Inspection·March 27, 2024

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview, observation, and record review, the facility failed to meet this requirement when a blood draw tourniquet (a device that is used to apply pressure to a limb or extremity in order to stop the flow of blood) remained on a resident (Resident 1 ' s) for an estimated six hours unnoticed and unattended to. This resulted in Resident 1 ' s hand being swollen and red, and had the potential for serious injury. Residents Affected - Few Findings A review of Resident 1's clinical record, indicated Resident 1 was admitted to the facility with diagnoses including dementia (memory and mental function loss), diabetes, communication deficits (inability to speak), and muscle weakness. On 3/27/24 at 1:45 PM, Resident 1 was observed to have a phlebotomy (blood draw) tourniquet around his wrist, tied tightly in a slip knot. The tourniquet was observed to be pressing deeply into Resident 1 ' s skin; his fingers were red and swollen. There were no staff present in Resident 1 ' s room. No staff were observed to come into his room by 1:50 PM. In a concurrent interview and observation on 3/27/24 at 1:50 PM, Licensed Vocational Nurse (LVN) A, who was assigned to Resident 1 that day, stated that she had not placed the tourniquet there, and it had likely been placed in the morning for a blood draw. LVN A confirmed that she had been in Resident 1 ' s room several times that morning and had not noticed the tourniquet. LVN A confirmed that Resident 1 ' s fingers were swollen and red, particularly the ring finger, and that there was a deep indentation in his skin around his wrist. In an interview on 3/27/24 at 1:55 PM, LVN B concurrently assessed Resident 1 ' s condition: I see a pressure indentation around his wrist from the tourniquet, it ' s swollen and red. LVN B stated that the tourniquet was placed there by an outside mobile phlebotomy service that morning, around 6-7:00, to draw a blood test on Resident 1. The time the tourniquet was placed on Resident 1 ' s arm, until it was brought to LVN A ' s attention, was more than six hours. LVN B further stated that there were several opportunities that day when staff interacted closely with Resident 1 and opportunities to notice the tourniquet, stating that medications were given to him by LVN A at 8:00 that morning, and that a CNA took his blood pressure around that time as well, which would have required him to sit up. He also received RNA (restorative nursing assistance; help with eating) around noon, and there had been a chance for it to be seen at that point. Review of Resident 1's Minimum Data Set (a standardized assessment of a resident's abilities) dated 3/3/24 indicated that Resident 1 was totally dependent on staff for most aspects of daily care, and (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555535 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 555535 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/27/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Valley Care Center 9000 Larkin Road Live Oak, CA 95953 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)