Healthcare Centre of Fresno

In the surveyor’s words

From the most serious findings on record at Healthcare Centre of Fresno, in the surveyor’s own words.

• Immediate jeopardy, widespreadF925Jul 12, 2024

  Based on observation, interview and record review the facility failed to maintain an effective pest control program to keep the facility free of pests for 181 out of 181 residents, when on 7/9/2024 the dish washing station was observed with roaches crawling in the sink with dirty dishes, numerous roaches crawling up the walls and dishwasher. The floor to the dish washing room had roaches crawling into the dish racks located near the sink on the floor where dirty dishes were placed to go into the dishwasher. The clean dish area had roaches crawling around the counter and wall. The dishwasher itself had roaches swimming in the water inside. The walls of the dishwashing area had roaches nesting in the corners. […]

• Actual harm, isolatedF689Oct 3, 2024

  Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision to prevent accidents for one of three sampled residents (Resident 1), when facility had knowledge of Resident 1's preference to sit outside, had a history of falls, and required assistance with personal care. Facility staff did not provide supervision while Resident 1 was outside and were unaware Resident 1 left the facility's premises on 10/1/24 unsupervised. These failures resulted in Resident wandering unsafely in the streets around the facility and suffering an avoidable auto versus pedestrian accident. […]

• Actual harm, isolatedF689Jul 15, 2024

  Based on observation interview and record review the facility failed to ensure an environment free of accident hazards for one of three sampled residents (Resident 1), when on 7/12/24 Resident 1 removed the window screw, opened the window, and jumped from the facility's second story. Certified Nursing Assistant (CNA) 1 noted a change in Resident 1's demeanor and heard Resident 1 stating she is done and did not report to licensed staff. This failure resulted in Resident 1 sustaining a fracture (broken bone) of multiple ribs on the right side, laceration (bleeding or tearing) of the liver, fracture of the right femur (bone of the thigh articulating at the hip and the knee), and right pneumothorax (when air builds up in the space between the chest wall and lung and puts pressure on the lung… […]

• Actual harm, isolatedF689Nov 29, 2023

  Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance to prevent accidents for one of five sampled residents (Resident 1) when Resident 1 fell out of bed during provision of care by Certified Nurse Assistant (CNA) without assistance from another staff member in accordance with the Comprehensive Assessment and needs of the resident. This failure resulted in Resident 1 having an avoidable fall, sustaining injuries of a Fractured Occipital Condyle (break at the base where skull meets spine), laceration (cut) to her nose, bruising, swelling to her left eye and experienced pain. […]

• No harm, potential for more than minimal, widespreadF755Jan 10, 2025

  Based on observation, interview and record review, the facility failed to follow the policy and procedures Medication Storage, Disposal of Medications and Medication Related Supplies and have a secure medication destruction bin (MDB- a bin for unused medications that are set to be destroyed) for two of two medication rooms (Medication room [ROOM NUMBER] and Medication room [ROOM NUMBER]), when the medication destruction bins' lids were not sealed. This failure had the potential for drug diversion (when healthcare providers obtain or use prescription medicines illegally) and overall unsafe medication practices. […]