Chowchilla Memorial Healthcare District

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct background checks (a screening process that reviews past employment, education, criminal records, driving records prior to hire) according to the facility's policy when five of five sampled employees (Licensed Vocational Nurse [LVN] 2, LVN 3, Certified Nurse Assistant [CNA] 1, CNA 2, CNA 3) did not have background or reference checks in their personnel files. This failure placed residents at risk for abuse which could lead to serious physical and psychological harm (lasting mental harm caused by severe distressing events that overwhelm an individual's ability to cope).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served in a safe and sanitary environment when:A bowl of shredded cheese, a bowl of sour cream and a bowl of sliced jalapenos were prepared and stored undated and unlabeled inside refrigerator 1. An opened bag of dry cereal was undated and unlabeled inside the dry storage room. These failures had the potential to contaminate resident food sources that could cause foodborne illness (feeling sick or not healthy) in a vulnerable population resulting in severe patient harm.

Inspectors wroteBased on observation, interview, and recorded review, the facility failed to provide a written notice, including the reason for change, prior to moving one of 12 sampled residents (Resident 20), to a different room within the facility. This failure resulted in Resident 20 being moved without appropriate written communication which had the potential to result in emotional distress and a violation of the resident's rights to make informed decisions regarding her care environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper storage and disposal of medication and biologics in accordance with facility policy and procedures in one of one sampled medication cart and one of one sampled wound cart when:1. In the medication cart an inhaler (A device for giving medicines in the form of a spray that is inhaled (breathed in) through the nose or mouth) was observed opened and used despite being past the expiration date. This failure had the potential to cause an increased risk of contamination, unsafe administration, and reduced effectiveness which could cause inadequate treatment of illnesses.2. The wound treatment cart was left unlocked and unattended. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow infection control and prevention standards of practice and provide a safe and sanitary environment to help prevent infection for four of six sampled residents (Resident 7, Resident 9, Resident 27, and Resident 28), when Licensed Vocational Nurse (LVN) 1 did not disinfect a shared resident blood pressure cuff (a medical device used to measure blood pressure) after resident care. This failure resulted in Resident 7, Resident 9, Resident 27, and Resident 28 being exposed to reusable medical equipment that had not been cleaned in between use which could result in the development and spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent accidents for one of three sampled residents (Resident 1), when Resident 1 was assessed to be at risk for falls and had a history of falls and effective interventions were not implemented to prevent a fall on 7/20/25. Resident 1 was assessed to have an unsteady gait (manner of walking), required to have one staff member assisting her with toileting, had falls on 9/7/23, 9/12/23, 1/3/24, and 8/29/24 and fell on 7/20/25. On 7/20/25, Resident 1 was assisted to sit on the toilet to void, staff stepped out of the bathroom, left her alone and Resident 1 fell and injured her left hip. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety when the sink faucet was covered with a black and brown substance. This failure placed residents who consumed food prepared in the facility kitchen at risk for foodborne illness (a disease caused by consuming contaminated food or drink).

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for two of 12 sampled residents (Resident 12 and Resident 78 ) when: 1. There was no CP created addressing Resident 12's diagnosis of Chronic Obstructive Pulmonary Disease (COPD - a group of lung diseases that block airflow and make it difficult to breathe.) 2. Resident 78 had a care plan for fluid overload (a person has too much fluid, potentially causing swelling, shortness of breath, and high blood pressure) related to kidney failure (when the kidneys stop working properly, leading to a buildup of waste in your blood, which can be dangerous if left untreated), but there was not a comprehensive assessment that reflected the medical issue. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality for two of 12 sampled residents (Resident 10 and Resident 22) when: 1. Resident 10's pharmacy recommendation to obtain Serum (blood test) B-12 (a vitamin essential for maintaining healthy red blood cells, nerves, and brain function), Creatinine Level (a blood test to check for the kidney's function), Liver Function (a blood test to check for liver's function) and BMP (Basic Metabolic Panel-measures various substances in the blood, including blood sugar and bone health) was not communicated to the Hospice provider. This failure had the potential to place Resident 10 at risk of receiving treatment or procedures against his wishes. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure effective infection prevention and control practices were implemented for nine of 14 sampled residents (Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20) when: 1. Licensed Vocational Nurse (LVN) 1 did not perform hand hygiene when entering and exiting the rooms for Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20. 2. LVN 1 did not remove gloves after providing patient care for Resident 16, 78, 14, and 20 and exited the room and walked down the hallway back to his medication cart (a mobile cart for storing and delivering medications). 3. LVN 1 did not take his medication cart located in Nursing Station 1 instead of bringing it to each room while administering medications and patient care for Resident 21, 11, 5, 16, 15, 78, 8, 14, and 20. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage and monitor the quality of care for one of 12 sampled residents (Resident 78), when the facility unjustly implemented a fluid restriction on Resident 78 without a clinical justification (diagnosis or medical need), comprehensive assessment or person-centered care plan. This failure had the potential for harm, including dehydration (occurs when your body loses more fluids than it takes in, leading to a lack of water and other vital fluids needed for normal bodily functions and could lead to a medical emergency) and electrolyte imbalance (having too much or too little of certain minerals (electrolytes) in your body, which can disrupt vital functions like muscle and nerve function, and fluid balance), for Resident 78 due to withholding fluid from him since admittance to the facility on 2/3/25.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one sampled residents (Resident 10) was free from accidents, when Resident 10 was smoking and had ashes fall on his shirt and into his wheelchair. This failure placed Resident 10's safety at risk and the ashes had the potential to burn the resident.

Inspectors wroteBased on observations, interview, and record review, the facility failed to provide the correct diet for one of 12 sampled residents (Resident 2) during lunch tray assembly when Resident 2 was on a fortified diet (an enrichment of food to increase calories [a unit of energy] and protein [essential to building and repairing body tissues, muscles, and bones] to sustain or gain weight) and dietary staff did not follow the diet order on 2/18/25 to provide Resident 2 with a Magic Cup frozen dessert (ice cream with added calories and protein for those experiencing involuntary weight loss). This failure had the potential to result in Resident 2 to not receive the adequate nutritional requirements to sustain or gain weight.

Inspectors wroteBased on interview and record review, the facility failed to follow its Hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures (P&P) for one of four sampled residents (Resident 10) when: 1. The pharmacy recommendation for Resident 10 to obtain Serum (blood test) B-12 (a vitamin essential for maintaining healthy red blood cells, nerves, and brain function), Creatinine Level (a blood test to check for the kidney's function), Liver Function (a blood test to check for liver's function) and BMP (Basic Metabolic Panel-measures various substances in the blood, including blood sugar and bone health) was not communicated to the Hospice provider. 2. The Hospice order for Resident 10 to discontinue all laboratory tests on 1/21/25 was not carried out and implemented. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), who had a history of falls and was assessed as a high fall risk, received adequate supervision and assistance to prevent injuries when Resident 1 had five falls between 5/8/24 and 6/28/24. This failure placed Resident 1 at risk for continued falls and had the potential to result in injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a resident-centered comprehensive care plan for two of three sampled residents (Resident 1and Resident 2), when: 1. Resident 1 was left unsupervised on 4/5/24 in the shower room resulting in fall. 2. Resident 2 ambulated without assistance on 4/18/24 in the facility hallway resulting in a fall. These failures resulted in Resident 1 and 2 falling to the ground and had the potential to result in injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and implement a person centered comprehensive care plan for one of three sampled residents (Resident 1), when Resident 1 fell on 4/5/24 and care plan interventions were not revised and updated. This failure placed Resident 1 ' s health and safety at risk when fall care plan interventions were not revised.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. One of one drawer that stored clean utensils had dried food on a spatula. This had the potential for pathogenic microorganism (an organism that is so small that it cannot be seen by the naked eye and is capable of causing disease) growth that could inadvertently (accidentally) be transferred to food and could also provide an environment for attraction of insects and rodents. 2. Five unlabeled food items and two expired food items were found in the resident nourishment refrigerator and kitchen refrigerators. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans (CP - a detailed approach to care customized to an individual resident's needs) for four of 12 sampled residents (Residents 4, 10, 24 and 26) when: 1. Residents 4, 10, and 24 did not have an individualized care plan developed and implemented for the use of side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. This failure had the potential for Residents 4, 10, and 24 to be injured while using the side rails. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide fire safety accommodations to ensure the residents remained safe while they smoked for four of four sampled residents (Residents 7, 9, 10 and 24), when Residents 7, 9, 10, and 24 were not provided with noncombustible (non flammable) aprons prior to smoking cigarettes. This failure had the potential to place the residents at risk for smoking related injuries.

Inspectors wroteBased on interview, and record review, the facility failed to ensure medical records were complete and accurately documented in accordance with accepted professional standards of practice for four of 12 sampled residents (Residents 1, 12, 17, and 26) when Resident 1, 12, 17 and 26's copy of Physician Orders for Life-Sustaining Treatment (POLST - a medical order signed by both the patient and medical provider that specifies the types of medical treatment a patient wishes to receive toward the end of life) were incomplete. This failure had the potential for the Resident 1, 12, 17 and 26's decisions regarding treatment options and end of life wishes to not be honored.

Inspectors wroteBased on interview and record review, the facility failed to follow its hospice (care that focuses on the quality of life for people who are experiencing an advanced, life-limiting illness) policy and procedures for two of two sampled residents (Residents 2 and 10) when the facility failed to ensure that hospice personnel caring for residents under hospice services were provided orientation to the facility's policies and procedures and staff were not aware of who was the designated hospice coordinator. This failure had the potential to place Residents 2 and 10 at risk of not receiving appropriate medical, physical, psychosocial, and spiritual support to manage symptoms associated with terminal illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity and respect when one of one sampled resident (Resident 26)'s foley catheter (an indwelling urinary catheter - a thin tube placed in the bladder to drain urine into a bag) drainage bag was without a dignity bag (a bag used to the cover and hold the catheter drainage/collection bag so it is not visible). This failure violated Resident 26's privacy and had the potential to affect the self-esteem, self-worth, and quality of life of Resident 26.