Fresno Postacute Care

F-F802.

a. During a review of the facility's Summer Menus (SM), dated 8/12/24, the SM indicated residents on regular texture, CCHO, regular portions diet, to receive 1/4 cup of sweet potato fries. The SM indicated 1/2 cup of sweet potato fries is large portions for residents on regular texture, CCHO diet.

During an observation on 8/12/24 at 12:32 p.m. in the kitchen, Dietary Aide (DA) 1 was not calling out CCHO from the meal tickets when telling the cook what to put on the plate.

During an observation of the lunch meal service on 8/12/24, starting at 12:32 p.m. in the kitchen, [NAME] 1 used a four oz. scoop to serve regular texture sweet potato fries to 20 residents (Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, 13) on regular texture, CCHO, regular portions diet.

During a review of the facility's Diet Type Report (DTR), dated 8/12/24, the DTR indicated the following residents are on regular texture, CCHO, regular portions diet: Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, 13).

b. During a review of the facility's SM, dated 8/12/24, the SM indicated residents on mechanical soft regular portions diet get #10 scoop (3.2 ounces) of ground roast beef. The SM indicated #16 scoop (2 ounces) of ground roast beef is small portions for residents on mechanical soft diet.

During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m. in the kitchen, [NAME] 1 used #16 scoop (small portions) to serve ground roast beef to eight residents (Resident 21, 57, 61, 54, 3, 55, 66, 28) on mechanical soft regular portions diet.

During a review of the facility's DTR, dated 8/12/24, the DTR indicated the following residents are on mechanical soft regular portions diet: Resident 21, 57, 61, 54, 3, 55, 66, 28).

c. During a review of the facility's SM, dated 8/12/24, the SM indicated residents on pureed regular portions diet get #8 scoop (4 ounces) of pureed roast beef. The SM indicated #12 scoop of pureed roast beef is small portions for residents on pureed diet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0803 During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m. in the kitchen, [NAME] 1 used #12 scoop (small portions) to serve pureed roast beef to seven residents (Resident 27, 1, 69, 2, 15, 49, Level of Harm - Minimal harm or 44) on pureed regular portions diet. potential for actual harm

During a review of the facility's DTR, dated 8/12/24, the DTR indicated the following residents are on pureed, Residents Affected - Many regular portions diet: Resident 27, 1, 69, 2, 15, 49, 44). d. During a review of the facility's SM, dated 8/12/24,

the SM indicated residents on regular texture, large portions diet get three oz of roast beef and 3/4 cup of sweet potato fries.

During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m., in the kitchen, [NAME] 1 served two #12 (5.34 oz) scoops of roast beef and two 4 oz scoop (one cup) of sweet potato fries to Resident 227 and Resident 20.

During a review of the facility's DTR, dated 8/12/24, the DTR indicated Resident 227 and Resident 20 are on regular texture, large portions diet.

During a review of the facility's policy and procedure (P&P) titled, Portion Sizes, dated 2023, the P&P indicated, The small and large portion servings will be served as printed on the cook's spreadsheets for every meal Double portions are used for residents with high caloric needs who are eating well and for whom large portions are inadequate.:

e. During an observation on 8/12/24 at 12:40 p.m. in the kitchen, DA 1 was not calling out Renal from the meal tickets when telling the cook what to put on the plate.

During an observation of the lunch meal service on 8/12/24 at starting at 12:31 p.m. in the kitchen, [NAME] 1 served roast beef and sweet potato fries to Resident 13 and Resident 45.

During a review of the facility's DTR, dated 8/12/24, the DTR indicated Resident 13 and Resident 45 are on renal diet.

During a review of the facility's SM, dated 8/12/24, the SM indicated. Renal diets. French Dip: Roast Beef Roll with Au Jus, Pineapple Ring ** No Fries.

During an interview on 8/12/24 at 1:20 p.m. with [NAME] 1, [NAME] 1 stated residents on renal diet should get pineapple rings and not sweet potato fries. [NAME] 1 stated DA 2 should call out if residents are on renal diet. [NAME] 1 confirmed while reading the menu that the portion sizes were incorrect for CCHO, mechanical soft, large portions and puree diets.

During an interview on 8/14/24 at 2:43 p.m. with Registered Dietitian (RD), RD stated she expects the kitchen staff to follow the portion sizes on the menu spreadsheet and follow what menu shows for all the different therapeutic diets. RD stated large portions is not double portions.

2. During an observation and concurrent interview on 8/12/24 at 12:21 p.m., with [NAME] 1, blended coleslaw in a blender. [NAME] 1 stated she had 12 servings portioned in the blender.

During an observation on 8/12/24 at 12:22 p.m. with DA 3, DA 3 poured a pitcher of pureed coleslaw into seven disposable bowls unmeasured.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0803 During a review of the facility's SM, dated 8/12/24, the SM indicated residents on pureed diet get #12 scoop of pureed coleslaw. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's DTR, dated 8/12/24, the DTR indicated the following residents are on pureed diet: Resident 27, 1, 69, 2, 15, 49, 44. Residents Affected - Many

During an interview on 8/14/24 at 2:43 p.m. with RD, RD stated she expects the kitchen staff to follow the portion sizes on the menu spreadsheet and not to guess what the portion sizes are.

3. During an observation on 8/12/24 at 10:52 a.m. in the kitchen, DA 2 was preparing chocolate pudding for

the residents' dessert for lunch.

During a concurrent interview and observation on 8/12/24 at 10:53 a.m. with DA 2 in the kitchen, DA 2 was using a #12 scoop when scooping chocolate pudding into approximately 20 bowls on a tray. There were approximately 10 bowls that were not full. DA 2 stated some bowls had less pudding that the other bowls since she did not fill up the scoop as much. DA 2 then put the lids on the bowls and started a new tray of bowls.

During an interview on 8/13/24 at 10:03 a.m. with DA 2, DA 2 stated, I don't think we had the ingredients for that [cappuccino mousse].

During an interview on 8/14/24 at 2:43 p.m. with RD, RD stated she expects the kitchen staff to follow the portion sizes on the menu spreadsheet and to fill up the scoops when portioning food items.

4. During an observation on 8/12/24 at 10:33 a.m. in the kitchen, [NAME] 1 was preparing coleslaw for the residents' side for lunch. The coleslaw did not have corn.

During a review of the facility's SM, dated 8/12/24, the SM indicated, French Dip-Roast Beef on a Soft Sandwich Roll, Au Jus, Sweet Potato Fries, Ketchup, Corn Coleslaw, Cappuccino Mousse, Milk for lunch.

During an interview on 8/13/24 at 10:01 a.m. with [NAME] 1, [NAME] 1 stated she did not put corn in the corn coleslaw. [NAME] 1 stated some ingredients were not in house for the recipes.

During a review of the facility's Resident Council Minutes (RCM), RCM, dated 5/29/24, the RCM indicated, Old business: Portion size, food preference.

During a review of the facility's RCM, dated 6/24/24, the RCM indicated, Old business: Portion size, food preferences. Dietary: Food continuously coming out late.

During a review of the facility's P&P titled, Menu Planning dated 2023, showed menus are planned to meet nutritional needs of residents in accordance with established national guidelines, physician's orders, and to

the extent medically possible, in accordance with the most recent recommended dietary allowances of the Food and Nutrition Board of the National Research Council National Academy of Sciences. Menus provide a variety of foods in adequate amounts each meal.

50409

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 28773 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure food was palatable and Residents Affected - Some flavorful when the lunch served for residents had firm and undercooked peas, dry and bland chicken, and bland rice.

This failure had the potential to result in residents to have decreased meal intake due to difficulty chewing and eating their food which can lead to resident's not meeting their nutrition needs.

Findings:

During an interview on 8/12/24 at 8:38 a.m. with Resident 29, Resident 29 stated food from the kitchen is dreadful.

During an interview on 8/12/24 at 8:40 a.m. with Resident 12, Resident 12 stated the broccoli was too watery and felt like it was cooked for days. Resident 12 stated the rice and mashed potatoes did not taste good. Resident stated lunch and dinner from the kitchen were not appetizing at all.

During an interview on 8/12/24 at 8:50 a.m. with Resident 177, Resident 177 stated the food tasted horrible and the cook did not know how to cook anything. Resident stated the food was either overcooked or undercooked.

During an interview on 8/12/24 at 10:59 a.m. with Resident 31, Resident 31 stated food from the kitchen does not taste good. Resident 31 stated the kitchen does not serve what is on the menu. Resident 31 stated

the chicken was dry and cold, and the soup from the kitchen was cold, nasty and watered down.

During an interview on 8/13/24 at 10:14 a.m. with Resident 49, Resident 49 stated food is not that good.

During an interview on 8/13/24 at 10:56 a.m. with Resident 26, Resident 26 stated she does not like the food from the kitchen and it is bland.

During a review of the facility's Summer Menus (SM), dated 8/13/24, the SM indicated, Curry Lemon Chicken, Garlic Rice, Peas w/ [with] onions, Parsley Garnish, Wheat Roll for lunch.

During a concurrent observation and interview on 8/13/24 at 12:15 p.m. with the Certified Dietary Manager (CDM) in Station 2 hallway, the regular and puree test tray were sampled. The regular diet had a plate of curry lemon chicken, garlic rice, and peas with onions. The peas were firm, undercooked and starchy. The curry lemon chicken was dry and had mild curry taste, and the garlic rice tasted like plain brown rice. The CDM confirmed the peas were firm and that that he could taste the curry better on the pureed chicken than

the regular chicken.

During an interview on 8/13/24 at 1:40 p.m. with Resident 12, Resident 12 stated the peas tasted like it came straight from the can and it was hard. Resident 12 stated, I did not like most of the food in the plate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0804 During a review of the facility's Resident Council Response (RCR), dated June 2024, the RCR indicated, Concern/Request Identified by the Resident Council: Food quality is not good . Department Head Response . Level of Harm - Minimal harm or To ensure that Residents get proper quality food and water. potential for actual harm

During a review of the facility's RCR, dated 7/29/2024, the RCR indicated, Concern/Request Identified by the Residents Affected - Some Resident Council: Food Quality & preferences . Department Head Response . look at food and tray cards for proper preferences and diets . educated staff, not reading cards [meal tickets] properly.

50409

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 28773

Residents Affected - Few Based on observation, interview, and record review, the facility failed to ensure pureed meat was able to hold its shape or form for seven of 64 sampled residents (Resident 27, 1, 69, 2, 15, 49, and 44). This failure had

the potential to result in residents choking or decreased meal intake.

Findings:

During a concurrent observation and interview on 8/13/24 at 12:15 p.m. with the Certified Dietary Manager (CDM) in Station 2 hallway, the pureed diet test tray was sampled. The pureed curry chicken was spread all over the plate and did not hold its shape or form. The CDM acknowledged that the pureed chicken did not hold its shape or form.

During a review of the facility's Diet Type Report (DTR), dated 8/12/24, the DTR indicated the following residents are on pureed diet:

a. Resident 27 is on CCHO, puree, nectar thick liquids diet.

b. Resident 1 is on regular puree, honey thick liquids diet.

c. Resident 69 is on fortified puree diet.

d. Resident 2 is on regular puree, honey thick liquids diet.

e. Resident 15 is on no added salt, puree, honey thick liquids diet.

f. Resident 49 is on regular puree, regular liquids diet.

g. Resident 44 is on regular puree, regular liquids, large portions diet.

During a review of the facility's diet manual (DM) titled, Regular Pureed diet, dated 2023, the DM indicated,

The pureed diet is a regular diet that has been designed for residents who have difficulty chewing and/or swallowing. The texture of the food should be of a smooth and moist consistency and able to hold its shape.

50409

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm 28773

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure:

1. Food preferences were not accommodated for three of 64 sampled residents (Resident 12, Resident 23, and Resident 18) and;

2. Options of similar nutritive value was served to residents who chose not to eat food that was on the menu for three of 64 sampled residents (Resident 31, Resident 51, Resident 34).

3. One of seven sampled residnet's (Resident 29) dislike of ham was not documented, and preference of potatoes was not documented or provided by kitchen staff on 8/19/24.

These failures had the potential to result in residents to have decreased meal satisfaction and not meet their nutrition needs which can lead to unplanned weight changes.

Findings:

1. a. During an observation of the lunch meal service on 8/12/24 at 12:57 p.m. in the kitchen, Resident 23's meal tray had chocolate pudding.

During a concurrent interview and record review on 8/14/24 at 12:57 p.m. with Dietary Aide (DA) 2, Resident 23's meal ticket (MT) indicated, Dislikes: Eggs, Fish, Meat, OTHER (No Chicken/Tofu), Coffee, Chocolate. DA 2 confirmed Resident 23 dislikes chocolate. DA 2 stated Resident 23 needed a different dessert.

b. During an observation of the lunch meal service on 8/12/24 at 1:08 p.m. in the kitchen, Resident 18's meal tray had chocolate pudding.

During a concurrent interview and record review on 8/14/24 at 1:08 p.m. with DA 4, Resident 18's MT indicated, Dislikes: Dessert (PUDDING). DA 4 confirmed Resident 18 dislikes pudding and the chocolate pudding was on her meal tray and should not have been.

c. During an observation of the lunch meal service on 8/12/24 at 1:16 p.m. in the kitchen, Resident 12's meal tray had chocolate pudding.

During a concurrent interview and record review on 8/12/24 at 1:16 p.m. with DA 4, Resident 12's MT indicated, Notes: Dislikes pudding. DA 4 confirmed Resident 12 dislikes pudding and the chocolate pudding was on her meal tray and should not have been.

During an interview on 8/13/24 at 12:26 p.m. with the Certified Dietary Manager (CDM), the CDM stated he expects residents with dislikes to have alternatives.

During a review of the facility's Resident Council Minutes (RCM), dated 5/29/24, the RCM indicated, Old business: Portion size, food preference.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0806 During a review of the facility's RCM, dated 6/24/24, the RCM indicated, Old business: Portion size, food preferences. Dietary: Food continuously coming out late. Level of Harm - Minimal harm or potential for actual harm During an interview on 8/14/24 at 2:44 p.m. with the Registered Dietitian (RD), the RD stated she expects the kitchen staff to follow the residents' food preferences. Residents Affected - Some 2. During a review of the facility's Summer Menus (SM), dated 8/13/24, the SM indicated, Curry Lemon Chicken, Garlic Rice, Peas w/ [with] Onions, Parsley Garnish, Wheat Roll, Margarine, Ice Cream, Milk for lunch.

a. During an observation on 8/13/24 at 11:38 a.m. in the kitchen, Resident 31's meal tray had rice, chicken, wheat roll, and orange drink.

During a review of Resident 31's MT, MT indicated, Dislikes: Vegetables (PEAS and CORN).

b. During an observation on 8/13/24 at 11:43 a.m. in the kitchen, Resident 51's meal tray had chicken, rice, wheat roll, iced tea, and milk.

During a review of Resident 51's MT, MT indicated, Dislikes: Vegetables (canned spinach, peas).

c. During an observation on 8/13/24 at 11:44 a.m. in the kitchen, Resident 34's meal tray had chicken, rice, wheat roll, milk, and lemonade.

During a review of Resident 34's MT, MT indicated, Dislikes: Vegetables (Peas).

During an interview on 8/13/24 at 12:26 p.m. with the CDM, the CDM stated he expects residents who dislike peas would have alternative vegetables.

During an interview on 8/14/24 at 2:44 p.m. with the RD, the RD stated she expects the kitchen staff to provide a different vegetable for those who do not like a vegetable on the menu.

During a review of the facility's policy and procedure (P&P) titled, Food Preferences, dated 2023, the P&P indicated, Resident's food preferences will be adhered to within reason. Substitutes for all foods disliked will be given from the appropriate food group.

48424

3. During a review of Resident 29's Admission Record (AR- a document that

provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/15/24, the AR indicated Resident 29 was admitted with the following diagnoses: diabetes mellitus (A disease which result in too much sugar in the blood), chronic kidney disease (when the kidneys have been damaged over time resulting in decreased function), vitamin D deficiency (vitamin deficiency that causes issues with your bones and muscles), and muscle weakness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0806 During a review of Resident 29's Minimum Data Set (MDS- resident assessment tool which indicates physical and cognitive abilities), dated 5/16/24, the MDS indicated a Brief Interview for Mental Status Level of Harm - Minimal harm or (BIMS-an assessment of cognitive function) score of 15 (0-7 severe cognitive impairment, 8-12 moderate potential for actual harm cognitive impairment, 13-15 no cognitive impairment), indicating Resident 29 had no cognitive impairment.

Residents Affected - Some During a concurrent observation and interview on 8/12/24 at 9:11 a.m. with Resident 29 in Resident 29's room, Resident 29's breakfast contained a slice of ham and no potatoes. Resident 29 stated he did not like ham and preferred to have potatoes in his meal. Resident 29 stated kitchen staff were aware of his food preference, and they did not provide it to him. Resident 29 stated he had communicated with kitchen staff about his preferences before. Resident 29 stated he would not eat his breakfast due to his preferences not being given to him.

During an interview on 8/14/24 at 2:43 p.m. with the registered dietitian (RD), the RD stated residents were expected to receive their requested food preferences. The RD stated if food preferences were not provided, residents would not receive the therapeutic benefit of their meals.

During an interview on 8/15/4 at 1:59 p.m. with registered nurse (RN) 1, RN 1 stated nursing staff and kitchen staff were responsible for ensuring food provided to the resident matched their wants and needs. RN 1 stated Resident 29 talked to kitchen staff about his preference himself, so it was the kitchen staff's responsibility to update his meal ticket. RN 1 stated it was important to update and document a resident's preference on their meal ticket in order to ensure residents received the food they actually wanted to eat.

During a concurrent interview and record review on 8/15/24 at 3:21 p.m. with the certified dietary manager (CDM), Resident 29's meal ticket, undated, was reviewed. The meal ticket did not show any dislikes, or resident preferences listed. The CDM stated Resident 29's food preferences were not listed on his meal ticket. The CDM stated Resident 29 was upset as a result of not being provided his preferred food items. The CDM stated Resident 29 had communicated his preferences to him and his meal ticket had never been updated. The CDM stated Resident 29's preferences should have been documented upon his admission on 11/3/2021. The CDM stated it was his responsibility to update resident meal tickets with any preferences or dislikes. The CDM stated it was important to document meal preferences and dislikes because the facility was Resident 29's home and if he did not receive his preferred food he would not eat.

During an interview on 8/16/24 at 10:40 a.m. with the director of nursing (DON) the DON stated, Resident 29 should have had his meal preferences documented. The DON stated it was important to document and provide Resident 29's preferences because he may skip out on his meals if his preferences weren't given to him.

During a review of the facility's policy and procedure (P&P) titled, Food Preference, dated 2023, indicated, . Resident's food preferences will be adhered to within reason . Food preferences will be obtained as soon as possible through the initial resident screen . Food preferences can be obtained from the resident . Updating of food preferences will be done as the resident's needs change and/ or during quarterly review.

During a review of the facility's P&P titled, Menu Planning, dated 2023, indicated, Menus are planned to consider: a. input received from residents .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0806 50409

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0810 Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Level of Harm - Minimal harm or 28773 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure adaptive equipment was Residents Affected - Few provided for one sampled resident (Resident 3) when Resident 3 was not provided a sippy cup on his meal tray.

This failure had the potential to limit Resident 3's ability to drink independently and safely. The facility census was 75.

Findings:

During an observation on 8/13/24 at 12:04 p.m. in the kitchen, Resident 3's meal tray has two regular cups with no handle.

During a review of Resident 3's meal ticket (MT), MT indicated, Adaptive Equip [equipment]: Sippy Cup.

During an interview on 8/14/24 at 10:05 a.m. with Dietary Aide (DA) 2, DA 2 stated the kitchen does not have enough sippy cups to go on residents' meal trays.

During an interview on 8/14/24 at 10:06 a.m. with DA 1, DA 1 stated the kitchen does not have enough sippy cups and regular cups so he would also use disposable cups.

During a review of Resident 3's Order Summary Report (OSR), dated 8/14/24, the OSR indicated, Light up utensils and sippy cup to decrease spillage during meals.

During an observation on 8/14/24 at 10:17 a.m. in Resident 3's room, there was a pitcher with straw and a coffee cup on the bedside table. There was no sippy cup at Resident 3's bedside.

During an interview on 8/14/24 at 10:18 a.m. with Registered Nurse (RN) 1, RN 1 stated Resident 3 uses a sippy cup or a cup with a handle for all his drinks for safety. RN stated, We don't give him that [cups with no handles]. RN stated Resident 3 uses cups with a handle because he is on seizure precautions.

During an interview on 8/14/24 at 11:13 a.m. with the Certified Dietary Manager (CDM), the CDM stated he expects the kitchen to provide sippy cups for adaptive equipment.

During an interview on 8/14/24 at 1:58 p.m. with Certified Nursing Assistant (CNA) 5, CNA 5 stated he is the CNA for Resident 3, and he assisted Resident 3 with his meals. CNA 5 stated he had never seen Resident 3 use a sippy cup before. CNA 5 stated Resident 3 had a disposable cup with no handle on his meal tray. CNA 5 stated he is not aware of Resident 3 having an order for a sippy cup.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0810 During a review of the facility's policy and procedure (P&P) titled, Self-feeding Devices, dated 2023, the P&P indicated, Devices commonly used . such as divider plates and feeding cups, will be kept in stock. A Level of Harm - Minimal harm or physician's order is recommended. The Food & Nutrition Services Department will store self-feeding devices. potential for actual harm Residents needing devices will receive them with each meal or snack, on their meal trays.

Residents Affected - Few 50409

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48424

Residents Affected - Some Based on observation, interview, and record review the facility failed to maintain medical records which were complete, and accurately documented in accordance with accepted professional standards and practices for three of seven residents (Resident 51, Resident 2 and Resident 22) when:

1. Resident 51's name was spelled incorrectly on his Physician Order for Life Sustaining Treatment (POLST-

a medical document which outlines a patient's preferences for end-of-life care).

This failure resulted in inaccurate medical records being kept for Resident 51 and had the potential to cause confusion to staff who read his POLST form.

2. Resident 2's copy of Physician Orders for Life-Sustaining Treatment (POLST) form was not signed and readily available as part of Resident 2's current medical records.

3. Resident 22's copy of Physician Orders for Life-Sustaining Treatment (POLST) form was inaccurately dated when signed and readily available as part of Resident 22's current medical records.

These failures had the potential risk for Residents' 2 and 22's decision regarding their healthcare and treatment options not being honored.

Findings:

1. During a review of Resident 51's Admission Record (AR- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes), dated 8/15/24, the AR indicated Resident 51 was admitted with the following diagnoses: heart failure (a condition that occurs when

the heart can't pump enough blood to meet the body's needs), atrial fibrillation (condition which causes an irregular and often times a faster heartbeat), and muscle weakness.

During an interview on 8/15/24 with certified nursing assistant (CNA) 11, CNA 11 stated POLST forms were present for every resident. CNA 11 stated POLST forms were important because they detailed what to do

during situations like cardiac arrest (medical emergency characterized by when the heart stops beating). CNA 11 stated POLST forms needed to be accurate because they were a doctor's order and in the residents official medical record.

During a concurrent interview and record review on 8/15/24 at 2:17 a.m. with registered nurse (RN) 1, Resident 51's POLST, dated 2/2/24 was reviewed. The POLST indicated Resident 51 had his last name spelled incorrectly. RN 1 stated the nurse who received the resident during their first admission was responsible for completing the POLST. RN 1 stated the nurse who filled out Resident 51's POLST form should have spelled his name correctly, the nurse should have looked at his identification or hospital forms to ensure the name was the same. RN 1 stated it was important to ensure the POLST had the correct spelling for Resident 51's last name because it was a medical record and it tells staff what treatment the specific resident needed for end of life care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0842 During a concurrent interview and record review on 8/15/24 at 9:36 a.m. with the medical records coordinator (MRC), Resident 51's POLST, dated 2/2/24 was reviewed. The POLST indicated Resident 51 had his last Level of Harm - Minimal harm or name spelled incorrectly. The MRC stated Resident 51's POLST form was documented incorrectly and was potential for actual harm not accurate. The MRC stated Resident 51's last name should have been spelled correctly to ensure he had

an accurate medical record. The MRC stated it was important to have accurate medical records, so staff Residents Affected - Some know they treated the correct resident.

During an interview on 8/16/24 at 10:40 a.m. with the director of nursing (DON), the DON stated the nurse who filled out Resident 51's POLST should have ensured the spelling of the name was accurate. The DON stated the MRC should have also reviewed the POLST for accuracy. The DON stated it was important to have an accurate POLST so staff could have been sure they took care of the correct resident.

During a review of the facility's Medical Records Coordinator job description, dated 10/19/15, the job description indicated, . The Medical Records Coordinator maintains customer records containing all items required by State and Federal Regulation, and Reliant policies . 1. Maintain accurate order of open charts .

During a review of the facility policy and procedure (P&P) titled, Charting and Documentation, dated 1/18, indicated, 3. Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate .

40641

Findings:

2. During a review of Resident 2's Admission Record, (AR-document containing resident profiles) dated 8/15/24, the AR indicated, Resident 2 was readmitted to the facility on [DATE REDACTED] with diagnoses which included convulsions (a medical condition that causes a person's muscles to contract and relax rapidly and repeatedly, resulting in uncontrolled shaking) and hyperlipidemia (high lipid levels in the blood).

3. During a review of Resident 22's AR dated 8/15/24, the AR indicated, Resident 22 was readmitted to the facility on [DATE REDACTED] with diagnoses which included Chronic Obstructive Pulmonary Disease (COPD- common lung disease causing restricted airflow and breathing problems) anemia (not enough healthy red blood cells) and chronic pain.

During a concurrent interview and record review on 8/15/24 at 8:19 a.m. with Medical Record (MR) person,

the MR person stated she was responsible in making sure resident records are accurate and complete. Resident 2's POLST form was reviewed, MR person stated no signature on Section D for patient or legally recognized decision maker. MR person stated the POLST form is not a complete document because there is no signature of resident or decision maker. MR person stated admission nurse and licensed nurses are responsible in making sure there was signature. MR person stated she was responsible in making sure the POLST form was complete.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0842 During a concurrent interview and record review on 8/15/24 at 8:24 a.m. with MR person, Resident 22's POLST form was reviewed, MR person stated the POLST form of Resident 22 was not accurate. MR person Level of Harm - Minimal harm or stated the date when the POLST form was completed was 1/4/24 and the date physician signed was 1/4/23. potential for actual harm MR person stated the POLST form was completed and came from general acute care hospital (GACH). MR person stated, . I did not checked the documents closely prior to scanning into the computer. MR person Residents Affected - Some stated they could have completed a new one that was complete and accurate.

During an interview on 8/16/24 at 2:35 p.m. with the Director of Nursing (DON), the DON stated the IDT (interdisciplinary team- group of health professionals from different disciplines who work together to treat a patient's condition or diagnosis) reviews resident records when admitted or readmitted back in the facility.

The DON stated Resident 2 and 22's POLST forms were inaccurate and incomplete.

During an interview on 8/16/24 at 3:35 p.m. with the Administrator (ADM), the ADM stated POLST forms needed to be accurate and complete before they are scanned in the computer system. The ADM stated, . Medical Records person should be checking records more closely to ensure accurateness of records before

it is put in the system .

During a review of the facility's policy and procedure (P&P) titled Physician Order for Life Sustaining Treatment, dated 3/21 indicated, . A completed, fully executed POLST is a physician order, and is immediately actionable . The POLST will be reviewed by the facility interdisciplinary team during the quarterly care planning conference .

https://www.[NAME]-[NAME].org/programs/support-services/services/healthcare-ethics/polst.html, .The POLST form is completed by a patient ' s physician (or by someone who has undergone special training about POLST and who works with the patient ' s physician) in conjunction with thorough conversation with

the patient regarding the patient ' s current and future health conditions and treatment preferences. Both the physician and patient must sign the POLST. If the patient lacks capacity to make medical decisions, the patient ' s legally recognized decision-maker can participate in both completing and signing the POLST form .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 48424 potential for actual harm Based on 0bservation, interview, and record review the facility failed to provide a sanitary environment to Residents Affected - Many help prevent the development and transmission of communicable diseases and infections for two of seven residents (Resident 61 and Resident 238) when Certified Nursing Assistant (CNA) 1 did not perform hand hygiene (process of washing or disinfecting hands to prevent the spread of germs) after leaving the shared room of Resident 61 and Resident 238, while carrying a bag of soiled (dirty or contaminated) linen. CNA 1 then moved the linen cart without performing hand hygiene.

This failure had the potential to contaminate the surface of the linen cart and cause cross contamination (when germs move from one area to another) of other surfaces.

Findings:

During an observation on 8/12/24 at 10:47 a.m. outside of Resident 61 and Resident 238's room, CNA 1 exited Resident 61 and Resident 238's room carrying a bag of soiled linen. CNA 1 disposed of the soiled linen bag and did not perform hand hygiene after; CNA 1 then pushed the linen cart forward without performing hand hygiene.

During an interview on 8/12/24 at 3:50 p.m. with CNA 1, CNA 1 stated he came out of Resident 61 and Resident 238's room to dispose of the soiled linen and pushed the linen cart forward without performing hand hygiene after. CNA 1 stated he should have performed hand hygiene before moving the linen cart. CNA 1 stated hand hygiene was important to prevent the spread of germs across surfaces.

During an interview on 8/14/24 at 2:35 p.m. with CNA 5, CNA 5 stated all staff were supposed to perform hand hygiene anytime they entered or exited a resident room. CNA 5 stated staff were not supposed to touch any surfaces until after they did hand hygiene. CNA 5 stated if a staff member needed to dispose of something they should have disposed of the item and then performed hand hygiene afterwards, before touching any surface. CNA 5 stated it was important to perform hand hygiene because it prevented cross contamination of other surfaces.

During an interview on 8/15/23 at 3:45 p.m. with the infection preventionist (IP), the IP stated CNA 1 should have conducted hand hygiene before moving the linen cart after he disposed of the soiled linen from Resident 61 and Resident 238's room. The IP stated all staff members were supposed to do hand hygiene

before they touched any surface because it helped keep the equipment and facility clean.

During an interview on 8/16/24 at 9:17 a.m. with the director of staff development (DSD), the DSD stated CNA 1 should have conducted hand hygiene before moving the linen cart after he disposed of the soiled linen from Resident 61 and Resident 238's room. The DSD stated performing hand hygiene was important because it helped prevent the spread of infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0880 During an interview on 8/16/24 at 10:40 a.m. with the director of nursing (DON), the DON stated CNAs were supposed to perform hand hygiene anytime they came out of rooms or came in contact with dirty linens. The Level of Harm - Minimal harm or DON stated if dirty materials were being disposed of staff should have done hand hygiene after their potential for actual harm disposal. The DON stated if staff did not perform hand hygiene, they could have carried infections with them

on their hands and they could potentially spread it to others. Residents Affected - Many

During a review of the facility's policy and procedure (P&P) titled, Handwashing, undated, the P&P indicated, . All staff members will wash their hands before and after direct resident care and after contact with potentially contaminated substances to prevent, to the extent possible, the spread of nosocomial (sickness a person receives when the stay in a facility) infections .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Minimal harm or potential for actual harm 41608

Residents Affected - Few Based on observation and interview, the facility failed to provide the minimum of at least 80 square feet per resident in 17 resident bedrooms (Rooms 4, 5, 6, 7, 8, 9, 10, 11, 12, 14, 15, 16, 17, 18, 19, 20 and 21) when there were two residents in rooms which did not meet the square footage requirement.

This failure had the potential to place residents at risk for not having sufficient space to accommodate residents' needs, privacy, and comfort.

Findings:

During a concurrent observation and interview on 8/16/24 at 11:05 a.m. with the Maintenance Supervisor (MS), facility tour was conducted. MS stated the rooms failed to provide the minimum square footage as required by regulation. Room variations were in accordance with the particular needs of the residents. The residents had a reasonable amount of privacy. Closets and storage space were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents.

Room Number Square Feet Number of Residents

4 142.2 2

5 142.1 2

6 143.2 2

7 140.97 2

8 142.1 2

9 142.1 2

10 142.1 2

11 142.1 2

12 142.1 2

14 142.1 2

15 142.2 2

16 142.1 2

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0912 17 141.7 2

Level of Harm - Minimal harm or 18 142.1 2 potential for actual harm 19 142.2 2 Residents Affected - Few 20 142.2 2

21 142.1 2

Recommend waiver continue in effect.

_____________________________________

Health Facilities Evaluator Nurse Date

Request waiver continue in effect.

______________________________________

Facility Administrator Date

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 41608

Residents Affected - Few Based on observation, interview, and record review, the facility failed to provide a sanitary, comfortable environment for four of 31 sampled residents (Resident 11, Resident 22, Resident 47 and Resident 60), when the smell of urine was noted in room [ROOM NUMBER] and hallway.

This failure had the potential for Resident 11, 22, 47 and 60, to experience an uncomfortable environment.

Findings:

During an observation on 8/12/24 at 8:15 a.m. in the hall outside of rooms [ROOM NUMBERS], a strong urine odor was noted.

During an observation in 8/12/24 at 8:20 a.m. with Resident 11 in room [ROOM NUMBER], there was a strong urine odor in the room. Resident 11 was sitting up in his bed, eating his breakfast. The privacy curtain was pulled between Resident 11's bed and Resident 60's bed.

During an observation on 8/12/24 at11:55 a.m. in the hall outside of room [ROOM NUMBER] and, a strong urine odor was noted.

During an observation and interview on 8/12/24 at 1:15 p.m. with Resident 11

in his room, Resident 11 stated, .I have a headache from the strong smell of urine in this room .

During an observation on 8/13/24 at 9:00 a.m. in the hall outside of rooms [ROOM NUMBERS], a strong odor of urine was noted.

During an observation on 8/13/24 at 3:41 p.m. in the hall between resident rooms [ROOM NUMBERS], a strong odor of urine was noted.

During an observation on 8/14/24 at 10:55 a.m. in the hall between room [ROOM NUMBER] and 16, a strong odor of urine was noted.

During a concurrent observation and interview on 8/16/24 at 10:15 a.m. with the Infection Preventionist (IP),

in room [ROOM NUMBER], the IP stated, .the smell of urine is very strong as if it was in the walls and floor .

the smell is not acceptable for the residents in this room .

During a concurrent observation and interview on 8/16/24 at 10:14 a.m. in room [ROOM NUMBER] with the Activities Coordinator (AC), the AC stated, . the room smells like urine . I would not want to stay in the room .

this is not a homelike environment .

During an interview on 8/16/24 at 10:30 p.m. in room [ROOM NUMBER] with the Maintenance Supervisor (MS), the MS stated, . the room has been deep cleaned twice and the odor of urine is still present . I would not want to live in this room .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0921 During an interview on 8/16/24 at 3:15 p.m. with the Administrator (ADM), the ADM stated, room [ROOM NUMBER] was cleaned twice and the odor was still present. The ADM stated he thought the odor was Level of Harm - Minimal harm or trapped in the laminate flooring. The ADM stated, the residents should not have to be in a room that smells potential for actual harm like urine.

Residents Affected - Few During a review of Resident 11's Admission Record [AR], dated 8/16/24, the AR indicated, Resident 11 was admitted on [DATE REDACTED] with diagnosis of Muscle Weakness, History of Falling, Chronic Pain, and Cancer of the Left Kidney.

During a review of Residents 11's Minimum Data Set (MDS- a resident assessment tool used to identify resident cognitive and physical function) Section C assessment dated [DATE REDACTED], indicated Resident 8's Brief

Interview of Mental status assessment (BIMS - assessment of cognitive status for memory and judgement) scored 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, 00-07 indicates severe impairment and 99 indicates they are unable to complete the interview). The BIMS assessment indicated Resident 15 had no cognitive impairment.

During a review of Resident 22's AR dated 8/15/24, the AR indicated Resident 22 admitted on [DATE REDACTED] with diagnosis of Heart Failure, Dysphagia (difficulty swallowing, Chronic Pain, Anxiety (feeling of fear, dread, uneasiness as a result to stress), and Depression (a persistent feeling of sadness, loss of interest in activities).

During a review of Resident 22's MDS Section C indicated, Resident 22 had a BIMS score of 14, no cognitive impairment.

During a review of Resident 47's AR dated 8/15/24, the AR indicated Resident 47 admitted on [DATE REDACTED] with diagnosis of Muscle Weakness, Difficulty Walking, Alcohol Abuse and Anxiety.

During a review of Resident 47's MDS Section C indicated, Resident 47 had a BIMS score of 7, moderate cognitive impairment.

During a review of Resident 60's AR dated 8/15/24, the AR indicated Resident 60 admitted on 1 with diagnosis of Cognitive Communication Deficit, History of Falling, and Muscle Weakness. m

During a review of Resident 60's MDS Section C indicated, Resident 60 had a BIMS score of 11, moderate cognitive impairment.

During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment dated 1/2018, the P&P indicated, .a. clean, sanitary, and orderly environment . f. pleasant neutral scents .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Level of Harm - Minimal harm or 28773 potential for actual harm Based on observation, interview, and record review, the facility failed to maintain an effective pest control Residents Affected - Some program when cockroaches were found in the facility kitchen and hallway.

This failure had the potential to result in residents, staff, and visitors to contract diseases caused by pests.

The facility census was 75.

Findings:

During a concurrent observation and interview on 8/12/24 at 10:31 a.m. with Dietary Aide (DA) 2 in the kitchen, there was a cockroach crawling on the wall at the dish machine area. DA 2 confirmed she saw the cockroach. DA 2 stated the kitchen had issues with cockroaches in the past.

During an observation on 8/12/24 at 10:32 a.m. in the kitchen, there was a cockroach crawling on the floor by

the handwashing station.

During an observation on 8/12/24 at 10:34 a.m. in the kitchen, there was a cockroach crawling on the floor under the food preparation table, near the three-compartment sink.

During an interview on 8/12/24 at 10:40 a.m. with the Certified Dietary Manager (CDM), the CDM stated the kitchen staff told him there has been issues with cockroaches in the kitchen.

During a concurrent observation and interview on 8/13/24 at 10:24 a.m. with Resident 30 in Station 2 hallway by the shower room, there was a cockroach crawling on the floor. Resident 30 stated he saw the cockroach and he has been seeing cockroaches often in the facility.

During a concurrent observation and interview on 8/13/24 at 10:25 a.m. with the Maintenance Supervisor (MS) in Station 2 hallway, the cockroach crawled into a crack on the shower room floor. The MS stated he saw where the cockroach went on the shower room floor and stated he would need to seal that up.

During an observation on 8/13/24 at 12:13 p.m. in Station 2 shower room, there was a cockroach crawling on

the floor.

During an interview on 8/13/24 at 12:37 p.m. with the Pest Control Technician (PCT), the PCT stated he is

the pest control technician that services the facility. The PCT stated he had been to the facility twice in July and June. PCT stated he had made recommendations to seal cracks in the corners of the kitchen at the dish machine area, but he is not sure if it had been done.

During a review of the facility's policy and procedure (P&P) titled, Pest Control, dated January 2018, the P&P indicated, This facility maintains an on-going pest control program to ensure that the building is kept free of insects and rodents.

50409

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 54 555426

F-F803.

During a review of the facility's Summer Menus for the lunch meal for August 12, 2024, showed the regular diet with regular portions to receive: 3 ounces french dip - roast beef, 1 soft sandwich roll, 2 ounces Au Jus juice/sauce, 1/2 cup sweet potato fries, #8 scoop (1/2 cup) corn coleslaw; #12 cappuccino mousse (cap mousse). The large portion showed: 3 ounces roast beef, 1 soft sandwich roll, 3/4 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Mechanical Soft diet showed: Ground roast beef #10 scoop, 1/2 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Puree diet showed: #8 scoop roast beef moisten with broth, #12 scoop puree roll, #8 scoop puree sweet potato fries, #12 scoop corn coleslaw, #12 scoop cap mousse. CCHO, regular texture diet showed: 3 ounces roast beef with 1 roll, 1/4 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Renal diet showed: 3 ounces roast beef, 1 roll, 2 ounces Au Jus, pineapple ring (no fries), #8 scoop corn coleslaw, Sugar cookies - 2 small.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0802 During a review of the facility's employee files (EF), the EF indicated DA 1 was hired on 6/23/22, DA 2 was hired on 10/26/23, and [NAME] 1 was hired on 2/20/23. DA 1, DA 2, and [NAME] 1 did not have a Level of Harm - Minimal harm or competency or skills check completed. potential for actual harm

During an interview on 8/14/24 at 11:13 a.m. with the Certified Dietary Manager (CDM), the CDM stated Residents Affected - Some there were no competency or skills check done for DA 1, DA 2 and [NAME] 1.

During a review of the facility's RCR, dated 7/29/2024, the RCR indicated, Concern/Request Identified by the Resident Council: Food Quality & preferences . Department Head Response . look at food and tray cards [meal tickets] for proper preferences and diets . educated staff, not reading cards [meal tickets] properly.

During a review of the facility's dietary in-services, the CDM was unable to provide documentation of in-services regarding portion sizes, following menus and therapeutic diets.

During a review of the facility's policy and procedure (P&P) titled, Demonstrating Food Safety and Job Competency for Food and Nutrition Services Employees, dated 2023, the P&P indicated, Food and Nutrition Services employees will be tested on the competency of their skill to meet the needs of the facility. Each employee must successfully complete the following within each year (12 months) for the job they were hired to perform: Verification of Demonstrated Job Competencies (Cooks or Diet Aids) - Attachment A and B, Equipment Competency for the appropriate equipment used in the job - Attachment C, 2 written tests.

50409

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 28773

Residents Affected - Many Based on observation, interview, and record review, the facility failed to ensure the planned menus were followed for the lunch meal on August 12, 2024 when:

1. Incorrect portion sizes were used on the therapeutic diets:

a. 1/2 cup (4 ounces) of sweet potato fries were served instead of 1/4 cup (2 ounces) to 20 residents (Resident 42, 5, 16, 6, 26, 9, 23, 60, 12, 74, 34, 4, 37, 24, 77, 25, 22, 29, 78, and 13) who were on a Consistent Carbohydrate (CCHO) diet (a diet that provides a consistent amount of carbohydrates at each meal and from day to day to help keep blood sugar levels stable); and

b. #16 scoop (2 ounces) of roast beef was served instead of #10 scoop (3.2 ounces) to eight residents (Resident 21, 57, 61, 54, 3, 55, 66, and 28) who were on a mechanical soft diet (a diet of soft-textured foods that are easy to chew and swallow); and

c. #12 scoop (2.67 ounces) of pureed roast beef was served instead of #8 scoop (4 ounces) to seven residents (Resident 27, 1, 69, 2, 15, 49, and 44) on a puree diet (designed for residents who have difficulty chewing and/or swallowing and the texture of the food should be of a smooth, moist consistency and able to hold its shape); and

d. Double portions of all food items were given to three residents (Resident 227, 20, and 44) on a large portion diet; and

e. 4 ounces of sweet potato fries were given to two residents (Resident 13 and 45) on a renal diet (diet with lower amounts of sodium, protein, potassium, and phosphorus provided for residents with limited kidney function) and did not receive the food stated on the menu.

2. Pureed coleslaw was not measured when placed into bowls; and

3. Cappuccino mousse was not served, and chocolate pudding was not filled up consistently in the scoop when portioned as the dessert; and

4. Corn coleslaw was not served.

These failures had the potential to result in residents on therapeutic diets to not meet their physician's prescribed diet order and their nutrition needs to not be met which can result in over or under nutrition.

Findings:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 54 555426 Department of Health & Human Services Printed: 09/13/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 555426 B. Wing 08/16/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Fresno Postacute Care 1233 A Street Fresno, CA 93706

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 0803 1. During a review of the facility's Summer Menus for the lunch meal for August 12, 2024, showed the regular diet with regular portions to receive: 3 ounces (oz.) french dip - roast beef, 1 soft sandwich roll, 2 Level of Harm - Minimal harm or ounces Au Jus juice/sauce, 1/2 cup sweet potato fries, #8 scoop (1/2 cup) corn coleslaw; #12 cappuccino potential for actual harm mousse (cap mousse). The large portion showed: 3 ounces roast beef, 1 soft sandwich roll, 3/4 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Mechanical Soft diet showed: Ground roast Residents Affected - Many beef #10 scoop, 1/2 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Puree diet showed: #8 scoop roast beef moisten with broth, #12 scoop puree roll, #8 scoop puree sweet potato fries, #12 scoop corn coleslaw, #12 scoop cap mousse. CCHO, regular texture diet showed: 3 ounces roast beef with 1 roll, 1/4 cup sweet potato fries, #8 scoop corn coleslaw, #12 scoop cap mousse. Renal diet showed: 3 ounces roast beef, 1 roll, 2 ounces Au Jus, pineapple ring (no fries), #8 scoop corn coleslaw, Sugar cookies - 2 small.

During an observation of the lunch meal service on 8/12/24 starting at 12:31 p.m. in the kitchen, the steam table had scoops for the following: #12 scoop for the regular texture roast beef, #16 scoop for the mechanical soft roast beef, #12 scoop for the pureed roast beef, and four-ounce (oz - unit of measurement) scoop (1/2 cup) for the regular texture sweet potato fries. Cross Reference