Other·April 28, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of California Department of Public Health-Licensing and Certification, during an abbreviated survey for Complaint: CA00518922. Representing the California Department of Public Health-Licensing and Certification: Federal ID 36067 RN HFEN. The abbreviated survey was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. Complaint CA00518922: Substantiated with deficiency-F 206.

F206 SS=G POLICY TO PERMIT READMISSION BEYOND BED-HOLD CFR(s): 483.15(e)(1)(2)

F206 (e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 1 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. (e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on observation, resident and staff interview, clinical record and administrative document review, the facility failed to permit a resident to return to the facility in the first available bed following hospitalization for one of three sampled residents, (Resident 1), when a facility bed was available and not offered to Resident 1. This failure prevented Resident 1 from returning to the facility which had been his long term residence and resulted in an extended acute care hospital stay and feelings of stress, anxiety, depression and frustration for Resident 1. Findings: Review of Resident 1's clinical record titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 2 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE "Admission Record" ( document containing resident personal information) indicated Resident 1 was admitted to the skilled nursing facility (SNF) on 3/28/12 with diagnoses that included "Blindness, Both Eyes, Type 2 Diabetes Mellitus [disorder which causes high blood sugar due to insufficient production of the hormone insulin which regulates blood sugar], End Stage Renal Disease [kidney failure], Major Depressive Disorder [persistent altered mood including feelings of hopelessness and worthlessness], Anxiety Disorder [disorder characterized by feelings of apprehension, worry, uneasiness and dread] and Convulsions [seizures]." The Admission Record indicated Resident 1's primary language was Spanish. On 1/31/17, during a telephone interview, the acute care hospital (ACH) 2 Case Manager (CM) 1 stated Resident 1 had been admitted to ACH 2 on 9/30/17. CM 1 stated Resident 1 had resided at the SNF for several years prior to admission to ACH 2 and wanted to return to the SNF. CM 1 stated Resident 1 had been cleared for discharge back to the SNF on 11/21/17. CM 1 stated she phoned the SNF and was informed by the Director of Nursing (DON) there were no male beds available in the SNF at that time. CM 1 stated Resident 1 was legally blind and on hemodialysis (a procedure to clean the blood of waste products using an artificial kidney when the resident's kidneys have failed). CM 1 stated she informed the DON on 11/21/17 Resident 1 wanted to return to the SNF in the first available bed. CM 1 stated the SNF later gave away the first available male bed to another resident. On 2/2/17 at 9:55 a.m., during a concurrent interview and clinical record review, the SNF Assistant Director of Nursing (ADON) reviewed Resident 1's record and stated Resident 1 was transferred to ACH 1 on 9/27/16 and had a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 3 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE seven day bed hold ( a resident's right to hold the bed at the SNF for seven days while in the hospital for treatment). The ADON stated Resident 1 left ACH 1 against medical advice and went to the emergency room at ACH 2 where he was admitted as an inpatient. The ADON stated that she was informed by ACH 2 on 11/21/16 that the Resident 1 was clear for discharge and wanted to return back to the SNF. The ADON stated Resident 1 was still in ACH 2. The ADON stated there had been two male beds available at the facility during the time Resident 1 was in ACH 2, but ACH 2 had not been informed of the availability of the beds by the SNF. The ADON stated according to the SNF policy and procedure she should have informed ACH 2 of the bed availability and provided the first male available bed to Resident 1, but she did not. On 2/2/17 at 12:45 p.m., during an interview, the SNF Administrator (Admin) stated the SNF had an open available male bed in December 2016, but she had an impression that the Resident 1 had been discharged to another facility. The Admin stated the facility received a call on 1/18/17 from CM 1 to see if a male bed was available for Resident 1. The Admin stated she told CM 1 that one male bed was available, but it had already been promised to a new resident. The Admin stated a new resident was admitted to the empty bed on 1/19/17. On 2/17/17 at 10:25 a.m., during an observation and concurrent interview at ACH 2, Resident 1 was lying in bed in his room. Resident 1 was alert and spoke through a Spanish speaking translator. Resident 1 stated he lived at the SNF for about six years before he was admitted to ACH 2. Resident 1 stated he was legally blind and could see only shadows. Resident 1 stated he found it difficult to adapt to new environments due to his visual FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 4 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE difficulties. Resident 1 stated he wanted to return to the SNF where he was familiar with the staff, environment and routines. Resident 1 stated when he felt under stress or anxiety at the SNF he would go outside to the patio area and walk around in fresh air which helped relieve his stress. Resident 1 stated he was not permitted to walk outside at ACH 2. Resident 1 stated at the SNF he enjoyed the activities and sitting outside with friends, but was not able to do those things at ACH 2. Resident 1 stated he felt stress, anxiety, depression and frustration due to his long hospitalization and lack of exercise and activities. On 2/17/17 at 11:25 a.m., during an interview and concurrent resident census review, the ADON stated a blank area on the daily census report meant the resident room was empty. The ADON stated room 8 B was empty from 11/29/16 to 12/5/16 and 18 B was empty from 1/5/17 to 1/18/17. The ADON stated the census indicated there was an open male bed available for admission during those dates but the SNF did not notify ACH 2 of the bed availability. The ADON stated on 1/16/17 she talked to CM 1 from ACH 2 and informed CM 1 that facility had one open male bed available but it was promised to another resident who was not from their SNF. The ADON stated she was not aware of the SNF policy or the legal requirement to re-admit the resident to the first available bed when she spoke with CM 1 on 1/16/17. The ADON stated she should have given the first available male bed to Resident 1 according to the SNF policy. Review of Resident 1's case manager liaison notes from ACH 2 dated 10/6/16, indicated, "...Writer called [SNF] and spoke with [ADON]. [ADON] reported that patient was once a resident there...[ADON] reported that patient's bedhold is expired and there are no longer FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 5 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE beds available at [SNF]." Review of Resident 1's case manager notes from ACH 2 dated 10/10/16, indicated, "Spoke to [ADON] at [SNF]...and she confirmed patient is long term patient that lost bed last week. Advised [ADON] per MD [doctor] possible d/c [discharge] this Thursday or Friday. She said to call back because at this time no LTC [long term care] bed available." Review of Resident 1's case manager notes from ACH 2 dated 10/13/16, indicated, "Called [ADON] at [SNF] and she said no bed available and no pending d/c at this time. She said to check on a weekly basis." Review of Resident 1's case manager notes from ACH 2 dated 11/7/16, indicated, "Phone call to [SNF] who reports no beds available today." Review of Resident 1's case manager notes from ACH 2 dated 12/1/16, indicated, "...spoke with [Admin] at [SNF] and asked if there is a male bed for the patient to return to. She stated no male beds at this time..." Review of Resident 1's case manager notes from ACH 2 dated 12/2/16, indicated, "...spoke with [ADON] at [SNF] and they will take the patient back once a male bed opens up." Review of Resident 1's case manager notes from ACH 2 dated 12/13/16, indicated, "...[SNF] continues with no male bed." Review of Resident 1's case manager notes from ACH 2 dated 1/20/17, indicated, "...spoke with [ADON] at [SNF] and she states they had an open male bed but filled it and did not have to hold it for [Resident 1] since he was past his 7 day bed hold." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 6 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Review of Resident 1's clinical record from ACH 2, titled, "[ACH 2] Skilled Nursing Patient Placement Inquiry Form," dated 1/30/17, indicated Resident 1 was admitted on 9/30/16 for complications related to hemodialysis and was ready for discharge back to the SNF on 11/21/17. The record indicated Resident 1 was still awaiting placement at a SNF. The administrative document titled, "[SNF] NEW Detailed Census Report By Payer" dated November and December 2016 and January 2017 indicated, there was one male bed available from 11/29/16 to 12/4/16 and from 1/4/17 to 1/18/17. On 3/23/17 at 11:25 a.m., during a telephone interview, CM 2 stated Resident 1 was still at ACH 2 awaiting placement at the SNF. CM 2 stated Resident 1 had been cleared for discharge back to the SNF in November of 2016. The SNF policy and procedure titled, "Readmission to the Facility" dated 2013, indicated, "1 ...resident whose hospitalization or therapeutic leave exceeds the bed hold period allowed by the state will be readmitted to the facility upon the first availability of a bed..." The SNF "Admission Agreement" dated 5/11, indicated, "VII. Bed Holds and Readmission ...if you are away from our Facility for more than seven days due to hospitalization or other medical treatment, we will readmit you to the first available bed ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 26GM11 Facility ID: CA040000012 If continuation sheet 7 of 8 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 555920 (X3) DATE SURVEY COMPLETED 04/06/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) FORM CMS-2567(02-99) Previous Versions Obsolete ID PREFIX TAG Event ID: 26GM11 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) Facility ID: CA040000012 (X5) COMPLETE DATE If continuation sheet 8 of 8