Health inspection·September 5, 2025

F 0656 Level of Harm - Actual harm Residents Affected - Few Resident 1's CP dated 7/28/25, the CP indicated, Resident had an unwitnessed fall on 7/28/25 with scratch and bump to mid back attempting to go to bathroom unassisted.Interventions/tasks.remind resident to use call light and ask for assistance as needed.3. During a review of Resident 1's PN dated 8/6/25 at 6:45 p.m., the PN indicated, At approx. (approximately) 6:45 p.m. CNA (certified nursing assistant) informed this CN (charge nurse) resident was found in resident restroom sitting on his buttocks on the floor. CNA asked resident what happened resident replied, I miss the toilet and fell on my a**.During a review of Resident 1's CP dated 8/6/25, the CP indicated, (Resident name) had an actual fall with no injury 8/6/25 in the bathroom.Interventions/Tasks.Bowel and Bladder retraining (resident physically taken to the restroom and intervention documented) . There was no evidence the facility implemented bowel and bladder retraining.4. During a review of Resident 1's PN dated 8/18/25 at 11:36 a.m., the PN indicated, Resident stated he fell this morning when preparing for the day. Resident sated he was going to the restroom without his assistive device this morning to get himself ready, when he lost balance and grabbed into the restroom's handrail and hit his (R) (right) ribon (rib on) [sic] the corner of the sink.During a review of Resident 1's CP dated 8/18/25, the CP indicated, (Resident 1) had an alleged fall on 8/18/25.Interventions.Continue interventions on the at-risk plan.5. During a review of Resident 1's PN dated 8/20/25 at 10:00 a.m., the PN indicated, Resident was found laying [sic] on his back on the floor facing the entrance door of the room. According to staff who witnessed the fall, resident was coming out of the restroom when he lost his balance and hang his hand on the corner of the neighbor's bed, turned around before slipping on the ground.Resident stated he got out of the restroom and slipped.During a review of Resident 1's CP dated 8/20/25, the CP indicated, (Resident 1) had an actual witnessed fall on 8/20/25 attempting to ambulate without assistance from bathroom.Interventions/Tasks.Send to acute (hospital) for evaluation and treatment as indicated.During a review of Resident 1's PN dated 8/20/25 at 8:43 p.m., the PN indicated, At approximately 1135 this writer assessed resident for pain and any delayed injuries due to fall. Resident reported experiencing pain in the (L) (left) leg and requested for pain pill.Notified (physician name) for breakthrough (medications that treats serious medical condition) RX (prescription) or possible send out to acute (hospital). MD (Doctor of Medicine) declined to give any more pain management and order received to send to (hospital name) for further eval, pain control and to rule out possible fracture.During a review of Resident 1's PN dated 8/20/25 at 8:49 p.m., the PN indicated, .At 7:30pm, this writer called (the hospital) again and got an update on resident who obtained a fracture on (L) hip and will be admitted .During a review of Resident 1's Imaging Report (IR-completed at the hospital) dated 8/20/25, the IR indicated Acute left femoral neck fracture extending to the lesser trochanter.During a review of Resident 1's History and Physical (H&P-completed at the hospital) dated 8/20/25, the H&P indicated, (Resident 1) is coming from a skilled nursing facility and has been evaluated in the past for recurrent falls.While he was at the skilled nursing facility, he states he tried to use the restroom on his own and had a fall. CT (computed tomography scan-imaging procedure that uses x-ray to create detailed images of internal organs, bones, and blood vessels) hip shows acute left femoral neck fracture extending to the lesser trochanter.Plan for surgical evaluation tomorrow.During a review Resident 1's Consultation Report (CR-completed at the hospital) dated 8/20/25, CR indicated, Reason for consultation narrative: left hip pain.patient is a.male who had a ground-level fall yesterday.He denies any pain except for the left side of his lower extremity.Plan.Patient is a.male with a rather vertical pattern of the femoral neck fracture. He has a subcapital (head of the bone) fracture that extends to the top of the lesser trochanter. Given that this is intracapsular (occurring within a capsule) and displaced (moved from its proper place), we recommend a hip (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555658 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 555658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 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)

F 0656 Level of Harm - Actual harm Residents Affected - Few hemiarthroplasty (surgical procedure to replace half of a joint).During a review of Resident 1's Discharge Summary (DS) dated 8/24/25 (four days after being admitted from the skilled nursing facility to the hospital), the DS indicated, Date of admission: [DATE].for left hip fracture status post (Resident 1's current condition) mechanical fall (fall caused by external, environmental factors) status post left hip hemiarthroplasty. Hip CT showed acute left femoral neck fracture extending to the lesser trochanter.patient had left hemiarthroplasty.During an interview on 9/5/25 at 2:50 p.m. with Certified Nursing Assistant (CNA) 1, CNA 1 stated Resident 1 had prior falls, would not call for assistance, and would take himself to the bathroom independently.During an interview on 10/6/25 at 1:13 p.m. with CNA 2, CNA 2 stated she was assigned to Resident 1 at the time of the fall (8/20/25). CNA 2 stated she was unaware Resident 1 was a fall risk and Resident 1 was on bowel and bladder retraining. CNA 2 stated Resident 1 would attempt to get up by himself and go to the bathroom, and she was unaware of any prior falls.During an interview on 10/6/25 at 2:33 p.m. with CNA 3, CNA 3 stated Resident 1 was a fall risk, and would go to the bathroom independently. CNA 3 stated she was not aware Resident 1 was on bowel and bladder retraining. CNA 3 stated when a resident was on bowel and bladder retraining it should show on the POC (point of care-used by CNAs to document and includes the Kardex that provides information on how to care for the resident) for the CNAs to document each time the resident was taken to the bathroom.During an interview on 10/6/25 at 2:39 p.m. with CNA 4, CNA 4 stated Resident 1 was a fall risk, and he was not on bowel and bladder retraining at the time of the fall (8/20/25).During an interview on 10/6/25 at 10:20 a.m. with Director of Nursing (DON), DON stated Resident 1 was placed on bowel and bladder retraining on 8/7/25 (13 days prior to the fall) due to Resident 1 falling on 7/27/25, 7/28/25, 8/6/25 when taking himself to the bathroom. DON stated when a resident was on bowel and bladder retraining the CNAs were required to physically take the resident to the bathroom and document it. DON stated the CNAs were made aware of the bowel and bladder retraining through the POC Kardex. DON stated the bowel and bladder retraining was appearing on the POC Kardex, but the task was not triggering for the CNAs to document each time Resident 1 was taken to the bathroom. DON During an interview on 10/14/25 at 3:38 p.m. with DON, DON stated at the time of the 8/20/25 fall the bowel and bladder retraining should have been ongoing. DON stated after 14 days the data collected was used to evaluate the effectiveness of the retraining and determine how Resident 1 was doing on bowel and bladder retraining. DON stated the bowel and bladder retraining was not implemented correctly on the POC prior to the 8/20/25 fall.During a review of the facility's policy and procedure (P&P) tilted, Care Plans, Comprehensive Person-Centered dated 3/22, the P&P indicated, A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident.the comprehensive, person-centered care plan.includes measurable objectives and timeframes.describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making.when possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers.the interdisciplinary team (group of professionals from different fields who collaborate to work toward a common goal, sharing expertise and knowledge to provide comprehensive care or solve a problem) reviews and updates the care plan.when there has been a significant change in the resident's condition.During a review of the facility's policy and procedure titled Falls and Fall Risk, Managing dated 3/2018, the P&P indicated, Resident conditions that may contribute to the risk of falls include.delirium (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 555658 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 555658 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/05/2025 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)

F 0656 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete (state of confusion) and other cognitive impairment.if a systemic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.if falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant.The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. Event ID: Facility ID: 555658 If continuation sheet Page 4 of 4