Chowchilla Memorial Healthcare District

In the surveyor’s words

From the most serious findings on record at Chowchilla Memorial Healthcare District, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 5, 2025

  Based 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. […]

• Actual harm, isolatedF692Nov 18, 2022

  Based on observation, interview and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring and systems to maintain acceptable parameters of nutritional status (desirable body weight range) for one of two sampled residents (Resident 15) when the Registered Dietitian (RD) did not continue to monitor or reassess the resident after weight loss occurred and the Interdisciplinary team (IDT) failed to monitor Resident 15's weight loss and the effectiveness of the interventions. […]

• No harm, potential for more than minimal, widespreadF812Feb 24, 2025

  Based 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). Findings: During a concurrent observation and interview on 2/18/25 at 9:15 a.m., with the Dietary Supervisor (DS), in the kitchen, the sink faucet located near the dish washing machine was observed with a black and brown substance. The DS stated the base of the sink faucet was not clean and the sink faucet should be cleaned daily. […]

• No harm, potential for more than minimal, widespreadF812Mar 1, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Nov 18, 2022

  Based on interview and record review, the facility failed to ensure a Registered Nurse (RN) was scheduled and in the facility for at least eight consecutive hours a day seven days per week, when the facility did not have an RN for 21 of 72 days from April 2022 through June 2022. This failure resulted in an inadequate RN facility staffing and the failure to have direct RN clinical oversight for a minimum of eight hours, seven days per week. Findings: During a concurrent interview and record review on 11/18/22, at 9:42 a.m., with the Director of Nursing (DON), the DON stated, she assumed the position of DON after she passed her board on October 17, 2022. She stated the DON at the time was the Minimum Data Set Nurse (MDSN) and there were on-call RN's covering the weekends. […]