Health inspection·March 12, 2025

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 observation, interview, and record review, the facility failed to ensure professional standard of care for one of two sampled residents (Resident 1) when blood glucose (sugar) test (measures the sugar level in the blood) was not checked timely as ordered by the physician. This failure had the potential for Resident 1 to have adverse health outcomes. Residents Affected - Few Findings: During a concurrent observation and interview on 3/12/25 at 11:05 a.m. with Resident 1, Resident 1 was in her room, sitting in a wheelchair. Resident 1 stated her blood sugar was checked four times a day, before each meal and at bedtime. Resident 1 stated Registered Nurse (RN) does not check her blood sugar before dinner. Resident 1 stated, [RN] checks it [blood sugar level] either while I'm already eating or after I'm done eating and by that time it [sugar level] is high and he gives me more insulin (lowers blood sugar level). During a review of Resident 1's Quarterly Minimum Data Set (MDS - a standardized, comprehensive assessment tool) dated 12/30/24, indicated, Resident 1 had a BIMS (Brief Interview for Mental Status which evaluates cognition, the ability to remember and think clearly) score of 15 (score range from 13 to 15 intact cognition). During an interview on 3/12/25 at 11:28 a.m. with Licensed Vocational Nurse (LVN), LVN stated it was the facility protocol and physicians order for blood sugar to be check prior to each meal. LVN stated checking during and after meals can result in a higher/inaccurate blood sugar level. During a review of Resident 1's medication administration record (MAR) dated 2/27/25 thru 3/9/25 the following blood sugar level were not checked timely as ordered: Blood sugar level was ordered to be checked before each meal at 6:30 a.m., 11:30 a.m., and 4:30 p.m., record indicated it was checked at: 2/27- 7:49 p.m. (3 hour and 19 minutes late) 2/28- 5:47 p.m. (1 hour and 17 minutes late) 3/1- 6:47 p.m. (2 hours and 17 minutes late) 3/2- 7:31 p.m. (3 hours and 1 minute late) 3/6- 6:07 p.m. (1 hour and 37 minutes late) (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 3 Event ID: 555658 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 555658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE River Walk Care Center 1100 West Morton Avenue Porterville, CA 93257 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)