Windsor Post-acute Healthcare Center Of Modesto

F-F203 stated Resident R203 had a stroke in February 2024 and was now on hospice care.

During an observation on 07/30/24 at 1:32 PM, the Restorative Nursing Assistant pulled back the covers in

the bed over Resident R203's left hand and the bandage/sock combination was in place. The Restorative Nursing Assistant stated she did not know why Resident R203 had the bandage/sock combination in place.

Review of the Care Plan, dated 07/26/24 and located in the EMR under the Care Plan tab, revealed a problem of ADL self-care performance deficit r/t [related to] weakness/decreased mobility, dx [diagnosis] of acute encephalopathy, DM [diabetes mellitus], dysphagia [swallowing disorder], hx [history] of CVA [cerebrovascular accident or stroke]. The Care Plan did include application of a sock to Resident R203's hand and did not identify restraint use.

During an interview on 07/31/24 at 3:42 PM, CNA2 stated she had not applied a sock to Resident R203's hand and had not seen this. CNA2 stated Resident R203 had previously unfastened his incontinence brief on one side and then urinated in the bed, soiling the bedding and that was likely why he had something applied to his left his hand. CNA2 stated Resident R203 was confused and dependent for care.

During an interview on 08/01/24 at 1:18 PM, LVN3 (the wound care nurse) stated she was not aware of Resident R203 wearing a sock on his left hand and further stated he should not be wearing one. LVN3 stated Resident R203 had one skin tear to his forearm that had a dry dressing applied; however, she was not aware of other skin issues to his arms or scratching. ADON1, who was present, stated the sock would prevent Resident R203 from accessing his body and there should be a physician's order for something like that.

During an interview on 08/02/24 at 3:35 PM, LVN5 stated she was Resident R203's nurse on 07/30/24 during day shift. LVN5 stated she was notified by the day shift CNA around 6:30 AM on 07/30/24 that Resident R203 had a sock

on his left hand. LVN5 stated she had not been aware of the sock being there prior to that day. LVN5 stated there was nothing in report about the sock and she asked the night shift nurse about it and was told the night shift nurse did not know about it. LVN5 stated she meant to go and check on the application of the sock on Resident R203's left hand but got busy, and when she went to give Resident R203 medications, his arm was covered with the bedding and she forgot. LVN5 stated she was not aware of a reason for the application of the sock. LVN5 stated Resident R203 was anxious at times and placed his hand in his incontinence brief and rubbed himself. LVN5 stated Resident R203 was not able to put the sock on his hand and would not be able to remove it either.

During an interview on 08/02/24 at 3:32 PM, the hospice LVN stated she had never seen a sock on Resident R203's hand and there were no directions from hospice that would warrant it. The hospice LVN stated Resident R203 would not have been able to put the sock on himself and did not think he could remove it. The hospice LVN stated Resident R203's sister stated he was putting his hand in his brief and was fidgeting in that area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0604 During an interview on 08/02/24 at 4:12 PM, the hospice Registered Nurse (RN) stated she saw Resident R203 on 07/30/24 and noticed a sock on his left hand. The hospice RN stated she did not know why it was there or if Level of Harm - Minimal harm or it was a facility intervention for something. The hospice RN stated hospice would not order a sock to be potential for actual harm applied.

Residents Affected - Few During an interview on 08/02/24 at 4:43 PM, the DON stated she had heard about the sock that was applied

on 07/30/24 to Resident R203's hand. The DON stated she did not know why it was there or who applied it. The DON verified the bandage/sock combination could function as a restraint. The DON stated for all restraints there should be a physician's order, assessment, and care plan in place.

Review of the facility's Use of Restraints policy dated April 2017 revealed, Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls . The definition of a restraint is based on the functional status of the resident and not the device. If the resident cannot remove a device in the same manner in which the staff applied it given that resident's physical condition (i.e. side rails are put back down, rather than climbed over), and this restricts his/her typical ability to change position or place, that device is considered a restraint . Examples of devices that are/may be considered physical restraints include . hand mitts . Practices that inappropriately utilize equipment to prevent resident mobility are considered restraints and are not permitted .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40824

Residents Affected - Few Based on interview, record review, and facility policy review, the facility failed to ensure one of two residents (Resident (R) 95) reviewed for ''Pre-Admission Screening and Resident Review (PASARR)'' had a level two assessment completed. Specifically, the facility failed to re-submit a positive PASSAR Level I screening,

after a PASARR Level II was not able to be conducted. This failure placed the resident at risk for unmet care needs and not receiving appropriate mental health support/services as needed.

Findings include:

Review of Resident R95's ''Admission Record,'' located in the electronic medical record (EMR) under the ''Profile'' tab, showed a facility admitted [DATE REDACTED] and re-admission on 06/03/24. Resident R95's primary medical diagnoses included schizoaffective disorder and bipolar disorder.

Review of Resident R95's admission ''Minimum Data Set (MDS)'' with an Assessment Reference Date (ARD) of 05/03/24, located in the EMR under the ''MDS'' tab, included a ''Brief Interview for Mental Status (BIMS)'' score of 12 out of 15, indicating Resident R95 had moderate cognitive impairment. Per the MDS, diagnoses included bipolar disease and schizoaffective disorder; and Resident R95 was noted to be taking antipsychotic medications.

Review of Resident R95's ''Care Plan,'' located in the EMR under the ''Care Plan'' tab, included problems including mood swings, agitation, hallucinations, aggressive behaviors with staff, makes non-factual claims regarding staff, difficult to redirect, demanding expectations of staff, yelling, screaming, disruptive, sexually inappropriate comments/insults, verbal aggression with staff and roommate, mood swings, and attention seeking behaviors. Additionally, she was noted to take psychotropic medications for the treatment of bipolar and schizoaffective disorders.

Review of Resident R95's letter, provided by the facility and dated 12/13/23, from the State of California- Health and Human Services Agency, Department of Health Care Services ''Re: Positive Level I Screening Indicates a Level II Mental Health Evaluation is Required,'' indicated a Level I screening was submitted by the facility on 12/14/23 with results indicating ''positive for suspected MI [mental illness] .Your facility will be contacted within two to four days to set up an appointment for an evaluator to conduct a Level II Mental Health Evaluation. The evaluation process involves a thorough review of your records and may include telephone contact or a visit with you. Once the Level II Mental Health Evaluation is complete, you will receive a report that will provide recommendations for specialized services .''

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0644 Review of Resident R95's letter, provided by the facility, dated 12/17/23 from the State of California- Health and Human Services Agency, Department of Health Care Services, UNABLE TO COMPLETE LEVEL II Level of Harm - Minimal harm or EVALUATION indicated they were ''unable to complete level II evaluation . Federal law requires all potential for actual harm individuals seeking admission to a Medicaid Certified Nursing Facility (NF) receive a Level I Mental Health Screening. The Level I Mental Health Screening identifies if an individual has a suspected Mental Illness (MI) Residents Affected - Few or an Intellectual/Developmental Disability or Related Condition (ID/DD/RC). If MI is suspected, then a Level II Mental Health Evaluation may be conducted to determine if the individual can benefit from specialized mental health services. a Level II Mental Health Evaluation was not scheduled for the following reason: The individual was unable to participate in the Evaluation. The case is now closed. To reopen, please submit a new Level I Screening .''

During an observation on 08/02/24 at 2:30 PM, Resident R95 was observed yelling in the hall stating staff did not care about her because they did not immediately stop what they were doing to bathe/shower her.

During an observation on 08/02/24 at 6:00 PM, Resident R95 was observed sitting up in her wheelchair in her room yelling it was about time that they bathed her.

During an interview on 08/01/24 at 10:47 AM, the Social Services Director (SSD) confirmed Resident R95 had a positive PASARR Level I screening dated 12/13/23. The SSD stated the normal process was for the PASARR office to call the facility during the week, the determination letter was dated 12/17/23 which was a Sunday, and she felt that maybe the nurses on duty did not have access to the PASARR information.

During an interview on 08/01/24 at 11:28 AM, the Director of Nursing (DON) confirmed Resident R95 had a positive PASARR Level I screening dated 12/13/23. The DON stated the state of California contracted with a company of psychologists that followed-up with PASARR Level II's. This process usually occurred during the week and the DON or Assistant DON would assist with the process. The DON stated she was not employed at the facility in 12/2023 and was not sure why the PASARR Level II letter dated 12/17/23 indicated that the resident was ''unable to participate in the evaluation.'' The DON confirmed the facility did not have a process

in place to ensure that follow-ups were completed but should have been.

During an interview on 08/01/24 at 1:26 PM, the PASRR Manager reviewed internal documentation that indicated the Level I screening was submitted by Registered Nurse (RN) 1 on 12/13/23. The normal process was for the contracted PASRR staff to contact the individual that submitted the Level I screening and in this particular case, the available staff that answered the phone could not answer the questions to complete the PASRR II screening. The expectation was for the facility to submit a new Level I PASRR screening so that

the Level II could be completed for determination of services needed.

During an interview on 08/01/24 at 1:51 PM, the Admissions Director (AD) stated the PASARR office did not typically notify the facility of screening results unless they spoke directly with someone at the facility. A determination letter would be uploaded to the PASARR system. The determination letter should be followed up by the person submitting the Level I screening. The AD was not sure why the PASARR screening was not followed up but should have been. The AD confirmed that the facility did not have a process in place to ensure that follow-ups were completed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0644 Review of the facility policy titled, ''Admission Criteria'' revised 03/2019 ''. All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disorders (RD) Level of Harm - Minimal harm or per the Medicaid Pre-Admission Screening and Resident Review (PASARR) process. a. The facility potential for actual harm conducts a Level I PASARR screen for all potential admissions, regardless of payer source, to determine if

the individual meets the criteria for a MD, ID or RD. b. If the level I screen indicates that the individual may Residents Affected - Few meet the criteria for a MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process . The social worker is responsible for making referrals to

the appropriate state-designated authority. c. Upon completion of the Level II evaluation, the state PASARR representative determines if the individual has a physical or mental condition, what specialized or rehabilitative services he or she needs, and whether placement in the facility is appropriate . The interdisciplinary team determines whether the facility is capable of meeting the needs and services of the potential resident that are outlined in the evaluation.''

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 21382

Residents Affected - Few 2. Review of Resident R253's undated Admission Record, located in the EMR Profile tab, revealed Resident R253 was admitted

on [DATE REDACTED] with diagnoses including secondary malignant neoplasm of unspecified ovary and cutaneous abscess of the abdominal wall with hospice services.

Review of the EMR revealed a POLST (Physician Order for Life Saving Treatment) completed by Resident R253 on 07/21/24 located in the Documents tab of the EMR which documented Resident R253 did not want resuscitation.

Review of the Orders tab of the EMR revealed a physician order for DNR (Do Not Resuscitate), dated 07/21/24.

Review of the care plan, dated 07/22/24 and located in the EMR Care Plan tab, revealed there was not a care plan for advance directives or her code status.

During an interview on 08/02/24 at 4:00 PM, the MDS Director confirmed a care plan for code status should have been initiated when Resident R253 was admitted .

Review of facility policy titled, ''Care Plans-Baseline,'' revised 03/2022, revealed, ''A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission.

Policy Interpretation and Implementation:

1. The baseline care plan includes instructions needed to provide effective, person-centered care of the resident that meet professional standards of quality care and must include the minimum healthcare information necessary to properly care for the resident including, but not limited to the following:

a. Initial goals based on admission orders and discussion with the resident/representative;

b. Physician orders;

c. Dietary orders;

d. Therapy services;

e. Social services; and

f. PASARR recommendations, if applicable.''

25232

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0655 Based on observation, record review, interview, and policy review, the facility failed to ensure that a baseline care plan included the usage of side rails for one of one resident (Resident (R) 304) reviewed for side rails Level of Harm - Minimal harm or out of a total sample of 32 residents; and included code status for one of 32 sampled residents (Resident R253). This potential for actual harm failure created the potential for staff to not have all the information needed to care for residents.

Residents Affected - Few Findings include:

1. Review of Admission Record,'' located under the ''Profile'' tab in the electronic medical record (EMR), indicated that Resident R304 was admitted to the facility on [DATE REDACTED] with a diagnosis of systemic lupus erythematosus (a chronic autoimmune disease) and systemic sclerosis (stiffening of the tissue).

During observation in Resident R304's room and interview on 07/30/24 at 10:00 AM, bilateral 1/4 side rails observed in

the up position. Resident R304 said that she used them sometimes to reposition.

During observation of Resident R304's room on 07/31/24 at 3:50 PM, bilateral 1/4 side rails were observed in the up position even though Resident R304 was sitting at the end of her bed. Again on 08/01/24 at 8:30 AM, observed Resident R304 lying in her bed with bilateral 1/4 side rails in the up position.

Review of admission ''Minimum Data Set (MDS)'' assessment, located under the ''MDS'' tab in the EMR, with

an Assessment Reference Date (ARD) of 07/27/24 indicated a ''Brief Interview of Mental Status (BIMS)'' score of 14 out of 15, indicating intact cognition.

Review of ''Side Rail Assessment,'' located under the EMR ''Evaluation'' tab and dated 07/22/24, revealed

the side rails were used to promote independence.''

Review of ''Physician Order,'' dated 07/22/24, located under the EMR ''Orders'' tab, indicated ''Side rail 1/4 X 2 up in bed as enabler to assist with bed mobility- nonrestraint.''

Review of ''Baseline Care Plan,'' located under the ''Evaluation'' tab, dated 7/23/24 indicated no evidence of side rails being used for positioning.

During an interview on 08/02/24 at 10:00 AM, the Director of Nursing (DON) confirmed that the baseline care plan did not address side rails.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15406 potential for actual harm Based on interview and record review, the facility failed to ensure one out of one residents (Resident (R) Residents Affected - Few 204) reviewed for bowel and bladder out of a total sample of 32 residents received timely care for constipation. The bowel protocol was not initiated until Resident R204 failed to have a bowel movement for five days. Resident R204 went a total of ten days without having a bowel movement putting him at risk for a fecal impaction.

Findings include:

Review of the undated Admission Record, located in the electronic medical record (EMR) under the Profile tab revealed Resident R204 was admitted to the facility on [DATE REDACTED] with diagnoses including COVID 19, type two diabetes mellitus, and acute kidney failure.

Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24, located in the EMR under the MDS tab, revealed Resident R204 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15. Resident R204 was continent of bowel and did not have constipation.

Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed Resident R204 was not prescribed any regularly scheduled medications for constipation. However, the physician prescribed the following bowel regimen:

Bowel Regimen: (1) MOM [milk of magnesia] 400 mg [milligrams]/5 ml [milliliters], give 30 cc [cubic centimeters] po [by mouth] Q [every] 24 hrs [hours] PRN [as needed] [for] constipation;

Bowel Regimen: (2) Dulcolax suppository 10 mg per rectum QD [day] PRN for constipation in MOM is ineffective;

Bowel Regimen: (3) Fleet Enema 7-19 gm [grams]/118 ml per rectum Q 3-day PRN for constipation if Dulcolax is ineffective.

Review of the POC [Point of Care] Response History, Task: Bowel Movements report from 07/17/24 through 08/01/24 in the EMR under the Tasks tab revealed Resident R204 had his first bowel movement on 07/27/24 (ten days

after admission).

Review of the Medication Administration Record (MAR) for July 2024 in the EMR under the Orders tab revealed Resident R204 first received medication (per the bowel protocol consisting of MOM 400 mg/5 ml, 30 cc) to treat constipation on 07/22/24. This was the fifth day of not having a bowel movement.

Review of the MAR for July 2024 in the EMR under the Orders tab revealed that after 07/22/24, the facility took timely action to address Resident R204's constipation by enacting steps two and three of the bowel regimen, receiving and administering orders for additional laxative medications, obtaining a complete blood count and basic metabolic panel, providing intravenous fluids, and providing extra oral fluids.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0684 Review of a Nurse's Note dated 07/26/24 in the EMR under the Progress Notes tab,

Level of Harm - Minimal harm or revealed Resident R204 was sent to the emergency roiagnom on [DATE REDACTED] due to not having a bowel movement. Resident R204 potential for actual harm returned later on 07/26/24 without having a bowel movement, Resident R204 did not have impaction or other complications. Residents Affected - Few

Review of Resident R204's EMR revealed that neither the Baseline Care Plan dated 07/18/24 under the Evaluation tab or the Care Plan initiated on 07/18/24 under the Care Plan tab included the problem of constipation.

During an interview on 07/30/24 at 2:15 PM, Resident R204 stated he had been extremely sick when he was admitted to the facility due to COVID 19 and had not felt like eating or drinking much. Resident R204 stated he was tired and did not want to be interviewed further.

During an interview on 08/01/24 at 1:43 PM, Assistant Director of Nursing (ADON) 1 stated the bowel protocol called for MOM was to be administered after 72 hours (three days) if a resident failed to have a bowel movement. ADON1 stated if MOM did not result in a bowel movement, then the Dulcolax suppository was given the next shift, and then if that did not work a fleets enema was given the next shift. ADON1 reviewed Resident R204's record and confirmed the bowel protocol was initiated on the fifth (07/22/24) day instead of

on the third day without Resident R204 having a bowel movement.

During an interview on 08/01/24 at 5:32 PM, the Director of Nursing (DON) stated MOM should be given if a resident went three days without a bowel movement. The DON stated if MOM did not produce a bowel movement, the suppository should be given on the next shift and if that did not produce a bowel movement,

the enema should be given on the next shift. The DON stated the managed care provider had contacted the facility and requested they conduct an investigation into the failure to institute the bowel protocol timely. The DON stated the investigation revealed that the bowel protocol was not initiated timely. The DON stated there were alerts in the EMR that prompted nurses that Resident R204 failed to have a bowel movement and was due for initiation of the bowel protocol. The DON stated the EMR flagged Resident R204's failure to have a bowel movement

after three days. The DON stated the floor nurses had not initiated MOM for two days (on 07/20/24 and 07/21/24) even though a failure to have a bowel movement was flagged in the EMR for Resident R204.

During an interview on 08/02/24 at 5:05 PM, the DON verified there was no care plan initiated to address Resident R204's constipation. The DON stated nurses should add acute problems that arose prior to the due date for developing a comprehensive care plan of 21 days after admission. The DON stated an episodic care plan should have been opened to address constipation for Resident R204.

A constipation/bowel policy was requested on 08/01/24; no policy was provided as of the survey exit on 08/02/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 15406 potential for actual harm Based on observation, interview, record review, and policy review, the facility failed to ensure one out of Residents Affected - Few three residents (Resident (R) 204) reviewed for nutrition/hydration out of 32 sampled residents received sufficient fluids to maintain adequate hydration status. Resident R204 was not assessed timely for fluid requirements even though he was prescribed intravenous (IV) fluids twice within the first ten days of admission due to poor nutritional and fluid intake. Resident R204's care plan goal for fluids was inadequate to meet his fluid needs, and his supplement intake was not monitored. Resident R204 was at risk for dehydration and weight loss.

Findings include:

Review of the undated Admission Record, located in the electronic medical record (EMR) under the Profile tab, revealed Resident R204 was admitted to the facility on [DATE REDACTED] with diagnoses including COVID 19, type two diabetes mellitus, and acute kidney failure. His stay was projected to be short term.

Review of the admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/26/24, located in the EMR under the MDS tab, revealed Resident R204 was intact in cognition with a Brief Interview for Mental Status (BIMS) score of 13 out of 15.

Review of the Weight Summary dated 07/17/24 through 08/02/24 in the EMR under the Vitals tab revealed Resident R204 weighed 170.2 pounds on 07/17/24 and was 72 (6') tall; his body mass index (BMI) was 23.4, within

the normal weight range.

Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/17/24:

-Monitor/document/report to MD [Medical Doctor] s/sx [signs/symptoms] of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on setting [sic]/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent sudden wt [weight] loss, dry sunken eyes every shift,

-I/O [intake and output] Monitoring: Fluid Intake Q [every] shift every shift for 30 Days. I/O Monitoring: Fluid Intake Total 24 hrs every night shift for 30 Days Review MAR [Medication Administration Record] and total intake for past 24 hours.

Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/18/24 the Physician ordered, Sodium Chloride Solution 0.9 %, Use 60 ml [milliliters]/hr [hour] intravenously (IV) one time only for poor po [oral] intake, rhabdomyolysis (medical condition that occurs when muscle tissue breaks down and releases harmful substances into the blood), AKI [acute kidney injury] for one day 1L [liter].

Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/24/24 the Physician ordered, Sodium Chloride Solution 0.9 %, Use 70 ml/hr intravenously one time only for poor po intake, constipation for one Day 1L IV.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0692 Review of the Order Summary Report from 07/17/24 through 08/01/24, located in the EMR under the Orders tab, revealed on 07/25/24 the Physician ordered, Give 500 ml extra fluid each shift. Level of Harm - Minimal harm or potential for actual harm Review of the Batch Update dated 07/24/24, provided by the facility, revealed Health Shakes were ordered with meals on 07/24/24 and were discontinued on 08/01/24. Residents Affected - Few

Review of the Medication Administration Record (MAR) for July 2024 did not show the Health Shakes were administered or consumed.

Review of the Medication Administration Record (MAR) for July 2024 revealed Resident R204's total fluid intake within 24 hours was documented as:

-07/18/24 1480 ml

-07/19/24 1530 ml

-07/20/24 940 ml

-07/21/24 1000 ml

-07/22/24 880 ml

-07/23/24 1600 ml

-07/24/24 1310 ml

-07/25/24 1070 ml

-07/26/24 2980 ml

-07/27/24 900 ml

-07/28/24 600 ml

-07/29/24 680 ml

-07/30/24 890 ml, and

-07/31/24 540 ml

Review of the Registered Dietitian Nutrition Assessment initiated on 07/23/24, located in the EMR under the Evaluation tab, revealed the assessment was initiated on this date; however, the sections for calculating estimated energy needs, protein needs, fluid needs, intake percentage, actual nutrition intake, nutrition goal, nutrition interventions, and nutrition plan were incomplete (blank).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0692 Review of the Registered Dietitian Nutrition Assessment initiated on 07/31/24, located in the EMR under the Evaluation tab, revealed the assessment was initiated on this date. Resident R204's fluid needs were calculated and Level of Harm - Minimal harm or were 2400 ml fluid per day. Resident R204 was documented as consuming 25% or less with poor nutritional intake potential for actual harm noted. Resident R204 was documented as receiving health shakes three times a day. Resident R204's risk for dehydration was not identified nor was the provision of IV fluids on 07/18/24 or 07/25/24. Residents Affected - Few

Review of the Care Plan, dated 07/26/24 and located in the EMR under the Care Plan tab, revealed a problem of, The resident has dehydration or potential fluid deficit r/t [related to] poor intake. The goal was,

The resident will drink/take in a minimum of 1000 cc's [cubic centimeters] each 24-hour period. The Dietitian's calculation on 07/31/24 (see Registered Dietitian Nutrition Assessment initiated on 07/31/24, in the EMR under the Evaluation tab) revealed a minimum intake of 2400 cc was necessary to meet Resident R204's fluid needs.

During an interview on 07/30/24 at 2:15 PM, Resident R204, who was lying in bed, stated he had been extremely sick when he was admitted to the facility due to COVID 19 and had not wanted to eat or drink much. Resident R204 stated

he was tired and did not want to be interviewed further. Resident R204 stated he was discharging to home soon.

During an interview on 08/01/24 at 8:51 AM, Licensed Vocational Nurse (LVN) 6 stated Resident R204's nutritional intake had been poor since admission, and he was currently being referred for hospice. LVN6 stated Resident R204 experienced constipation during his stay and had received IV fluids in the facility. LVN6 stated Resident R204 was monitored for intake and output during his stay, documented on the MAR. LVN6 stated Resident R204 was expected to discharge home today.

During an interview on 08/01/24 at 1:52 PM, Assistant Director of Nursing (ADON) 1 verified intake and output records were monitored by nursing staff in accordance with the Physician's Orders.

During an interview on 08/02/24 at 8:53 AM, the Registered Dietitian (RD) stated her standard was to complete nutrition assessments on newly admitted residents, and especially those at higher risk, within the first seven days of admission. The RD stated she assessed Resident R204 on 07/31/24 and verified this was 14 days

after admission. The RD stated she calculated Resident R204's fluid needs on 07/31/24 and he required 2400 ml per day. The RD verified the care plan had a goal of 1000 ml per day for fluid intake, which was inadequate to meet his needs. The RD stated the nurses had communicated with her about Resident R204 not eating or drinking well. The RD stated the provision of IV fluids was a trigger for high nutritional/dehydration risk. The RD verified Resident R204 was at high nutrition risk due to poor intake and provision of IV fluids; she stated she had not completed Resident R204's nutritional assessment timely.

During a joint interview on 08/02/24 at 10:14 AM, the RD, Dietary Director, and the Director of Nursing (DON) stated on 07/24/24 the Physician wrote an order for Health Shakes to be administered three times a day with meals. The RD stated the order was discontinued on 08/01/24 once Boost (supplement) was initiated. The DON stated the facility did not document supplements that were administered with meals; it was considered part of the meal. The DON stated only supplements administered between meals by nurses were recorded

on the MAR. The DON and RD verified there was no documentation of whether Resident R204 received the Health Shakes or what his intake of the Health Shakes was. The RD verified it would be helpful to know if the shakes were consumed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0692 During an interview on 08/02/24 at 5:10 PM, the DON verified the care plan goal indicated 1000 cc of fluid intake per 24 hours. The DON stated it may have been written incorrectly and may have been associated Level of Harm - Minimal harm or with the Physician's Order for nursing to administer 500 cc of fluid per shift (two shifts daily) a total of 1000 potential for actual harm cc. The DON verified the care plan should be accurate.

Residents Affected - Few Review of the facility's Resident Hydration and Prevention of Dehydration policy dated October 2017 revealed, The facility will strive to provide adequate hydration and to prevent and treat dehydration . The dietitian will assess all residents for hydration as part of the comprehensive assessment . Minimum fluid needs will be calculated and documented on initial, annual, and significant change assessments . Nursing will monitor and document fluid intake and the dietitian will be kept informed of status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0838 Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Level of Harm - Minimal harm or potential for actual harm 40824

Residents Affected - Many Based on interview and facility assessment reviews, the facility failed to create and implement a comprehensive Facility Assessment to determine what resources the facility needs to meet the needs of its residents which had the potential to affect 161 residents residing in the facility.

Findings include:

Review of the ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List'' dated 07/2021 was not a comprehensive Facility Assessment.

Review of the ''Facility Assessment Tool'' provided by the facility and updated 07/30/24.

During an interview on 08/02/24 at 6:04 PM with the Administrator confirmed that the current ''Facility Assessment'' dated 07/30/24 was updated and created after the surveyors entered the facility on 07/30/24. Additionally, the Administrator provided ''SNF/NF [Skilled Nursing Facility/Nursing Facility] Capabilities List,'' dated 07/2021, which he stated was a ''snapshot'' of what the facility was able to provide. The Administrator was unable to provide annual ''Facility Assessments'' for 2020, 2021, 2022, and 2023.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0865 Have a plan that describes the process for conducting QAPI and QAA activities.

Level of Harm - Minimal harm or 40824 potential for actual harm Based on interview, review of facility documents, and facility policy review, the facility failed to ensure a Residents Affected - Many Quality Assurance Performance Improvement (QAPI) plan was developed and implemented to drive quality assurance (QA) measures. This failure had the potential to affect all 161 residents who currently live in the facility.

Findings included:

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''. Establishing a QAPI Plan that guides quality efforts and serves as the main document that supports the QAPI implementation . Providing frequent leadership and staff training on the QAPI plan and its underlying principles, including the concept that systems of care and business practices must support quality care or be changed .''

Review of facility documents revealed the facility did not have a QAPI Plan.

During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed the facility did not have a QAPI Plan.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0867 Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. Level of Harm - Minimal harm or potential for actual harm 40824

Residents Affected - Some Based on interview, review of facility documents, and facility policy review, the facility failed to ensure bed hold audits were completed per the performance improvement project. This failure had the potential to affect residents who were emergently sent out to the hospital.

Findings included:

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 included, ''. Performance improvement projects (PIPs) are initiated when problems are identified . Prioritizing identified quality issues based on risk of harm and frequency of occurrence, and determining which will become the focus of PIPs . Planning, conducting and documenting PIPs .Taking systematic action targeted at the root causes of identified problems. This encompasses the utilization of corrective actions that provide significant and meaningful steps to improve processes and do not depend on staff to simply 'do the right thing'.''

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' dated 03/2020 included ''. The methodology for analysis and action is guided by a written QAPI plan that includes: . Methods and frequency of monitoring performance improvement projects .''

Review of facility documents revealed the facility did not have a QAPI Plan.

Review of a facility document titled ''Quality Assurance Performance Improvement Action Plan'' dated 04/10/24 and provided by the Director of Nursing (DON) included Bed Holds were not being issued to residents/RPs in advance of transfers (or within 24 hours if emergent). The Action Plan solution included ''Upon transfer to the acute from SNF [Skilled Nursing Facility] . assigned charge nurse will ensure a copy of

the bed hold policy is given to resident/RP prior to transfer. If unpractical due to emergency situation, attempt(s) will be made to contact the resident/RP within 24 hours of transfer. ADON [Assistant Director of Nursing] on assigned unit will assist in procress [sic] as needed. Follow Up: ADON will audit for compliance

on a weekly basis. Medical Records will also audit for completion/obtained signatures on bed hold form.''

Review of facility documents revealed that bed holds were not being provided to residents/responsible parties (RPs). Resident R99, Resident R126, Resident R151, and Resident R68 had emergent hospital transfers after the facility identified a deficient practice with bed holds and did not receive bed hold notices.Cross-reference

F-F625.

During an interview on 08/01/24 at 3:15 PM, the DON confirmed the facility had a PIP in place for ensuring Bed Hold notifications were provided to residents or their responsible parties. The DON confirmed the PIP included conducting audits for bed hold notifications, which she was not able to provide.

During an interview on 08/02/24 at 3:01 PM, ADON1 stated she was aware of the PIP for bed holds but had not been conducting audits herself, because this was being done by Medical Records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0867 During an interview on 08/02/24 at 3:01 PM, the Medical Records Director (MRD) stated when a resident was sent out to the hospital there should be a transfer/discharge notice and bed hold notification provided to Level of Harm - Minimal harm or the resident/RP upon discharge. MRD stated she started conducting bed hold audits in May 2024, however potential for actual harm confirmed that audits were incomplete.

Residents Affected - Some During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed he was made aware that bed hold audits had not been completed per the facility's current PIP but should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 40824 potential for actual harm Based on interview, review of facility documentation, and review of facility policy, the Quality Assurance and Residents Affected - Many Performance Improvement (QAPI) committee failed to ensure the required members of the committee attended the quarterly meetings. This failure had the potential to affect all 161 residents who currently live in

the facility.

Findings include:

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program'' revised 04/2014 and provided by the facility did not include QAPI attendance expectations.

Review of the facility policy titled, ''Quality Assurance and Performance Improvement (QAPI) Program- Analysis and Action'' revised 03/2020 and provided by the facility did not include QAPI attendance expectations.

During an interview on 08/02/24 at 6:04 PM, the Administrator confirmed that QAPI meetings were held at a minimum every quarter and that all meetings should include an Administrator, DON, Infection Preventionist (IP), and Medical Director (MD). The Administrator confirmed that for the third and fourth quarters of 2023

the MD did not attend QAPI meetings, and for the first quarter of 2024 neither the IP or MD were in attendance but should have been.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 25232 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that two of three residents Residents Affected - Few (Resident (R) 81 and Resident R79) reviewed for catheters out of 32 sampled residents received catheter care in a manner to prevent cross-contamination. Nursing staff did not change gloves appropriately while providing catheter care to Resident R81 and the facility failed to ensure Resident R79's catheter bag was kept off the floor. This failure has the potential for staff to spread infections between residents.

Findings include:

1. Review of Resident R81's undated Admission Record under the ''Profile'' tab in the electronic medical record (EMR) indicated that Resident R81 was readmitted to the facility on [DATE REDACTED] with a diagnosis of obstructive and reflux uropathy, unspecified.

Review of Resident R81's urinalysis culture, dated 02/04/24 and located under the tab ''Results'' in the EMR, indicated that Resident R81 had a urinary tract infection which had bacteria including Citrobacter freundii (healthcare associated infection).

During suprapubic catheter observation with Licensed Vocational Nurse (LVN) 1 on 08/02/24 at 8:41 AM, LVN1 put gloves on and cleaned Resident R81's suprapubic catheter. Then without changing her gloves, LVN1 rinsed and patted dry Resident R81's suprapubic catheter. LVN1 removed her gloves at this time and washed her hands. LVN1 placed a new pair of gloves on and placed a dressing around Resident R81's suprapubic catheter.

During an interview on 08/02/24 at 9:00 AM, LVN1 did not realize that she did not change her gloves when going from dirty to clean and confirmed that she should have.

During an interview on 08/02/24 at 10:00 AM, the Director of Nursing (DON) confirmed that gloves should be changed when going from a dirty area to a clean area.

During an interview on 08/02/24 at 3:04 PM, the Infection Preventionist (IP) confirmed gloves should be changed when going from a dirty to clean area.

Review of facility provided ''In-Service Sign-In Sheet,'' dated 05/22/24, indicated LVN1 attended this training

on Personal Protective Equipment (PPE) about donning (put on) and doffing (take off). There was no evidence of an agenda.

40824

2. Review of Resident R79's undated ''Admission Record,'' located in the EMR under the ''Profile'' tab, indicated an original admitted [DATE REDACTED] and re-admission on 03/18/23 with a primary diagnosis of asthma and comorbidities including benign prostatic hyperplasia with lower urinary tract symptoms.

Review of Resident R79's quarterly ''Minimum Data Set (MDS),'' located in the EMR under the MDS tab, with an Assessment Reference Date (ARD) of 06/21/24 included a ''Brief Interview for Mental Status (BIMS)'' score of seven out of 15 indicating the resident had severe cognitive impairment. Per the MDS, Resident R79 had an indwelling catheter.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 25 555118 Department of Health & Human Services Printed: 09/17/2025 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 555118 B. Wing 08/02/2024

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

Almond Vista Healthcare 2030 Evergreen Avenue Modesto, CA 95350

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 Review of Resident R79's ''Care Plan,'' located in the EMR under the ''Care Plan'' tab and dated 07/14/19, included placement of a supra pubic catheter related to neurogenic bladder. Level of Harm - Minimal harm or potential for actual harm Review of Resident R79's ''Order Summary Report,'' located in the EMR under the ''Orders'' tab, included suprapubic catheter 16 French with 10 cubic centimeter (cc) flush every shift dated 11/24/23 and suprapubic catheter to Residents Affected - Few gravity drainage every shift dated 01/30/20.

During an observation and interview on 08/02/24 at 3:24PM with LVN2, Resident R79 was lying in bed with the linens over his head and his urinary collection bag on the floor next to his bed without a dignity bag. LVN2 confirmed the urinary collection bag was on the floor, should have been in a dignity bag, and off the floor due to risk for infection.

During an interview on 08/02/24 at 5:40 PM, DON stated it was her expectation that urinary collection bags be in a dignity bag and kept off the floor due to risk for infection.

Review of the facility's policy titled, ''Catheter Care, Urinary'' revised 08/2022 indicated ''The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections . Be sure

the catheter tubing and drainage bag are kept off the floor .''

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 25 555118