Health inspection·July 16, 2024

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Resident 1's CT Pelvis w/o [without] Contrast [dye used to show abnormal areas in body], dated 6/4/24 was reviewed. The CT scan indicated, . Comminuted fracture [bone broken in at least two places] of the right pubic symphysis and extending into the superior pubic ramus with minimal displacement [change in position] and surrounding soft tissue edema [swelling] . During an observation on 7/16/24 at 10:43 a.m. in Resident 1's room, Resident 1's bed was empty because he was hospitalized due to an unrelated illness and there were two fall mats at his bedside. During an interview on 7/16/24 at 10:45 a.m., with Resident 2, Resident 2 stated he had been Resident 1's roommate for a few weeks but was not present during any of the falls. Resident 2 stated Resident 1 had an alarm which would go off when he tried to get out of bed, or his wheelchair and the staff would come running in to check on him. Resident 2 stated he had never seen Resident 1 receiving one on one supervision (clinical status unstable enough to require staff to observe them at all times) with staff. During an interview on 7/16/24 at 10:50 a.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated she was familiar with Resident 1. CNA 1 stated Resident 1 had frequent falls while in the facility. CNA 1 stated Resident 1 was alert but not oriented, impulsive and would not call for help. CNA 1 stated Resident 1 frequently got out of bed by himself when in his room alone which increased his fall risk. CNA 1 stated staff would take Resident 1 to activities or sit him by the nurse's station to provide extra supervision during the day which prevented falls. CNA 1 stated she worked the night shift at times and Resident 1 would frequently get out of bed when left alone. During an interview on 7/16/24 at 10:54 a.m. with CNA 2, CNA 2 stated Resident 1 was alert but forgetful. CNA 2 stated she was aware Resident 1 was a high fall risk. CNA 2 stated Resident 1 had an alarm on his bed and chair which would go off when he tried to get. CNA 2 stated, Someone always has an eye on him when he is up during the day. CNA 2 stated Resident 1 would not remember to use his call light for help. During a concurrent interview and record review on 7/16/24 at 12:26 p.m. with Licensed Vocational Nurse (LVN) 1, LVN 1 stated Resident 1 was at high risk for falls. LVN 1 stated Resident 1 had interventions in place to prevent falls and injuries such as bed/chair position alarm, frequent visual checks, call light within reach, reminders to use call light, fall mats, the star program, bed low position and non-skid footwear. LVN 1 was unable to clarify the frequency of frequent visual checks. LVN 1 stated Resident 1 had frequent checks while he was out of his room in his wheelchair, but the checks were not done while he was in his room. LVN 1 stated the star program was used for residents at high fall risk. LVN 1 stated the therapy department would evaluate the resident and assign a red or white star depending on the amount of assistance they required, white stars indicated the resident was safe to ambulate alone and the red stars indicated the residents required assistance. LVN 1 stated Resident 1 was assigned a red star because he was not safe to ambulate or transfer by himself. LVN 1 reviewed Resident 1's diagnoses and stated Resident 1 had metabolic encephalopathy, confusion, history of falls and a urinary tract infection (UTI-bacteria grows in the urinary tract [the body's drainage system for removing urine]) which increased his fall risk. Resident 1' s Health Status Note, dated 5/29/24 at 0830 (8:30 a.m.), indicated, . [name of CNA] heard alarm coming from resident ' s room and walked in and noted resident standing in between the bed and the window . attempted to get to resident before he could move further . resident began walking forward . appeared to lose his balance and fell forward . resident denied pain at time of fall . Resident 1' s fall risk care plan initiated 5/9/24 was reviewed, the care plan indicated, . Resident at risk for falls R/T [related to] generalized muscle weakness, and poor safety awareness r/t intermittent episodes of confusion . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 2 of 4 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 - Minimal harm or potential for actual harm Residents Affected - Few unwitnessed non-injury fall in room [ROOM NUMBER]/8/24 . Witnessed fall in room [ROOM NUMBER]/14/24 . Unwitnessed fall in room [no date] with skin tear to right RA [fore arm] . Witnessed fall hit head, noninjury on 5/29/24 . Unwitnessed fall 6/28/24 . will remain free from falls through the next review period . Target Date 9/5/24 . Continue reminders to use call light . Bed in lowest position. Floor mats in place. Increase CNA rounding . Verbal reminders to not ambulate [walk]/transfer without assistance . bed alarm, increase CNA rounding at night . Delayed injury: right pubic rami fracture from witnessed fall confirmed 05/31/2024. RP [responsible party]/MD [physician] notified. Xray and radiology report given to Ortho [orthopedic - a physician specializing in treatment of the musculoskeletal system (bones, joints, ligaments, tendons, or muscles)] surgeon for evaluation . LVN 1 stated Resident 1' s mental status fluctuated throughout the day so interventions to educate or remind him to not get up alone or to use call light would be ineffective. LVN 1 stated the most effective interventions for Resident 1 was supervision and distraction because he did not fall when he was out of his room supervised. LVN 1 stated Resident 1 would need constant supervision to prevent falls. During a concurrent interview and record review on 7/16/24 at 1:30 p.m. with the DON, the DON stated Resident 1 had history of frequent falls prior to his admission. The DON stated Resident 1 fell on 5/29/24 but did not complain of pain when he was assessed. The DON stated Resident 1 complained of pain later in the day, so the nurse notified the physician and received an order for an X-ray of the hip. Resident 1' s Risk Benefit Analysis: High Fall Risk/Unavoidable Falls, dated 5/23/24 was reviewed and indicated, . The above-named patient has been identified as being a high-risk alert for falls . You/the Resident and family are encouraged to participate in the development of the plan of care. IT IS IMPROTANT THAT YOU ACKNOWLEDGE THAT THESE APPROACHES WILL NOT ABSOLUTELY PREVENT A FALL OR PREVENT SERIOUS INJURY FROM OCCURING . The interdisciplinary team [IDT-group of healthcare professionals who work together to provide care] has reviewed your/the residents fall risk associated with your/the resident' s medical and cognitive condition and have discussed approaches that may be included in your/the resident ' s plan of care . circle appropriate . Low bed [circled] . RNA/PT/OT [circled] . Toileting assistance [circled] . No being left alone in your own room [not circled] . The DON stated the interventions circled were active interventions. The DON stated the IDT had decided Resident 1' s falls were unavoidable. The DON stated the facility was responsible to keep the resident safe from falls. DON stated it would be too expensive to place Resident 1 on one on one. The DON stated Resident 1 had received every intervention but was still falling which made the falls unavoidable. The DON stated he fractured the pelvis but had a history of fracturing the same area in the past. During a telephone interview on 8/15/24 at 12:07 p.m. with LVN 2, LVN 2 stated he was the charge nurse on 5/29/24 when Resident 1 fell. LVN 2 stated he was at the nurse' s station and heard Resident 1' s bed alarm go off, so he walked down the hall to the room and saw CNA 3 walk into the resident' s room. LVN 2 stated when he walked into Resident 1' s room, the resident was laying face down shifted to his right side. LVN 2 stated the resident denied pain at the time, but within a half hour pointed to his right groin and said it hurt. LVN 2 stated Resident 1 was unable to verbalize his severity of pain using the numeric pain scale (based on 0-no pain, 1 to 3-mild pain, 4 to 6-moderate pain and 7-10 severe pain), so he utilized the FACES pain scale (visual scale to rate pain). LVN 2 stated the FACES pain scale indicated he was sore, not in moderate or severe pain. LVN 2 stated the resident denied severe pain. LVN 2 stated he notified the physician when Resident 1 complained of pain and was given an order for a hip X-ray. LVN 2 stated Resident 1 was not sent to the emergency department because he was not in a large amount of pain. I figured it was possibly just bruised. LVN 2 stated the physician declined to send the resident to the ED and wait for the X-ray results. LVN 2 stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 3 of 4 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 555530 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/16/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Chowchilla Memorial Healthcare District 1104 Ventura Ave. Chowchilla, CA 93610 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 - Minimal harm or potential for actual harm Residents Affected - Few X-ray was done on 5/30/24 and the results were received on 6/1/24. LVN 2 stated the physician was notified of the X-ray results and he had ordered a CT scan. LVN 2 stated the resident was not sent to the hospital after the X-ray because the physician stated the injury was not normally fixed by surgery. LVN 2 stated Resident 1's pain was easily controlled by oral pain medication, and he did not require surgery or hospitalization for the injury. LVN 2 stated the physician was aware the resident had a fracture; the CT scan was a precaution to verify the resident did not require surgery. LVN 2 stated Resident 1's intervention of keeping up in activities was successful because he was supervised, and the staff could intervene before he got up and fell. LVN 2 stated Resident 1 had not been on a one-on-one supervision while in his room, but supervision was the most effective intervention to prevent him from falling. During a telephone interview on 8/15/24 at 12:35 p.m. with CNA 3, CNA 3 stated she was the CNA who had witnessed Resident 1' s fall on 5/29/24. CNA 3 stated Resident 1 had a mobility alarm on his bed which had gone off. CNA 3 stated she walked into the resident' s room and found him standing at bedside, when she had walked towards him, he fell. CNA 3 stated Resident 1 denied pain at the time of the fall. During a review of Resident 1' s Interdisciplinary Team Meeting, dated 5/30/24 was reviewed. The IDT note indicated, . Resident had a witnessed fall in room [ROOM NUMBER]/29/24 . approximately 08:30 am, CNA [name] heard alarm coming from resident room and walked in and noted resident standing in room in between the bed and the window . resident appeared to lose his balance and fell forward . Resident denied any pain at time of fall . approximately 40 minutes later resident complained of minimal right groin area . PMD (primary Medical Doctor) was notified and ordered X-ray of right hip . IDT met and unavoidable was put in place previous fall 5/22/24. Will keep encouraging resident to use call light . During a review of the facility' s policy and procedure (P&P) titled Assessing Falls and Their Causes, dated 7/2019, the P&P indicated, . Purpose . provide guidelines for assessing a resident after a fall and to assist staff in identifying causes of the fall . Falls are a leading cause of morbidity and mortality among the elderly in nursing homes . Falling may be related to underlying clinical or medical conditions . After a fall . evaluate for possible injuries to the head, neck, spine, and extremities . If there is evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately . Observe for delayed complications of a fall for approximately seventy-two (72) hours . Document any observed signs or symptoms of pain, swelling, bruising, deformity and/or decreased mobility . During a review of the facility ' s P&P titled, Falls and Fall Risk, Managing and Prevention, dated 9/15/23, the P&P indicated, . the 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 . Staff will assist and supervise those residents that are at identified at risk for falls . The IDT staff, with the input of the attending physician, will implement a resident-centered fall prevention plan . If the resident has a current care plan for falls this care plan will be updated by adding the new fall to problem including date and short description of fall. A new approach will also be added Starting on date of new fall . If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions . All Residents determined to be at a risk for falls with a score of 10 or higher will be placed in the facility Fall Prevention Program to prevention injuries from fall . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555530 If continuation sheet Page 4 of 4