility. LN 2 stated, "Dialysis is extremely important. The resident can't afford to miss any [treatments]; especially [Resident 1]. He was already compromised medically." On 9/13/17 at 3:30 p.m., during an interview, LN 1 stated, "As a licensed staff, for the dialysis patients, I make sure there is an appointment [dialysis appointment] made. I make sure there's transportation. The SSD arranges the transportation. All LNs can call for transportation arrangements. Our corporation has our own transportation...Resident dialysis is extremely important and can't be missed...it's detrimental." On 9/26/17 at 2:19 p.m. during an interview, the SSD stated she informed Resident 1's nurse, LN 9, on 8/24/17 that Resident 1 missed his dialysis treatment due to the unavailability of transportation. The SSD stated she informed LN 9 again on 8/25/17 that Resident 1 missed his dialysis treatment on that day due to transportation problems. The SSD stated she did not document that she informed LN 9 regarding the missed dialysis treatments. On 10/9/17 at 9:01 a.m., during a telephone interview, LN 9 stated, "When it comes to dialysis, we go to the SSD; she has the information. I don't remember [the SSD] telling me that [Resident 1]'s dialysis appointment had any problems. If that was relayed to me I could have done something to help...I remember FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 11 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sending [Resident 1] on 8/26/17 [to the GACH] for abdominal pain and I came to find out he had not had his dialysis for a few days. The Resident told me. [Resident 1] told me [on 8/26/17] that he had not had his dialysis in 3 days. On 9/13/17 at 4:50 p.m., during an interview, the DON stated, "I expect the licensed nurses to know that dialysis is very important. If there was no transportation arrangement that can be arranged then that should have been reported to the doctor so an order to be sent to ER [emergency room] could have been gotten. If I was here I would have sent him [Resident 1] to the ER to be dialyzed." On 12/5/17 at 12:41 p.m., during an interview, the SSD stated, "[LN 9] came to me at least a couple of times to ask if arrangement was done for [Resident 1's] transportation. I know the nurse [LN 9] was aware. The DON knew that I couldn't get any transportation on that first day, 8/24/17. All of the nursing staff knew about the missed dialysis on 8/24 because we talked about it at our 9 am morning report." 3. Review of Resident 1's care plan dated 8/23/17 indicated, "Focus, The resident needs hemodialysis. The resident will have immediate intervention should any s/sx of complications from dialysis occur...Date initiated: 8/23/17." Review of Resident 1's IDT Note dated 8/24/17 at 8:47 a.m., indicated, "...2. Problem ... Hemodialysis with AV shunt to left arm. 2A. IDT recommendations, Continue orders per MD [physician]. HD [hemodialysis] on scheduled days. C. IDT attendees: C1. Attendees: DON, MDS nurse, DSD, SSD, DSM. The IDT note was electronically signed by the DON. On 9/13/17 at 12:31 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 12 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the Social Services Director (SSD) stated she had attempted to schedule Resident 1's dialysis (hemodialysis) treatments on 8/24/17, 8/25/17 and 8/26/17 but had difficulties with obtaining transportation to the dialysis unit for Resident 1. The SSD stated she was unable to find a company who could provide transportation on 8/24/17 and the company scheduled for 8/25/17 called that morning and canceled their transportation appointment. The SSD stated on 8/26/17 a transportation company arrived to take Resident 1 to dialysis but was informed by a nurse that he required transportation by gurney, which they were unable to provide, and they left the SNF. The SSD stated Resident 1 did not receive his dialysis treatment on 8/24/17, 8/25/17 or 8/26/17. On 9/26/17 at 2:19 p.m. during an interview, the SSD stated she informed Resident 1's nurse, LN 9, on 8/24/17 that Resident 1 missed his dialysis treatment due to the unavailability of transportation. The SSD stated she informed LN 9 again on 8/25/17 that Resident 1 missed his dialysis treatment on that day due to transportation problems. The SSD stated she did not document that she informed LN 9 regarding the missed dialysis treatments. On 10/9/17 at 9:01 a.m., during a telephone interview, LN 9 stated, "When it comes to dialysis, we go to the SSD; she has the information. I don't remember [the SSD] telling me that [Resident 1]'s dialysis appointment had any problems. If that was relayed to me I could have done something to help...I remember sending [Resident 1] on 8/26/17 [to the GACH] for abdominal pain and I came to find out he had not had his dialysis for a few days. The Resident told me. [Resident 1] told me [on 8/26/17] that he had not had his dialysis in 3 days. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 13 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE On 9/13/17 at 4:50 p.m., during an interview, the DON stated, "I expect the licensed nurses to know that dialysis is very important. If there was no transportation arrangement that can be arranged then that should have been reported to the doctor so an order to be sent to ER [emergency room] could have been gotten. If I was here I would have sent him [Resident 1] to the ER to be dialyzed." On 12/5/17 at 1:06 p.m., during an interview, the DON stated she reviewed the packet of information received from the GACH on 8/21/17 for Resident 1. The DON stated staff were aware Resident 1 required dialysis. The DON stated staff talked about two of Resident 1's missed dialysis treatments during stand-up meetings (staff meetings held at the beginning of the morning shift and beginning of the afternoon shift). The DON stated, "We were all aware [of Resident 1's missed dialysis appointments]." The DON stated LN 9 had informed her regarding Resident 1's missed dialysis appointments during stand-up meetings on 8/24/17. The DON stated her understanding was LN 9 would notify the Medical Director (MDR) regarding the missed appointments. On 9/13/17 at 5:14 p.m., during an interview, the MDR stated Resident 1 was his patient and had many medical problems. The MDR stated he was not aware Resident 1 had not dialyzed between 8/23/17 and 8/26/17 while at the SNF. The MDR stated, "No, I didn't know that he missed his dialysis. Nobody told me. It is very important for a dialysis patient to get their dialysis especially with [Resident 1]. He can't afford to miss any of his dialysis treatments. The facility should have called me so I could have ordered to get him dialyzed. Nobody notified me that he missed at least 3 days of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 14 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dialysis. [Resident 1] was already compromised health wise. Or call the patient's nephrologist [kidney specialist] and get an order to send him out to the hospital. When a patient like [Resident 1] missed his dialysis, potassium [salt in the blood which can have a direct effect on the heart muscle if the level is too high or too low] level goes up to a dangerous level. The edema [swelling from retention of fluid in the body] gets worse and [Resident 1] had significant swelling already. Again, I did not get any notification of any kind about [Resident 1] missing his dialysis and I should have." Review of facility policy titled, "Notification" dated 8/1/15 indicated, "Staff informs the resident, consults with their attending physician, and notifies the resident's surrogates when:...The facility's inability to obtain or administer, on a prompt and timely basis, drugs, equipment, supplies or services as prescribed under conditions which present risk to the health, safety or security of the residents...Treatment needs to be altered significantly..." Review of Resident 1's clinical record titled, "Progress Note" dated 8/26/17 at 12:40 p.m., indicated, "At approx [approximately] 11 a.m. resident [Resident 1] complaint of SOB [shortness of breath], nurse assessed resident and determined he would benefit from being sent to ER [emergency room]...Ambulance arrived at 11:15 to transport to ER..." The Progress Note was electronically signed by LN 9. Review of the GACH clinical record titled, "ED [emergency department] Dictation, Final Report" dated 8/26/17 indicated, "Date of Service: 8/26/17. Chief Complaint: Severe upper sternal [breastbone area] pain and shortness of breath...History of Present Illness: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 15 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Apparently, due to scheduling problems, his [SNF] has been unable to arrange for any dialysis for him over the last week of admission. He has had increasing shortness of breath...He says he feels like something is going to explode inside...He does have increasing swelling of his ankles. He is markedly orthopneic [needs to sit upright to breathe]...He is mouth breathing [breathing through open mouth]...Interventions: As luck would have it, the dialysis nurse was immediately available, so we sent the patient up directly to dialysis...Final Diagnosis: 1. pulmonary edema. 2. Missed dialysis appointments. 3. Pleural effusion [collection of fluid between the two membranes that surround the lungs]. 4. Chronic renal failure..." Review of the GACH clinical record titled, "History and Physical" dated 8/26/17, indicated, "...for unclear reasons he has not had any dialysis since his transfer to [SNF] on 8/23/17. Today the patient developed acute shortness of breath with pain with inspiration [breathing in]...was transferred to the ER for evaluation. Upon arriving here he was found to be in acute pulmonary edema and sent to the dialysis unit for emergent [needed immediately] dialysis and we have been called to admit him [to the GACH]...Assessment: Acute pulmonary edema due to missed dialysis..." Review of the GACH clinical record titled, "Discharge Summary" dated 9/5/17 indicated Resident 1 "...was readmitted basically due to unable to have hemodialysis [at the SNF]." The Discharge Summary indicated Resident 1 had a cardiopulmonary arrest (heart and breathing stop) on 9/5/17 and expired at the GACH. The Discharge Summary indicated, "...I [physician] was notified that the patient had a code blue [cardiopulmonary arrest]...unfortunately not able to make it..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 16 of 17 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 055869 (X3) DATE SURVEY COMPLETED 12/11/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE VALLEY SKILLED NURSING CENTER 515 E Orangeburg Ave Modesto, CA 95350 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of dialysis patient education material "Dialysis Connection" @www.nwkidney.org vol. 2, issue 1, Winter 2013, indicated, "Missing dialysis can be deadly...Dialysis replaces your kidney function and removes fluid and wastes that build up in your blood...Shortening or skipping treatments has serious risks. When you miss dialysis, fluids, toxins and potassium build up in your bloodstream, making you feel weak...Fluid overload and high potassium levels can lead to trips to the hospital, a need for emergency dialysis and heart complications." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: NY3511 Facility ID: CA030000026 If continuation sheet 17 of 17