Other·September 12, 2018

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Amended to remove CA 00541934 and to add CA 00554036. Substantiated with the following findings, F-656, F-686, F-689. Investigated by 35737 HFEN RN. The following reflects the findings of the California Department of Public HealthLicensing and Certification during a RECERTIFICATION SURVEY. Representing the California Department of Public Health: 29470 HFEN RN, 35737 HFEN RN, 39617 HFEN RN, 28358 HFEN RN. Capacity: 49 Census: 49 Sample: 22 The following FRI's were included during the RECERTIFICATION survey: CA 00587621: Substantiated with no deficiencies. Investigated by 29470 HFEN RN. CA 00554036: Substantiated with the following findings, F-656, F-686, F-689. Investigated by 35737 HFEN RN.

F550 Resident Rights/Exercise of Rights

F550 06/04/2018 SS=D 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: RVJ611 Facility ID: CA040000012 If continuation sheet 1 of 78 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 06/01/2018 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 CFR(s): 483.10(a)(1)(2)(b)(1)(2) §483.10(a) Resident Rights. The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section. §483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. §483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source. §483.10(b) Exercise of Rights. The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States. §483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility. §483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 2 of 78 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 06/01/2018 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to treat residents with dignity and respect for two of 22 sampled residents (Resident 5 and Resident 22) when: 1. A Certified Nurse Assistant (CNA) was standing while feeding Resident 22 her lunch. 2. Two CNA's were standing next to Resident 5 while feeding her lunch. These failures had the potential to violate the residents' rights to be treated with dignity and respect and in a manner which recognized each resident's individuality. Findings: 1. On 5/29/18 at 12:06 p.m., during an observation in the recreation/dining room, there were five dining room table with 15 residents waiting for their lunch trays. There were three CNA's distributing the Residents lunch trays. On 5/29/18 at 12:40 p.m., during an observation in the recreation/dining room, Resident 22 sat at a table in her wheelchair FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 3 of 78 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 06/01/2018 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 and began to eat her lunch with no assistance. On 5/29/18 at 12:48 p.m., during an observation, CNA 4 asked Resident 22 if she needed assistance with her lunch. Resident 22 stated she needed help with eating her lunch. CNA 4 picked up the resident's fork and began to feed Resident 22 while standing next to the resident. On 5/29/18 at 12:52 p.m., CNA 4 stated she should have sat down while feeding Resident 22 because staff needed to be at eye level with the residents when feeding them. CNA 4 stated standing while feeding a resident was not respectful. On 5/29/18 at 1:15 p.m., during an interview in the recreation/dining room, Resident 22 stated she did not know how she felt when CNA 4 stood while feeding her. Resident 22's most recent quarterly Minimum Data Set (MDS)(a resident assessment tool) dated 3/8/18, indicated the resident had a cognitive status of 9 of 15 which indicated moderate impairment and the resident needed a one person extensive assistance in eating. 2. On 05/29/18 at 12:29 p.m., during an observation Resident 5 received her lunch tray, she took a spoon and filled it with food. Resident 5 spilled food while attempting to feed herself. Resident 5 began to lick the food off the handle of the spoon. Resident 5 placed the spoon down and began to pick at her food with her hands. On 05/29/18 at 12:37 p.m., during an observation Resident 5 called out for help and stated, "I cant see my food, I need help to eat." CNA 7 came into the dining room and was asked by CNA 4 to assist Resident 5. CNA 7 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 4 of 78 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 06/01/2018 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 pushed Resident 5's wheelchair inward in attempt to get through an area where she could stand next to Resident 5. CNA 7 fed Resident 5 while standing up. On 5/29/18 at 12:40 p.m., during an observation CNA 7 interrupted feeding Resident 5 and stepped out of the DR for 5 minutes. On 5/29/18 at 12: 45 p.m., during an observation CNA 7 returned to feed Resident 5. CNA 7 squeezed behind resident 5's wheel chair and lifted an exercise ball in order to get through. CNA 7 continued to feed Resident 5 while standing. 05/29/18 12:45 p.m., during an observation Resident 5 complained to CNA 7 that her food was bland and tasteless. CNA 7 stated she did not understand Resident 5 and requested to switch with CNA 10. CNA 10 fed Resident 5 while standing. On 5/29/18 at 2:15 p.m., during an interview, CNA 7 stated the residents needed to be fed without any interruptions. CNA 7 stated she needed to feed the resident while sitting and needed to be at eye level. CNA 7 stated, "It is the correct way for the CNA's to be sitting, but there was no room to bring in a chair, there was not a lot of space." On 5/29/18 at 2:20 p.m., during an interview, CNA 10 stated the residents were supposed to be fed at eye level. CNA 10 stated she should have sat down while she fed Resident 5. The facility policy and procedure, titled, "Assistance with Meals" dated 6/17, indicated, "...Residents who cannot feed themselves will be fed with attention to safety, comfort and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 5 of 78 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 06/01/2018 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 dignity, for example...Not standing over residents while assisting them with meals..."

F558 SS=E Reasonable Accommodations Needs/Preferences CFR(s): 483.10(e)(3)

F558 06/04/2018 §483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to reasonably accommodate two of 22 sampled residents (Resident 5 and Resident 39) with needs and preferences when: Resident 5 was provided with delayed and interrupted feeding assistance during a meal and Resident 39's shower room preference was not always accommodated. This failure deprived Resident 5 and Resident 39's from an individualized homelike environment. Findings: 05/29/18 10:20 a.m., during an observation of the shower room for "A wing", a shower was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 6 of 78 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 06/01/2018 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 being given with the shower room door left open. A privacy curtain was available and covered the opened shower room door. 05/29/18 02:41 p.m., during an observation and concurrent interview, the Environmental Service Supervisor (ESS), stated the shower room ventilation unit was not working. The ESS stated the vent had no suction and would tell the maintenance supervisor. 05/30/18 02:30 p.m., during an interview, CNA 2 stated there were two showers in the facility that were available to the residents. CNA 2 stated the shower room door to A wing shower remained opened while showers were given because, "it got too stuffy in [the shower room] when the shower room door was closed." CNA 2 stated the B wing shower room was not always available because it was used for storage. CNA 2 stated Resident 39 preferred not to shower if he had to shower in the A-wing shower. 05/30/18 02:52 p.m., during an interview, Resident 39 stated he did not like to shower in the A-wing shower room because the shower door did not close shut. Resident 39 stated, "They tell me the door does not close all the way, I prefer not to shower if that is the only shower room available." Resident 39's MDS (minimum data set) (evaluation of memory and care needs) assessment dated 4/8/18, indicated a Resident 39 was cognitively impaired with a cognitive assessment score of six out of 15. (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact.) 2. On 05/29/18 at 12:29 p.m., during an observation Resident 5 received her lunch tray, she took a spoon and filled it with food. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 7 of 78 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 06/01/2018 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 Resident 5 spilled food while attempting to feed herself. Resident 5 began to lick the food off the handle of the spoon. Resident 5 placed the spoon down and began to pick at her food with her hands. On 05/29/18 at 12:37 p.m., during an observation Resident 5 called out for help and stated, "I cant see my food, I need help to eat." CNA 7 came into the dining room and was asked by CNA 4 to assist Resident 5. CNA 7 pushed Resident 5's wheelchair inward in attempt to get through an area where she could stand next to Resident 5. CNA 7 fed Resident 5 while standing up. On 5/29/18 at 12:40 p.m., during an observation CNA 7 interrupted feeding Resident 5 and stepped out of the DR for 5 minutes. On 5/29/18 at 12: 45 p.m., during an observation CNA 7 returned to feed Resident 5. CNA 7 squeezed behind resident 5's wheel chair and lifted an exercise ball in order to get through to continue feeding Resident 5. On 5/29/18 at 2:15 p.m., during an interview, CNA 7 stated the residents needed to be fed without any interruptions. Resident 5's MDS dated 5/4/18 indicated Resident 5 required extensive assistance (weight bearing support) for eating. The facility policy and procedure, titled, "Assistance with Meals" dated 6/17, indicated, "...Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example...Not standing over residents while assisting them with meals..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 8 of 78 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 06/01/2018 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

F577 Right to Survey Results/Advocate Agency Info CFR(s): 483.10(g)(10)(11)

F577 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 07/02/2018 §483.10(g)(10) The resident has the right to(i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (ii) Receive information from agencies acting as client advocates, and be afforded the opportunity to contact these agencies. §483.10(g)(11) The facility must-(i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 9 of 78 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 06/01/2018 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 any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents. This REQUIREMENT is not met as evidenced by: Based on observation, resident and staff interview, the facility failed to ensure the most recent surveys of the facility were posted in a readily accessible area for the residents, family members, and legal representatives of the residents. This failure deprived residents and the public of the opportunity and the right to view the information in the necessary postings. Findings: On 5/30/18 at 11:15 AM, during the Resident Council interview, the Resident council president, Resident 32, stated he was pretty sure the survey results were in a binder outside of the administrators office. On 5/31/18 at 2:37 PM, during an interview and concurrent observation with the Administrator (ADM) in the hallway, the ADM pointed at a wall across from her office and stated the survey results should be on the wall in a bracket container for the binder. On the wall were to embedded screws in the wall which, the ADM stated, held the container for the survey binder. The ADM stated she did not know where the binder with the survey results was, or how long it had been missing from the wall. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 10 of 78 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 06/01/2018 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 On 6/01/18 at 10:42 AM, during an observation across the hall from from the nurses' station a bulletin board was posted on the wall. On the board was a sign which indicated the survey results were available in the ADM office upon request. The facility's admission agreement titled, "California Standard Admission Agreement For Skilled Nursing Facilities..." dated 5/11, indicated, "...Sec. 483.10 Resident rights...(g) Examination of survey results. A resident has the right to-- (1) Examine the results of the most recent surveys of the facility conducted by Federal or State surveyors...The facility must make the results available for examination in a place readily accessible to residents..."

F584 SS=D Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) 06/25/2018 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 11 of 78 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 06/01/2018 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 §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced by: Based on observation, resident and staff interview and document review, the facility failed to provide a homelike environment when 6 of 19 resident rooms had window curtains which were unhooked and hanging from the curtain rails. These failures resulted in an environment that was not homelike and had the potential to affect the resident's psychosocial well being. Findings: On 5/30/18 at 9:05 AM, during an observation and concurrent interview in room 16, a portion FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 12 of 78 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 06/01/2018 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 of the window drapes were unhooked and hanging from the curtain rod. Certified Nurse Assistant (CNA) 1 stated the window drapes were not hooked to the curtain rod. CNA 1 stated she would not like to see the window drapes at her home hanging from the curtain rod. On 5/30/18 at 2:10 PM, during an interview and concurrent observation in room 18, a portion of the window drapes were unhooked and hanging from the curtain rod. Resident 47 stated, "no not okay" when he looked at the window drapes. Resident 47 stated "no" he would not like to see window drapes in his home hanging off the curtain rod. On 5/30/18 at 2:14 PM, during an observation and concurrent interview in room 18, the Environmental Services Worker (ESW) stated the hanging window drapes should be hooked to the curtain rod. The ESW stated she would not like her window curtains at home to be hanging off the rod. The ES stated it was the responsibility of all staff to recognize drapes are hanging and to report it to the housekeeping or the maintenance staff. The ESW stated she was not sure if environmental services (housekeeping) were responsible for maintaining the drapes. On 5/30/18 at 2:15 PM, during an observation, the window drapes in rooms 13, 14, 15, 16, 17, 18, had portions of the drapes hanging from the curtain rod. The drape hooks had become disconnected from the curtain rod. On 5/30/18 at 2:25 PM, during observation and concurrent interview in rooms 13, 14, 15, 16, 17, and 18, the Environmental Services Supervisor (ESS) stated portions of the window drapes in rooms 13, 14, 15, 16, 17, and 18 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 13 of 78 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 06/01/2018 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 were hanging off of the curtain rails. On 5/30/18 at 2:48 PM, during an interview outside of room 17, the ESS stated it was the responsibility of the Environmental Services to make sure the drapes were in good working order, "the drapes must have come lose with people opening and closing them." The ESS stated the was a log book at the nurse's station for staff to report equipment that needed repair. On 5/30/18 at 3:04 PM, during an interview and concurrent document review at the nurse's station, the Maintenance Supervisor stated the CNAs could document the drapes neede to be fixed. The MS reviewed the log book and found only one documentation dated on 6/30/18 for the window drapes in room 16. The facility policy, "Maintenance Service" dated 2009, indicated, "...Maintaining the building in compliance with current federal, state...regulations and guidelines..."

F636 SS=D Comprehensive Assessments & Timing CFR(s): 483.20(b)(1)(2)(i)(iii)

F636 06/23/2018 §483.20 Resident Assessment The facility must conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity. §483.20(b) Comprehensive Assessments §483.20(b)(1) Resident Assessment Instrument. A facility must make a comprehensive assessment of a resident's needs, strengths, goals, life history and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 14 of 78 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 06/01/2018 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 preferences, using the resident assessment instrument (RAI) specified by CMS. The assessment must include at least the following: (i) Identification and demographic information (ii) Customary routine. (iii) Cognitive patterns. (iv) Communication. (v) Vision. (vi) Mood and behavior patterns. (vii) Psychological well-being. (viii) Physical functioning and structural problems. (ix) Continence. (x) Disease diagnosis and health conditions. (xi) Dental and nutritional status. (xii) Skin Conditions. (xiii) Activity pursuit. (xiv) Medications. (xv) Special treatments and procedures. (xvi) Discharge planning. (xvii) Documentation of summary information regarding the additional assessment performed on the care areas triggered by the completion of the Minimum Data Set (MDS). (xviii) Documentation of participation in assessment. The assessment process must include direct observation and communication with the resident, as well as communication with licensed and nonlicensed direct care staff members on all shifts. §483.20(b)(2) When required. Subject to the timeframes prescribed in §413.343(b) of this chapter, a facility must conduct a comprehensive assessment of a resident in accordance with the timeframes specified in paragraphs (b)(2)(i) through (iii) of this section. The timeframes prescribed in §413.343(b) of this chapter do not apply to CAHs. (i) Within 14 calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 15 of 78 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 06/01/2018 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 mental condition. (For purposes of this section, "readmission" means a return to the facility following a temporary absence for hospitalization or therapeutic leave.) (iii)Not less than once every 12 months. This REQUIREMENT is not met as evidenced by: Based on interview, and record review, the facility failed to complete a comprehensive MDS (minimum data set) assessment (evaluation to determine level of care and functional abilities) for one of 22 sampled residents (Resident 200) when Resident 200 returned from the general acute care hospital (GACH) on 5/4/18 and did not have an MDS comprehensive assessment completed. This failure resulted in the incomplete timely assessment and initiation of a plan of care that met all of Resident 200's needs. Findings: On 6/1/18 at 11:05 a.m., during an interview and concurrent record review the Social Service Designee (SSD) stated Resident 200's comprehensive assessment had not yet been completed following her return from the GACH. The SSD stated the assessment was supposed to be completed within 14 days following her return from the GACH. On 6/1/18 at 2:03 p.m., during an interview and record review, Licensed Nurse (LN 6) stated Resident 200 was discharged to the GACH on 4/29/18 and returned to the facility on 5/4/18. LN 6 stated Resident 200 returned with a pressure ulcer on her coccyx and was having problems with recurrent urinary tract infections. LN 6 stated Resident 200 had been sent to the acute care hospital for her acute changes of condition. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 16 of 78 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 06/01/2018 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 On 6/1/18 at 4 p.m., during an interview and record review, the Director of Nursing (DON) stated Resident 200 returned from the acute care hospital on 5/4/18. The DON stated, "We did not complete a comprehensive MDS assessment within 14 days of her return. The assessment is late because the assessment was not completed." Resident 200's electronic MDS assessment validation report indicated the following MDS comprehensive, discharge and entry tracking; a full comprehensive assessment on 3/21/18, followed by an unplanned discharge to GACH on 3/26/18, a return from the GACH on 4/13/18, an unplanned discharge to GACH on 4/29/18 and a return to the facility on 5/4/18. Review of facility CMS's RAI Version 3.0 Manual Chapter 2; Assessments for the RAI dated 10/2017, indicated "Page 2-1 ...The OBRA (Omnibus Budget Reconciliation Act) regulations require nursing homes that are Medicare certified, Medicaid certified or both, to conduct initial and periodic assessments for all their residents. The Resident Assessment Instrument (RAI) process is the basis for the accurate assessment of each resident ...Page 2-3 ...An RAI must be completed for any individual residing more than 14 days on a unit of a facility that is certified as a long term care facility for participation in the Medicare or Medicaid programs...Regardless of the resident's length of stay, the facility must still have a process in place to identify the resident's needs and must initiate a plan of care to meet those needs upon admission ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 17 of 78 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 06/01/2018 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

F655 Baseline Care Plan CFR(s): 483.21(a)(1)-(3)

F655 SS=E PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 06/13/2018 §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must(i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to(A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan(i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 18 of 78 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 06/01/2018 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 administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan for two of 22 residents (Resident 34 and Resident 200) when Resident 34 had no care plan following an admission to hospice and Resident 200 had no care plan developed for the her urinary retention and the use of an indwelling Foley catheter (a flexible rubber tube that is inserted into the bladder to drain urine) (F/C). This failure had the potential to result in a lack of care, services and continuity of care and communication among facility staff for Resident 34 and Resident 200. Findings: Resident 34's record indicated "... HOSPICE CARE ADMISSION CONSENT", dated 5/21/18 and signed by the resident's responsible party. On 5/31/18 at 8:30 a.m., during an interview and concurrent record review, the Director of Nursing (DON) reviewed Resident 34's record and was unable to find a care plan which identified the resident was on hospice The DON stated the resident was placed on hospice while at an acute facility and just prior to being readmitted to the facility. The DON stated a care plan for hospice should have been developed for Resident 34. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 19 of 78 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 06/01/2018 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 On 5/29/18 at 10:30 a.m., during an observation of Resident 200 and concurrent interview with Certified Nursing Assistant (CNA 2) Resident 200 had an indwelling Foley catheter attached to a drain bag. CNA 2 stated Resident 200 returned from the acute care hospital with the indwelling Foley catheter. On 6/1/18 at 2:03 p.m., during an interview and concurrent record review, Licensed Nurse (LN 6) stated Resident 200 returned from the acute care hospital on 5/4/18. LN 6 stated Resident 200 used an indwelling F/C for urinary retention. LN 6 stated Resident 200 had no care plan to indicate need for an indwelling F/C. LN 6 stated Resident 200 needed to have a care plan that addressed her urinary retention and the use of F/C. The facility policy and procedure titled, "Care Plans - Baseline" dated 12/16, indicated, "... to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty- eight (48) hours of the resident's admission...The baseline care plan will be used until the staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered care plan."

F656 SS=E Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 06/13/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 20 of 78 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 06/01/2018 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 objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on staff interview and record review, the facility failed to develop and implement a baseline care plan for five of 22 sampled residents (Resident 3, Resident 5, Resident 10, Resident 20, and Resident 34) when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 21 of 78 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 06/01/2018 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 Resident 3 did not have a fall risk care plan, Resident 5 did not have a care plan for activities of daily living, Resident 10 did not have a care plan revision following a fall and Resident 34 did not have a hospice care plan. For Resident 20 this failure resulted in the unmet needs for pressure ulcer (wound that result from direct pressure) prevention. For Resident 3 and Resident 10 this failure placed the residents at risk for repeat falls and injuries. For Resident 5 this failure resulted in the unmet need for feeding assistance during meals. For Resident 34 this failure had the potential to result in a lack of interventions care, services and continuity of care and communication among facility staff. Findings: On 5/4/18 at 2:35 p.m., during a telephone interview, the Director of Nursing stated Resident 20 was no longer ambulatory and was bedridden on her return from the GACH. The DON stated Resident 20 had a surgical incision to the right hip and no pressure ulcers. The DON stated Resident 20 was at risk for skin breakdown because she was bedridden. The DON stated Resident 1 developed two pressure ulcers, a stage 2 (partial thickness loss or broken skin can also resemble a fluidfilled blister) on the right heel and a stage 2 on her coccyx. The DON stated Resident 20 developed the pressure ulcers as a result of her change of condition. The DON stated Resident 20 nursing notes indicated a stage 2 to her coccyx on 10/19/17 and a blister was identified on 10/27/17 to the right heel. The DON stated the care plan for pressure ulcer prevention was not revised until after the pressure ulcers developed. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 22 of 78 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 06/01/2018 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 On 6/1/18 at 4:15 p.m., during an interview, and concurrent record review, the DON stated Resident 20's care plan dated 9/26/17, pressure ulcers interventions indicated to encourage good nutrition and hydration in order to promote healthier skin. The DON stated Resident 20 did not have pressure ulcers on 9/26/17 and was only at risk. The DON stated the facility identified Resident 20 developed skin breakdown to her coccyx (tail bone) on 10/19/17. The DON stated Resident 20's right heel was noted with redness on 11/2/17. The DON stated the care plan interventions were not revised until after the breakdown occurred. The DON stated, "We could have been a little more timely [on the care plan revision for pressure ulcer prevention.]" Resident 20's care plan dated 9/26/17 indicated, two updated entries, "10/26/17 Resident is noted with fluid-filled blister to the right heel" and "11/12/17 Resident noted to have pressure associated skin damage with eschar to the right heel; fluid filled blister resolved ...Goal The resident will maintain or develop clean and intact skin by the review date. The resident will have not complication [related to] right hip surgical incision through the review date. Interventions Encourage good nutrition and hydration in order to promote healthier skin. Follow facility protocols for treatment of injury. Monitor pressure associated skin damage to the right heel with eschar for signs and symptoms of worsening for 14 days." On 4/25/18 at 2:20 p.m., during an interview and concurrent record review, Licensed Nurse (LN 3) stated Resident 3 had sustained multiple falls in the facility. LN 3 stated Resident 3 was considered "High Risk" for falls as indicated on his fall risk assessment dated 10/30/17. LN 3 stated Resident 3 had a fall in the outside FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 23 of 78 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 06/01/2018 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 grounds of the facility on 1/15/18 at 10:30 p.m. LN stated Resident 3 had another fall on 3/18/18 at 8:27 p.m. in the outside grounds of the facility. LN 3 stated Resident 3 did not have a care plan to address Resident 3's high fall risk. LN 3 stated, "There are several opportunities that were missed and no care plan was ever put in to address his fall risk ...we should have identified that he had no fall risk care plan." Resident 3's fall risk assessment dated 10/30/17, indicated Resident 30 scored 18 and was categorized "High Risk" for falls. Resident 3's nursing progress notes dated 1/15/18, indicated, "11:40 p.m. ...CNA brought resident into facility, report to writer found resident outside sitting up holding his head with buttock on the floor, unwitnessed fall, resident was able to get up with CNA assistance ..." Resident 3's nursing progress notes dated 3/18/18, indicated, "9:04 p.m., at 8:27 p.m., CNA found resident outside sitting on the floor leaning back against the bench ..." On 4/25/18 at 11:25 a.m., during an interview, and concurrent record review, LN 4 stated Resident 10 had a fall on 4/5/18 at 5:30 p.m. LN 4 stated Resident 10 was found outside on the ground. LN 4 stated Resident 10's fall risk assessment dated, 11/5/17, indicated she had a score of 10 and was considered "Moderate Risk" for falls. LN 4 stated Resident 10's fall risk care plan dated 5/24/16 indicated her risk for falls. LN 4 stated Resident 10's care plan did not indicated any new interventions following the fall from 4/5/18. LN 4 stated Resident 10's care plan needed to be revised with new interventions for fall prevention. On 5/3/18 at 3:20 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 24 of 78 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 06/01/2018 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 and concurrent record review, LN 9 stated she was the nurse on duty when Resident 10 fell on 4/5/18 in the outside grounds. LN 9 stated the care plan for fall prevention had not been revised following the fall. LN 9 stated the care plan did not have new interventions to reduce the risk for repeated falls. LN 9 stated Resident 10 could potentially fall again. Resident 10's progress notes dated 4/5/18, indicted, " ...At 5:30 p.m., staff member informed this writer that resident is lying on the ground underneath tree outside ..." On 05/29/18 at 12:29 p.m., during an observation Resident 5 received her lunch tray, she took a spoon and filled it with food. Resident 5 spilled food while attempting to feed herself. Resident 5 began to lick the food off the handle of the spoon. Resident 5 placed the spoon down and began to pick at her food with her hands. 5/29/18 12:37 p.m., Resident 5 requested assistance from staff to be fed. Resident 5 stated she could not see her food. On 5/29/17 at 12: 56 p.m., during an interview, CNA 14 stated, "[Resident 5] will say she has trouble seeing in order to get attention." CNA 14 stated Resident 5 required assistance to be fed by staff because she was unable to feed herself without dropping her food. Resident 5's MDS (minimum data set) assessment (evaluation to determine level of function and care needs) dated 5/4/18, indicated, Resident 5 required extensive assistance (weight bearing support) with the support of one staff member for eating. On 6/1/18 at 3:30 p.m., during an interview and concurrent record review, LN 2 stated Resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 25 of 78 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 06/01/2018 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 5 needed to be fed by staff from time to time. LN 2 stated Resident 5's care plan for activities of daily living (ADL) was not in the record. LN 2 stated the ADL care plan would indicate how much help she needs with feeding. Resident 34's record indicated "... HOSPICE CARE ADMISSION CONSENT", dated 5/21/18 and signed by the resident's responsible party. On 5/31/18 at 8:30 a.m., during an interview and concurrent record review, the Director of Nursing (DON) reviewed Resident 34's record and was unable to find a careplan which identified the resident was on hospice The DON stated the resident was placed on hospice while at an acute facility and just prior to being readmitted to the facility. The DON stated a careplan for hospice should have been developed for Resident 34. The facility policy and procedure titled, "Care Plans - Baseline" dated 12/16, indicated, "... to assure that the resident's immediate care needs are met and maintained, a baseline care plan will be developed within forty- eight (48) hours of the resident's admission...The baseline care plan will be used until the staff can conduct a comprehensive assessment and develop an interdisciplinary person-centered care plan."

F658 SS=D Services Provided Meet Professional Standards CFR(s): 483.21(b)(3)(i)

F658 06/20/2018 §483.21(b)(3) Comprehensive Care Plans FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 26 of 78 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 06/01/2018 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 The services provided or arranged by the facility, as outlined by the comprehensive care plan, must(i) Meet professional standards of quality. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to administer medications in a manner that met professional standards of quality when Licensed Nurse (LN 3) pre-poured medications for three residents during the morning medication pass. This failure placed the residents at risk for medication errors. Findings: On 5/31/18 at 08:30 a.m., during an observation and concurrent interview, LN 3 was preparing medications for cart AB. LN 3 had three medication cups and was pouring medications into each medication cup at the same time. The cups were unlabeled and had different colored pills. LN 3 stated, "I am preparing medications for three residents I have three medication cups and I am working on getting their over the counter medications into their cups." LN 3 stated, "I have not marked [the medication cups with the name of the residents] yet but I know their medications." LN 3 was unable to explain how she distinguished which medication cup belonged to which resident. LN 3 stated, "I have always done it this way, I guess I am pre pouring the medications. I don't think it is a safe practice, an error can occur." The facility policy and procedure titled, "Administering Medications" dated 12/12, indicted, "Medications shall be administered in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 27 of 78 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 06/01/2018 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 a safe and timely manner, and as prescribed ...7 The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving a medication ..." Review of professional reference titled, "Long term Care Nursing: Medication Pass" https://ceufast.com/course/long-term-carenursing-medication-pass dated 12/4/17, indicted, "Medication Pass The medication pass takes up the most hours of the day and evening shifts ....Do NOT, under any circumstance try to pre-pour medications to save time. Pre-pouring medication is against regulations."

F686 Treatment/Svcs to Prevent/Heal Pressure Ulcer F686 06/20/2018 SS=G CFR(s): 483.25(b)(1)(i)(ii) §483.25(b) Skin Integrity §483.25(b)(1) Pressure ulcers. Based on the comprehensive assessment of a resident, the facility must ensure that(i) A resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and (ii) A resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 28 of 78 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 06/01/2018 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 This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 20) remained free from developing pressure ulcers (localized injury to the skin and or underlying flesh usually over a bony area as a result of pressure/friction/shear) when Resident 20 did not receive interventions to prevent pressure ulcers after becoming bedridden following a fall that resulted in a hip fracture. This failure resulted in Resident 20's development of two Stage 2 (partial thickness loss or broken skin can also resemble a fluidfilled blister) pressure ulcers, one to the coccyx (tail bone) and one to the right heel, and placed Resident 20 at risk for increased discomfort, infection and not reaching her highest practicable level of wellbeing. Findings: Resident 20's clinical record titled, "Progress Notes" dated 9/20/17, at 10:36 p.m., indicated, "At 5:50 p.m., LN [licensed nurse] was summoned to grass area near gazebo where resident [Resident 20] was found lying on her left side in the grass ..." Resident 20's General Acute Care Hospital (GACH) clinical record titled, "ED (emergency department)" dated 9/20/17, indicated, "Chief Complaint Patient present with Fall GLF (ground level fall) from a SNF (skilled nursing facility) unwitnessed, fall from standing position ...86 [year old] female [with history of] dementia, brought in by ambulance from facility after found down on the grass outside around 7:50 p.m. tonight. Largely nonverbal at baseline, but does grimace with palpation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 29 of 78 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 06/01/2018 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 [touching with light pressure] of right hip ..." Resident 20's GACH clinical record titled, "ED Provider Notes" dated 9/20/17, indicated, "XR [X-Ray] R [right] hip with R hip fracture...Will consult ortho (orthopedic) (bone specialist) and admit to medicine for R hip fracture. IMPRESSION: dementia, R hip fracture." On 10/9/17 at 1:05 p.m., during an observation of Resident 20 and a concurrent interview with Certified Nursing Assistant (CNA) 1, Resident 20 was lying in bed (on a regular mattress) with her eyes closed. CNA 1 stated Resident 20 was no longer able to walk and was less responsive after the fall on 9/20/17. Record review of Resident 20's face sheet (document containing resident personal information) indicated Resident 1 was admitted to the facility on 8/23/13 with a diagnosis of dementia (loss of mental ability impairing memory and judgement). On 10/9/17 at 1:48 p.m., during an interview, Licensed Nurse (LN) 1 stated Resident 20 was no longer able to walk after her return from the acute care hospital. LN 1 stated Resident 20 was now bedridden which was a significant change in condition after her fall of 9/20/17. Review of Resident 20's clinical record titled, "Progress Notes" dated 9/26/17 at 11:49 p.m., indicated, "Resident on alert charting s/p [status post] return from [hospital] r/t [related to] fracture/surgery to [right] hip. Resident remained in bed throughout evening only [complaining of] pain during ADL [activities of daily living] care or changing position, LN administered PRN (when necessary) pain medication." Review of Resident 20's clinical record titled, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 30 of 78 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 06/01/2018 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 MDS (minimum data set) Assessment (evaluation of memory recall and care needs) dated 9/26/17, indicated Resident 20 had a significant change of condition. The MDS indicated Resident 20 was no longer ambulatory and was at risk for developing pressure ulcers. The MDS indicated Resident 20 experienced pain which limited day to day activities because of pain. On 5/4/18 at 2:35 p.m., during a telephone interview and concurrent record review, the Director of Nursing (DON) stated Resident 20 returned from the hospital on 9/26/17 with a surgical incision to the right hip and with no pressure ulcers. The DON stated Resident 20 was identified to be at risk for skin breakdown on 9/9/17 prior to her change of condition. The DON stated Resident 20's Braden scale (evaluation for predicting pressure sore risk), dated 9/9/17 indicated Resident 20's score was 18 and categorized as "AT RISK for developing pressure ulcers." The DON stated Resident 20's pressure ulcer risk care plan interventions were to monitor skin and check for incontinence. The DON stated Resident 20 continued to be at risk for skin breakdown after her return from the hospital because she was bedridden. The DON stated there was no Braden scale assessment completed following her return from the hospital on 9/26/17. The DON stated Resident 20's Braden scale assessment should have been completed but was not. The DON stated Resident 20 experienced a decrease in nutritional intake and was not eating much which caused a significant weight loss. The DON stated Resident 20 developed two pressure ulcers, a stage 2 on the right heel and a stage 2 on her coccyx. The DON stated Resident 20 developed the pressure ulcers following the fall on 9/20/17 as a result of her change of condition. The DON stated the clinical record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 31 of 78 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 06/01/2018 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 for Resident 20, in the nursing notes, indicated a stage 2 developed on the coccyx on 10/19/17 and a blister was identified on 10/27/17 to the right heel. The DON stated the pressure ulcer on the coccyx healed on 11/17/17 and the pressure ulcer to the right heel had not yet healed. The DON stated the facility started floating (remove of direct pressure) Resident 20's heels [off the mattress] and had initiated an air mattress after the skin breakdown was identified. The DON stated the expectation for pressure ulcer prevention was for the nurses to update the care plan and implement preventative interventions as soon as the pressure ulcer risks were identified. Review of Resident 20's clinical record titled, "Progress Notes" dated 9/26/17 at 2:46 p.m., indicated, "Skin assessment on return from [hospital] reveals scattered bruising to [right upper extremity] ...surgical incision to the right hip ..." Review of Resident 20's clinical record titled, "Progress Notes" dated 10/2/17 at 11:26 a.m., indicated, "Dietary Note ...Skin: surgical incision to the right hip [due to] fall ..." Review of Resident 20's clinical record titled, "Progress Notes" dated, 10/18/17 at 11:58 p.m., indicated, "LN was summoned to resident ...Upon assessment LN observed open stage [2] pressure sore to coccyx area ..." Review of Resident 20's clinical record titled, "Progress Notes" dated, 10/19/17 at 4:17 a.m., indicated, "stage 2 pressure ulcer to mid coccyx area 0.5cm length [by] 0.2cm width...new treatment order obtained..." There was no measurement of wound depth taken. Review of Resident 20's clinical record titled, "Progress Notes" dated, 10/22/17 at 4:37 a.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 32 of 78 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 06/01/2018 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 indicated, "...Resident on alert charting for stage [2 pressure ulcer] to coccyx ..." Review of Resident 20's clinical record titled, "Progress Notes" dated, 10/26/17 at 6:39 p.m., indicated, "[Physician] in house to assess resident [right] heel/ankle. Resident has unstageable ulcer (wound with full loss of skin and flesh covered by a thick coat of dead matter and unable to be staged) ..." Review of Resident 20's clinical record titled, "Progress Notes" dated 10/31/17 at 1:25 p.m., indicated, "...Skin: coccyx stage [2] pressure area with dressing dry and intact, and [right] heel dried open blister area..." Review of Resident 20's care plan dated 9/26/17, indicated, "The resident has potential/actual impairment to skin integrity of the (right hip) [related to] surgical wound (right hip incision)...Goal The resident will maintain or develop clean and intact skin by the review date. The resident will have no complication [related to] right hip surgical incision through the review date. Interventions Encourage good nutrition and hydration in order to promote healthier skin." The care plan had two updated problem entries that indicated, "10/26/17 Resident is noted with fluid-filled blister to the right heel" and "11/12/17 Resident noted to have pressure associated skin damage with eschar (dead tissue covering wound) to the right heel; fluid filled blister resolved ...Intervention Follow facility protocols for treatment of injury. Monitor pressure associated skin damage to the right heel with eschar for signs and symptoms of worsening for 14 days." On 6/1/18 at 4:18 p.m., during an interview and concurrent record review, the DON stated, the facility had not implemented timely preventive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 33 of 78 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 06/01/2018 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 pressure ulcer interventions for Resident 20. The DON stated, "I educated the staff to promote the floating of her heels because I noticed it was not being done. I cannot recall the exact date when this started. We could have been a little more timely with the care plan interventions." The DON stated the facility implemented an air loss mattress after Resident 20's pressure ulcers were identified. The DON could not provide documentation of the date for the implementation of the air mattress for Resident 20. The facility policy and procedure titled, "Pressure Ulcer Risk Assessment" dated 3/05, indicated, "The purpose of this procedure is to provide guidelines for the assessment and identification of residents at risk of developing pressure ulcers. Preparation 1. Review the resident's care plan to assess for any special needs of the resident. 2. Assemble the equipment and supplies as needed. General Guidelines 1. Pressure ulcers are usually formed when a resident remains in the same position for an extended period of time causing increased pressure or a decrease of circulation (blood flow) to that area, which destroys the tissues ...4. Because a resident at risk can develop a pressure ulcer within 2 to 6 hours of the onset of pressure, the at risk resident needs to be identified and have interventions implemented promptly to attempt to prevent pressure ulcers. The admission evaluation helps define those initial care approaches."

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 06/20/2018 §483.25(d) Accidents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 34 of 78 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 06/01/2018 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 The facility must ensure that §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards for two of 15 sampled residents (Resident 20 and Resident 39) when: 1. Resident 20 fell outside on an uneven and unpaved walkway of the facility. 2. Resident 39 hoarded personal items at the bedside that created a fall risk hazard in the room and utilized the privacy curtain (fire FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 35 of 78 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 06/01/2018 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 retardant curtain suspended from the ceiling to circle around the bed to provide privacy during personal care) as a rod to hang his clothes and hangers. For Resident 20 these failures resulted in a fracture to the right hip which required surgical repair and a five day stay in the general acute care hospital (GACH), pain, decline in physical function, significant weight loss and development of pressure ulcers (wounds resulting from direct pressure) to the coccyx (tail bone) and to the right heel. For Resident 39 these failures created a fall risk and fire hazard. Findings: 1. Resident 20's face sheet (document containing resident personal information) indicated Resident 20 was admitted to the facility on 8/23/13 with diagnosis of dementia (loss of mental ability impairing memory and judgement). Resident 20's clinical record titled MDS (Minimum Data Set) Assessment (evaluation tool used to guide the development of care plan needs) dated 9/8/17, indicated Resident 20 had severe cognitive impairment. The MDS assessment indicated Resident 20 required extensive assistance from staff for bed mobility, dressing, toilet use and personal hygiene. The MDS indicated Resident 20 required limited assistance (guided maneuvering of limbs) for bed to chair transfers and eating, and required staff supervision for ambulation and locomotion. Review of Resident 20's fall risk assessment dated 9/9/17, indicated Resident 20 was at "Moderate" risk for falls with a score of 10 points. The "FALL RISK ASSESSMENT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 36 of 78 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 06/01/2018 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 INSTRUCTIONS" indicated, "...assess the resident status in the eight clinical condition parameters listed...assigning the corresponding score which best describes the resident in the appropriate assessment column ...If the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls ..." The fall risk assessment dated 9/9/17 did not match with the corresponding score described on the fall risk assessment instructions. On 5/4/18 at 3 p.m., during a telephone interview, and concurrent record review, the DON stated Resident 20's fall risk assessment dated 9/9/17 indicated Resident 20 was at moderate risk for falls. The DON stated anything over 10 is considered "At risk, it can be moderate or high, the risk for falls is there." Resident 20's fall risk care plan dated 8/23/13, indicated, "Risk for falls characterized by multiple risk factors related to: age factor and underlying medical conditions [diagnosis] DEMENTIA IS CURRENTLY [ambulatory] WITHOUT ASSIST/STEADY GAIT, CAN MAKE NEEDS KNOWN." Resident 20's revised fall risk care plan dated 10/2/16, indicated, "Resident had witnessed fall on 10/2/16." Resident 20's revised fall risk care plan dated 8/26/17 indicated, "Resident had unwitnessed fall on 8/26/17. Goal No falls during review period. Interventions/Tasks Encourage resident to ask for assistance when going from room to activities. Encourage resident to use handrails or assistive devices properly. Put on alert charting for 72 hrs. Reinforce need to call for assistance. Resident to wear proper and no slip footwear. Resident to wear skid free socks when in bed..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 37 of 78 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 06/01/2018 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 Resident 20's clinical record titled, "Progress Notes" dated 9/20/17, at 10:36 p.m., indicated, "at 5:50 p.m., LN [licensed nurse] was summoned to grass area near gazebo where resident [Resident 20] was found lying on her left side in the grass ..." Resident 20's GACH clinical record titled, "ED (emergency department)" dated 9/20/17, indicated, "Chief Complaint Patient present with Fall GLF (ground level fall) from a SNF (skilled nursing facility) unwitnessed, fall from standing position ...86 [year old] female [with history of] dementia, brought in by ambulance from facility after found down on the grass outside around 7:50 p.m. tonight. Largely nonverbal at baseline, but does grimace with palpation [touching with light pressure] of right hip ..." Resident 20's GACH clinical record titled, "ED Provider Notes" dated 9/20/17, indicated, "XR [X-Ray] R [right] hip with R hip fracture...Will consult ortho (orthopedic) (bone specialist) and admit to medicine for R hip fracture. IMPRESSION: dementia, R hip fracture." Resident 20's GACH clinical record titled, "Operative Report" dated 9/23/17, indicated, " ...Right sub-capital valgus impacted femoral neck (fracture is a crack near the hip joint, located between the top (head) of the bone of the leg and the main part of the latter) fracture ...Procedure performed: ORIF (open reduction and internal fixation)(surgery used to fix broken bone by reducing or putting the bone back into place, next an internal device such as screw, plates, rods or pins are used to hold the broken bone together) right hip ...Decision made to proceed with operative treatment ...DESCRIPTION OF PROCEDURE: Today on day of surgery, after the patient was cleared for medical intervention. The patient was brought FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 38 of 78 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 06/01/2018 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 to room with the help of anesthesia ...Preoperative (before surgery) antibiotics were given ...A 1 1/2 inch incision was performed along the lateral proximal thigh. Three ...partially threaded cannulated screws were placed over guidewires across the fracture in an inverted triangle fashion ...Wounds copiously (large amount) irrigated (watered) with sterile (germ free) saline. Fascia [fibrous membrane covering muscles] was approximated ...Wounds dressed (bandaged) sterilely in the operating room." Resident 20's GACH clinical record titled, "Discharge Summaries" dated 9/25/17, indicated Resident 20 would be discharged to the facility on 9/26/17 following a five day stay in the GACH for treatment of the right hip fracture. Resident 20's clinical record titled, "Progress Notes" dated 9/26/17 at 2:08 p.m., indicated, "Resident returned to facility from [GACH] via gurney and accompanied by 2 medics." Resident 20's clinical record titled, "Progress Notes" dated 9/26/17 at 11:49 p.m., indicated, "Resident on alert charting s/p [status post] return from [GACH] r/t [related to] fracture/surgery to [right] hip. Resident remained in bed throughout evening only [complaining of] pain during ADL [activities of daily living] care or changing position, LN administered PRN (when necessary) pain medication." Resident 20's clinical record titled MDS dated 9/26/17, indicated Resident 20 had a significant change of condition. The MDS indicated Resident 20 was no longer ambulatory and was requiring extensive assistance from staff for eating. The MDS indicated Resident 20 experienced pain which limited day to day FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 39 of 78 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 06/01/2018 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 activities because of pain. Resident 20's pain was rated 7/10, zero being no pain and ten as the worst pain imaginable. Resident 20's September 2017 medication administration record (MAR) indicated a pain level experienced by Resident 20 ranged from five to seven following her return from the GACH. On 10/9/17 at 1:05 p.m., during an observation of Resident 20 and a concurrent interview with Certified Nursing Assistant (CNA) 1, Resident 20 was lying in bed with her eyes closed. CNA 1 stated Resident 20 fell outside from an unpaved walkway into the grass in September (2017). CNA 1 stated Resident 20 was transferred to the GACH the day of the fall. CNA 1 stated Resident 20 was no longer able to walk and was less responsive after the fall. On 10/9/17 at 1:10 p.m., during an observation of the external walkways of the facility, and a concurrent interview, with Maintenance Supervisor (MS) 1, an unleveled and unpaved dirt walkway was proximate to a patio exit and across from the gazebo. On the surface and on the path of the dirt walkway a sprinkler head, a sprinkler shut off valve which resembled the bottom of a bucket and a metal pole protruded creating a trip hazard. At the end of the unpaved walkway a tree trunk with roots lifted the ground which created additional trip hazards was visible. MS 1 stated he knew about Resident 20's fall and believed Resident 20 fell outside by the gazebo. MS 1 stated he checked on the outside walkway areas to look for trip hazards that could have caused Resident 20's fall. MS 1 stated he walked around the facility on 10/2/17 and 10/9/17 during the morning and did not identify any trip hazards. MS 1 stated the unleveled ground had never been an issue. MS 1 stated the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 40 of 78 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 06/01/2018 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 protruding metal pole, sprinkler head and shut off were present during his rounds. MS 1 stated he had not considered the unpaved and uneven walkway as a trip hazard. MS 1 stated he did not consider the sprinkler head, sprinkler shut off valve or the metal pole as trip hazards. MS 1 was asked to measure the trip hazards identified. The sprinkler head protruded six inches high, the sprinkler shut off measured six inches high and was nine and one-half inches in diameter, the metal pole was four inches high. MS 1 identified additional areas surrounding the facility with unleveled walking surfaces. An unpaved and uneven dirt walkway initiated from the covered patio on the side exit of the building and extended alongside the lawn and was lower than the paved sidewalk and grassy area adjacent to it. MS 1 measured a two inch drop from the paved walkway to the unpaved area. MS 1 pointed out to the unleveled ground outside the activity office exit. MS 1 stated the walkway had unleveled ground that measured two inches on both sides. MS 1 pointed out to the drain trap outside of the laundry room which protruded four inches. MS 1 stated, "I see the potential for trip hazards now, I had not thought about it before." MS 1 stated the residents of the facility had accessibility to all of the surrounding walkways of the facility, including the ones identified to have trip hazards. On 10/9/17 at 2:20 p.m., during an interview, LN 1 stated he had taken care of Resident 20 for two months prior to her fall. LN 1 stated Resident 20 would walk inside and out throughout the facility using her walker prior to her fall. LN 1 stated, "[Resident 20] is non weight bearing, she has had a significant change since she fell. [On 9/20/17]" LN 1 stated Resident 20 experienced pain since the fall and required narcotic pain medication to keep her comfortable. LN 1 stated all of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 41 of 78 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 06/01/2018 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 residents of the facility had access to the entire grounds of the facility. LN 1 stated staff would do rounds every two hours to ensure the residents who were outside were ok. LN 1 stated he maintained a safe environment inside the facility by keeping all hallways clear and free from clutter. LN 1 stated he checked the outside for fall hazards and would inspect the pavement for cracks, displaced water hoses, gardening tools or anything unusual. On 10/9/17 at 2:35 p.m., during an observation and concurrent interview, LN 1 could not recall the last time he performed an environmental check. LN 1 was asked to identify areas of the external facility grounds determined to be trip hazards. LN 1 looked at the unpaved and uneven dirt walkway that was unleveled. LN 1 stated, "The area has uneven ground and can be a trip hazard to the residents walking outside." LN 1 stated the protruding metal pole, the protruding sprinkler head and sprinkler shut off and the tree trunk raising the ground were all considered trip hazards. LN 1 stated, "It is not safe for the residents to be outside in these areas." LN 1 stated Administration would be responsible for making the necessary repairs to the outside walkways. On 10/9/17 at 3:10 p.m., during an interview and concurrent record review, LN 5 stated she was the nurse assigned to Resident 20 on 9/20/17, the day of the fall. LN 5 stated Resident 20 fell outside at 7:50 p.m. LN 5 stated Resident 20 was seen last sitting in the dining room at 7:40 p.m. LN 5 stated Resident 20 got up and walked outside with her walker. LN 5 stated Resident 20 walked with a limp to her right leg which was caused by a knee inversion. LN 5 stated Resident 1 had a history of falls indoors and not outside. LN 5 stated the root cause of Resident 20's fall was from several factors, the unleveled ground, the easy FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 42 of 78 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 06/01/2018 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 accessibility to the outside at all hours and the lack of lighting. LN 5 was asked if the identified factors had ever been addressed with the Director of Nursing (DON) or the Administrator (Adm). LN 5 stated the concerns she addressed as root cause for falls were not addressed with the DON or with the Adm before. LN 5 reviewed Resident 20's care plan on falls and stated the care plan did not address external environmental factors that should have been addressed due to Resident 20's fall risk. On 10/9/17 at 4:15 p.m., during an interview, the Administrator (ADM) 1 stated she had not walked through the outside grounds of the facility. ADM 1 stated she was not aware of the walkways that had unleveled ground and did not know where Resident 1 had fallen. ADM 1 stated she did not know the facility had poor lighting at night time. ADM 1 stated the facility doors leading to the external walkways remained unlocked 24 hours per day. ADM 1 stated the residents were able to exit and walk throughout the facility grounds whenever they wanted because the facility was their home. ADM 1 stated the residents were able to exit through the doors at any time they wanted. On 10/10/17 at 10:30 a.m., during a telephone interview, CNA 2 stated Resident 20 was in her room at 7 p.m. on 9/20/17. CNA 2 stated Resident 20 ambulated by herself and didn't ambulate outside of the facility very much. CNA 2 stated on 9/20/17 LN 5 was alerted by another resident that Resident 20 had fallen. CNA 2 stated LN 5 found Resident 20 outside on the ground. CNA 2 stated the only time staff provided supervision to the residents outside was during the smoking times. CNA 2 stated she did not know if there were any trip hazards in the outside walkways of the facility. CNA 2 stated the outside of the facility was not well lit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 43 of 78 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 06/01/2018 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 during the night and could contribute to falls as well. On 4/23/18 at 10:20 a.m., during an observation and concurrent interview, Maintenance Supervisor (MS) 2 stated he started work as the "Maintenance Supervisor" three weeks ago. MS 2 stated the residents of the facility had access to all of the facility grounds. During the tour, MS pointed out to an unpaved area behind the facility with unleveled ground. The area was being used for storage next to a parked facility van. MS 2 pointed out to a folded up table and a long piece of wood leaning against the wall of the building, a large gray colored rubber trash can, a bed with a corroded frame and springs, and two dirt soiled mattresses. MS 2 stated the residents had access to the unpaved area being used for storage. MS 2 stated this was an unsafe area for the residents to have access to. On 4/23/18 at 10:55 a.m., during an observation and concurrent interview, ADM 2 walked toward the unleveled and unpaved back area of the facility being used for storage. ADM 2 stated the area was unleveled. ADM 2 walked toward the walkway proximal to the facility car entrance and pointed to a walkway with broken cement. ADM 2 stated, "This walkway is broken and uneven." On 4/25/18 at 11:07 a.m., during an interview, LN 4 stated she knew the Residents had access to all of the grounds of the facility. LN 4 stated, "I always wondered why the residents were allowed back there. There is not supervision when the residents get out and go back there. It is dangerous." LN 4 stated she was a newer nurse to the facility and she had not addressed this concern with management. LN 4 stated she asked the certified nursing assistants to do rounds outside of the facility at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 44 of 78 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 06/01/2018 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 least every hour. LN 4 stated the residents could come in and out from the facility into the enclosed walkways/grounds as they pleased. LN 4 stated the doors were not alarmed and did not signal when a resident was coming in our out. On 4/25/18 at 2:10 p.m., during interview, LN 5 stated the residents of the facility had access to all areas of the facility grounds. LN 5 stated the areas in the back of the facility could be a hazard for the residents that used the walkways. LN 5 stated she had the certified nursing assistants do outside rounds at least every two hours. LN 5 stated she thought there was limited lighting in the back of the facility during the night time. LN 5 stated during the rainy season the areas in the back of the facility got wet and slippery with mud and created more hazards. LN 5 stated she had not brought this concern to management's attention. On 5/4/18 at 2:35 p.m., during a telephone interview, the Director of Nursing stated Resident 20's trigger for weight loss was the fall followed by the surgical hip repair. The DON stated Resident 20 was not eating much and had a 3.7% (percent) weight loss in one month and 6.6% weight loss in two months. The DON stated Resident 20's weight went from 106 lbs. (pounds) to 99 lbs. from September 2017 to November 2017. The DON stated Resident 20's weight for April 2018 was 89 lbs. (a 16.03% weight loss since September 2017). The DON stated Resident 20 was no longer ambulatory and was bedridden on her return from the GACH. The DON stated Resident 20 had a surgical incision to the right hip. The DON stated Resident 20 was at risk for skin breakdown because she was bedridden. The DON stated Resident 1 developed two pressure ulcers, a stage 2 (partial thickness loss or broken skin can also FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 45 of 78 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 06/01/2018 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 resemble a fluid-filled blister) on the right heel and a stage 2 on her coccyx. The DON stated Resident 20 developed the pressure ulcers as a result of her change of condition. The DON stated Resident 20's nursing notes indicated a stage 2 to her coccyx on 10/19/17 and a blister was identified on 10/27/17 to the right heel. The DON stated the pressure ulcer to the coccyx healed on 11/17/17 and the pressure ulcer to the right heel had not yet healed. Resident 20's clinical record titled, "Progress Notes" dated 9/26/18 at 2:46 p.m., indicated, "Skin assessment on return from [GACH] reveals scattered bruising to [right upper extremity] ...surgical incision to the right hip ..." Resident 20's clinical record titled, "Progress Notes" dated 10/2/17 at 11:26 a.m., indicated, "Dietary Note ...Skin: surgical incision to the right hip [due to] fall ..." Resident 20's clinical record titled, "Progress Notes" dated, 10/20/17 at 1:04 p.m., indicated, "Resident continues on monitoring [related to] right hip surgical incision and stage 1 pressure ulcer ..." Resident 20's clinical record titled, "Progress Notes" dated, 10/22/17 at 4:37 a.m., indicated, " ...Resident on alert charting for stage [2 pressure ulcer] to coccyx ..." Resident 20's clinical record titled, "Progress Notes" dated, 10/26/17 at 6:39 p.m., indicated, "[Physician] in house to assess resident [right] heel/ankle. Resident has unstageable ulcer ..." Resident 20's clinical record titled, "Progress Notes" dated 10/31/17 at 1:25 p.m., indicated, " ...Skin: coccyx stage [2] pressure area with dressing dry and intact, and [right] heel dried open blister area ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 46 of 78 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 06/01/2018 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 The facility policy and procedure titled, "Maintenance Service" dated 12/09, indicated, "Maintenance service shall be provided to all areas of the building, grounds, and equipment...1. The Maintenance Department is responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times ...g. Maintaining the grounds, sidewalks, parking lots, etc., in good order ...10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned." The facility policy and procedure titled, "Grounds" dated 5/08, indicated, "Facility grounds shall be maintained in a safe and attractive manner...3. Areas around the building (i.e., sidewalks, patios, gardens, etc.,) shall be maintained in a safe and orderly manner at all times." The facility policy and procedure titled, "Safety and Supervision of Residents" dated 7/17, indicated, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facilitywide priorities ...Facility-Oriented Approach to Safety 1. Our facility-oriented approach to safety addresses risks for groups of residents. 2. Safety risks and environmental hazards are identified on an ongoing basis through a combination of employee training, employee monitoring, and reporting processes: QAPI reviews of safety and incident/accident data; and a facility- wide commitment to safety at all levels of the organization ...4. Employees shall be trained on potential accident hazards and demonstrate competency on how to identify and report accident hazards, and try to prevent avoidable accidents. 5. The QAPI Committee and staff shall monitor interventions to mitigate FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 47 of 78 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 06/01/2018 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 accident hazards in the facility and modify as necessary. Individualized, Resident-Centered Approach to Safety 1. Our individualized, resident-centered approach to safety addresses safety and accident hazards for individual residents...." 2. Resident 39's MDS assessment dated 4/8/18, indicated a Resident 39 was cognitively impaired with a cognitive assessment score of six out of 15. (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact.) On 5/31/18 at 10 a.m., during an observation in Resident 39's room, there were 13 shirts hanging from Resident 39's privacy curtain. Stacks of clothes and a pair of shoes were stored on top of his bed. Resident 39's night stand adjacent to the bed was cluttered with cups, sugar packets, stacks of paper, napkins, and newspapers that spilled on to the floor. On 5/31/18 at 10:02 a.m., during an interview, Resident 39 stated, "I have no choice but to have all my clothes with me on my bed. Everyone steals everything here. So far no one has stolen anything but I keep my clothes next to me in case...I am afraid my clothes will get stolen." On 5/31/18 at 10:05 a.m., during an interview, Certified Nursing Assistant (CNA) 3 stated, "The resident removes his clothes from the closet and hangs his clothes himself on the privacy curtain because he does not want them stolen. He thinks people will steal from him." On 5/31/18 at 10:10 a.m., during an interview, the laundry/housekeeper (LH) stated, "I hang his clothes in his closet, he takes them out himself. Resident thinks staff will steal his clothes...It is difficult to deep clean his room or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 48 of 78 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 06/01/2018 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 take his dirty clothes because resident will get mad if we touch his items. The CNA's have to convince the resident to let us in to deep clean his bed area. I have to take his dirty clothes to wash when resident is not looking." On 5/31/18 at 11 a.m., during an interview, LN 3 stated she was not aware resident 39 was hanging clothing on his privacy curtain. LN 3 stated Resident 39's collection of belongings at the bedside created a trip hazard and placed him at risk for accidents and falls. On 5/31/18 at 11:42 a.m., during an interview, the Social Service Director (SSD) stated, "The resident can harm himself with all the clutter in his room and fall. If there was a fire he will burn down...no plans as of now on what to do about his behavior." On 6/01/18 at 8:19 a.m., during an observation in Resident 39's room, 13 shirts were hanging on the privacy curtain and clothing was stored on the bed. Resident 39's care plan dated 3/2/16, indicated, "Risk for falls characterized by, multiple risk factors related to: unsteady gait, Dementia and depression. Poor safety awareness... Interventions/Tasks...Ensure environment is free of clutter..." The facility policy and procedure titled, "Safety and Supervision of Residents" dated 7/17, indicated, "Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facilitywide priorities... Our individualized, residentcentered approach to safety addresses safety and accident hazards for individual residents." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 49 of 78 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 06/01/2018 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

F727 RN 8 Hrs/7 days/Wk, Full Time DON CFR(s): 483.35(b)(1)-(3)

F727 SS=F PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 08/14/2018 §483.35(b) Registered nurse §483.35(b)(1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. §483.35(b)(2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. §483.35(b)(3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. This REQUIREMENT is not met as evidenced by: Based on staff interview and facility document review, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. This failure resulted in a lack of administrative oversight and a risk of jeopardizing the quality of skilled nursing care to residents. On 5/29/18 at 8:44 AM, during the Entrance Conference interview , the Director of Nursing (DON) stated he was a full time DON at the facility. The DON stated the facility had no nursing waiver. On 6/01/18 at 11:26 AM during an interview, the DON stated did not have registered nurse coverage for eight consecutive hours, seven days a week, since the end of March of this FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 50 of 78 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 06/01/2018 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 year. The DON stated the the registered nurse who had been employed by the facility was part time and worked the weekends and some week days. The DON stated now there is no registered nurse on duty at the facility two of the seven days of the week. Review of the facility "Nurse Schedule" indicated no assigned days documented for the DON for February 2018, March 2018, April 2018, May 2018. The facility "Nurse Schedule" for February 2018 indicated LN 3 (a registered nurse) was scheduled for 16 out of 28 days, the remaining 12 days indicated no registered nurse coverage. The facility "Nurse Schedule" for March 2018 indicated LN 3 (a registered nurse) was scheduled for 14 out of 31 days, the remaining 17 days indicated no registered nurse coverage.

F759 SS=E Free of Medication Error Rts 5 Prcnt or More CFR(s): 483.45(f)(1)

F759 08/17/2018 §483.45(f) Medication Errors. The facility must ensure that its§483.45(f)(1) Medication error rates are not 5 percent or greater; This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to ensure the medication error rate did not exceed 5 percent or greater when there were 69 medication pass opportunities for error and four errors resulting in a medication error rate of 5.8 percent. This failure resulted in the medication error for (Resident 2, Resident 9, Resident 46, and the significant medication error of Resident 49. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 51 of 78 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 06/01/2018 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 Findings: On 5/31/18 at 8:15 a.m., during a morning medication pass observation and concurrent interview, LN 4 prepared medications for Resident 9. LN 4 stated Resident 9 received a medicated analgesic ointment to her back for pain management. LN 4 prepared and applied a topical ointment with analgesic properties (Menthol 10% Methyl-salicylate 15%) on to Resident 9's back. On 5/31/18 at 8:45 a.m., during a morning medication pass observation and concurrent interview, LN 3 prepared medications for Resident 49. LN 3 administered the following medications Iron (supplement) 325 mg 1 tab, EC (enteric coated) ASA (aspirin) 81 mg 1 tab, Vitamin D (mineral-supplement)1000 iu (international units) 1 tab, Stool Softener 100 mg 1 cap, Miralax (laxative) 17 gm given with 6 oz of juice, Depakote (medication used for treatment of seizures) DR (delayed release) 500 mg 1 tab, Metformin (medication used to treat diabetes/high blood sugar) 500 mg 1 tab, Metoprolol (medication used to treat high blood pressure) ER (extended release) 100 mg 1 tab, Lisinopril (medication used to treat high blood pressure) 10 mg 1 tab, and Amlodipine (medication used to treat high blood pressure) 5 mg 1 tab. LN 3 stated, "I have poured 9 tablets and the Miralax powder." On 5/31/18 at 9:05 a.m., during a morning medication pass observation and concurrent interview, LN 3 prepared medications for Resident 46. LN 3 stated she was not going to administer Resident 46's ordered Psyllium Powder because she did not know how much to give. LN 3 stated the order needed to be clarified. On 5/31/18 at 9:15 a.m., during a medication FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 52 of 78 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 06/01/2018 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 pass observation and concurrent interview, LN 3 prepared and administered medications for Resident 2. Among the medications Resident 2 received during the morning medication pass, was 1 capsule of Acidophilus (supplement used for a healthy gut). On 6/1/18 at 8 a.m., during the reconciliation of the observed medication pass. Resident 9's physician orders for May 2018, indicated, "[topical analgesic] 7.5 % (Menthol Topical Analgesic) Apply to Left Lower Back topically one time a day ..." 06/01/18 at 9:43 a.m., during an interview and concurrent record review of Resident 9's physician orders, LN 4 stated, "We are not administering the correct orders." On 6/1/18 at 8:15 a.m., during the reconciliation of the observed medication pass. Resident 49's morning medication included Furosemide 30 mg one time per day. The dose was scheduled to be administered at 9 a.m. Resident 49's May 2018, Medication Administration Record (MAR) indicated, Furosemide 30 mg was initialed as administered by LN 3. On 6/1/18 at 9:56 a.m., during an observation and concurrent interview, LN 2 opened the medication cart to verify Resident 49's morning medication pack. LN 2 stated Resident 49's Furosemide 30 mg medication pack was not with the rest of his medication carts. LN 2 opened the bottom drawer of the medication cart and stated Resident 49 had a new Furosemide medication cart being stored on the bottom of the drawer. LN 2 stated Resident 49 needed Furosemide for the treatment of his congested heart failure. LN 2 stated, "This medication is important for him, if he misses it, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 53 of 78 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 06/01/2018 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 he might experience edema (swelling) and SOB (shortness of breath). On 6/1/18 at 10 a.m., LN 3 was unavailable for interview. On 6/1/18 at 8:30 a.m., during the reconciliation of the observed medication pass. Resident 2's physician orders for May 2018 indicated, "Lactobacillus Rhamnosus (GG) Capsule Give 1 capsule by mouth one time a day." On 6/1/18 at 10:15 a.m., during an observation and concurrent interview and record review, LN 2 looked at the available over the counter bottle of Acidophilus and stated, "I gave 1 tab today, and the bottle serving size says serving is 2 caps." LN 2 stated the order was incomplete and there was no dosage on the physician order to indicate the strength of Acidophilus to administer. On 6/1/18 at 8:40 a.m., during the reconciliation of the observed medication pass. Resident 46' physician orders for May 2018 indicated, "PSYLLIUM ORAL POWDER 1.7 GRAMS MIX WITH 8 oz OF FLUID ...Once Daily ..." On 6/1/18 at 10:30 a.m., during an observation, interview and concurrent record review, LN 2 stated Resident 46's order of Psyllium indicated a dosage of 1.7 grams. LN 2 stated, "Our measuring cup does not have that measurement. It is not clear as to how much to administer... The order needs to be clarified." The facility policy and procedure titled, "Administering Medications" dated 12/12, indicted, "Medications shall be administered in a safe and timely manner, and as prescribed ...7 The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 54 of 78 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 06/01/2018 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 dosage, right time and right method (route) of administration before giving a medication ..."

F760 SS=D Residents are Free of Significant Med Errors CFR(s): 483.45(f)(2)

F760 08/17/2018 The facility must ensure that its§483.45(f)(2) Residents are free of any significant medication errors. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure Resident 49 was free of a significant medication error when Licensed Nurse (LN 3) did not administer a morning dose of Furosemide (water pill used to treat fluid overload) This failure placed Resident 49 at risk for swelling and shortness of breath from fluid overload. Findings: On 5/31/18 at 8:45 a.m., during a morning medication pass observation and concurrent interview, LN 3 prepared medications for Resident 49. LN 3 administered the following FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 55 of 78 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 06/01/2018 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 medications Iron (supplement) 325 mg 1 tab, EC (enteric coated) ASA (aspirin) 81 mg 1 tab, Vitamin D (mineral-supplement)1000 iu (international units) 1 tab, Stool Softener 100 mg 1 cap, Miralax (laxative) 17 gm given with 6 oz of juice, Depakote (medication used for treatment of seizures) DR (delayed release) 500 mg 1 tab, Metformin (medication used to treat diabetes/high blood sugar) 500 mg 1 tab, Metoprolol (medication used to treat high blood pressure) ER (extended release) 100 mg 1 tab, Lisinopril (medication used to treat high blood pressure) 10 mg 1 tab, and Amlodipine (medication used to treat high blood pressure) 5 mg 1 tab. LN 3 stated, "I have poured 9 tablets and the Miralax powder." On 6/1/18 at 8:15 a.m., during the reconciliation of the observed medication pass. Resident 49's morning medication included Furosemide 30 mg one time per day. The dose was scheduled to be administered at 9 a.m. Resident 49's May 2018, Medication Administration Record (MAR) indicated, Furosemide 30 mg was initialed as administered by LN 3. On 6/1/18 at 9:56 a.m., during an observation and concurrent interview, LN 2 opened the medication cart to verify Resident 49's morning medication pack. LN 2 stated Resident 49's Furosemide 30 mg medication pack was not with the rest of his medication carts. LN 2 opened the bottom drawer of the medication cart and stated Resident 49 had a new Furosemide medication cart being stored on the bottom of the drawer. LN 2 stated Resident 49 needed Furosemide for the treatment of his congested heart failure. LN 2 stated, "This medication is important for him, if he misses it, he might experience edema (swelling) and SOB (shortness of breath). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 56 of 78 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 06/01/2018 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 On 6/1/18 at 10 a.m., LN 3 was unavailable for interview. The facility policy and procedure titled, "Administering Medications" dated 12/12, indicted, "Medications shall be administered in a safe and timely manner, and as prescribed ...7 The individual administering the medication must check the label THREE (3) times to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving a medication ..."

F761 SS=E Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 08/01/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 57 of 78 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 06/01/2018 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 authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, staff interview and administrative document review, the facility failed to write the open date on one opened multi-dose vial of medication, "Influenza (flu) (a contagious viral infection) Vaccine (a substance containing a harmless form of germs that cause a disease.)" which was stored in the refrigerator in a medication room. This failure had the potential for the administration of an ineffective medication. Findings: On 6/01/18 at 2:54 PM, during an observation and concurrent interview in the medication storage room an opened 5 milliliter (ml) (a liquid measure) multi dose vial of "Influenza Vaccine" was on the top shelf in the refrigerator. The vial was in a box labeled "Influenza Vaccine" and the plastic top was off the vial. There was no open date written on the vial or on the box whic contained the vial. LN 2 stated there was no open date written on the box or on the opened vial of "Influenza FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 58 of 78 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 06/01/2018 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 Vaccine." The top of the vial had a circular piece of rubber noted to have multiple puncture marks in the rubber top. LN 2 stated there should be an open date put on the vial when it is opened. LN 2 stated it was important to have an opened date on the vial because the flu vaccine was to be used within 28 days after it was opened and used. LN 2 stated the vaccine could lose it's effectiveness if it was used after 28 days of being opened. Review of the manufacturer information indicated, "...Storage and Handling...Once the stopper of the multi-dose vial has been pierced the vial must be discarded within 28 days..." The facility policy and procedure titled, "Medication Administration Injectable Vials and Ampules" dated 5/16, indicated "...vials and ampules of injectable medications are used in accordance with the manufacturer's recommendations...Expiration dating not specifically referenced in the manufacturer's package insert should not exceed 28 days once the vial has been opened."

F806 SS=D Resident Allergies, Preferences, Substitutes CFR(s): 483.60(d)(4)(5)

F806 06/04/2018 §483.60(d) Food and drink Each resident receives and the facility provides§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences; §483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice; This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 59 of 78 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 06/01/2018 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 by: Based on observation, interview, and record review, the facility failed ensure and accomodate each residents food preferences for one of 22 residents (Resident 39) when meal alternatives and food preferences were not honored. This failure resulted in Resident 39 feeling helpless and ignored, and placed him at risk for weight loss. Findings: On 5/29/18 at 8:41 AM, during an interview, Resident 39 stated, "The food is ugly, I don't eat it. Look at it. It is plain, cold and [has] no flavor." Resident 39 stated, "Nothing else is offered to me. They [staff] just drop my tray in front of me and then pick it. They don't even look at my plate to see if I even ate or if I want anything else to eat... it makes me mad and seems like staff don't care." On 5/29/18 at 1 PM, during a meal observation outside of Resident 39's room, Resident 39 ate 0% of his lunch and covered his plate. On 5/29/18 at 1:02 PM, during an observation and concurrent interview, Resident 39 stated he did not like his food and did not eat his lunch. Resident 39's lunch meal was uneaten, with portions of chicken, rice and fruit mixed together. Resident 39 stated, "I mixed the rice, chicken and watermelon together. I always do that and send it back to the kitchen." On 5/29/18 at 1:04 PM, during an observation outside resident 39's room, the Certified Nursing Assistant (CNA) 6 picked up Resident 39's meal tray and did not uncover the plate to see how much Resident 39 had eaten. CNA 6 did not offer Resident 39 a meal alternative. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 60 of 78 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 06/01/2018 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 On 5/29/18 at 1:05 PM, during an interview, CNA 6 stated the [Resident 39] ate 0-25%. CNA 6 stated, "Let me look at his tray." CNA 6 removed Resident 39's tray from the cart and uncovered the plate and stated, "The Resident ate maybe 25%." CNA 6 stated the residents have to ask for a meal alternative if they do not like the meals served to them. On 5/31/18 at 8 AM, during an observation of Resident 39's breakfast tray, Resident 39 ate 0% of his breakfast. Resident 39's food tray had food portions mixed together under the covered plate. On 5/31/18 at 8:02 AM, during an interview, Resident 39 stated, "I will not eat it [breakfast], I don't like how the sausage looks." Resident 39 stated, "Staff never offers me an alternative, I did not know I had other meal options." On 5/31/18 at 11:13 AM, during an interview, the Licensed Nurse (LN) 3 stated, she knew Resident 39 did not always eat his meals. LN 3 stated, " the CNAs report it to me at least once a month. The CNA's document he eats at least 50-70% and he always drinks his high calorie drinks in the morning. Family brings him food a couple days a week. He has good and bad days in regards to food." LN 3 stated, "The CNA's are expected to let me know if resident is eating less than 25% or 50%. If resident says he does not want his food then the CNA should offer an alternate meal. But unless the resident requests an alternate meal then we do not know he wants something else... that is something staff can improve on." On 5/31/18 at 11:20 AM, during an interview, the Certified Dietary Manager (CDM) stated, "He does not like his renal diet, he wants to have beans and Hispanic food because that is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 61 of 78 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 06/01/2018 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 his right... He mixes his food and returns it back to the kitchen. He has been doing that for the last month. He is eating only the snacks... I am confused because I look at his meal percentage and it does not reflect what is sent back on his tray." On 5/31/18 at 2:52 PM, during an interview, the CNA 6 reviewed the meal percentage log. CNA 6 stated, "I remember he ate 0 to 25% for lunch on 5/29/18 but I documented 75 to 100%... I did not let the nurse know of his low intake." CNA 6 stated, "I should have offered the resident an alternative." On 5/31/18 at 2:54 PM, during an interview, the Registered Dietician (RD) stated, "The CNA's need to be documenting correctly the meal percentages and letting the nurse know if intake is low." The RD stated, "The CNA's need to offer meal alternatives and not wait for residents to ask. Not all residents are able to ask. The meal alternatives are posted and the CNAs should give residents other options." Resident 39's MDS (minimum data set) (an evaluation of care needs) assessment dated 4/8/18, indicated Resident 39 was cognitively impaired with a cognitive assessment score of six out of 15. (0-7 severe cognitive impairment, 8-12 moderate cognitive impairment, and 13-15 cognitively intact.) Resident 39's care plan dated 11/29/18, indicated, "Interventions/tasks #12 attempt to meet residents needs with appropriate diet ... #12 will offer packaged items when possible." Resident 39's care plan dated 7/26/16, indicated, "To maintain adequate nutrition and hydration ... Interventions/Tasks...monitor and record percent of fluid and food intake...notify MD of any significant/severe changes." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 62 of 78 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 06/01/2018 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 The facility policy and procedure titled, "Resident Food Preferences" dated 7/17, indicated, "... When possible, staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes..." The facility policy and procedure titled, "Dietary Documentation" undated, indicated, " ...The daily intake of the resident's meals shall be recorded by the nursing assistants within their daily notes ..."

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 08/09/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 63 of 78 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 06/01/2018 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 standards for food service safety. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to store and serve food in accordance with professional standards for food service safety when: 1. Both internal and external freezer thermometers indicated 20°F (Fahrenheit) (temperature scale) on one of one freezers. 2. Brown colored and yellow slime like substance was noted inside the ice machine on one of one ice machine. 3. Expired cans of a nutritional supplement were in the medication room refrigerator. These failures had the potential to result in residents acquiring a foodborne illness. 1. On 5/29/18 at 8:16 AM, during an observation in the kitchen, the thermometer inside the freezer indicated 20°F. The external thermometer indicated 20°F. Food items in the freezer were: one package of hotdogs, one case omelet, one case vanilla ice cream, 13 gallon tub of vanilla ice cream, 17.5 pounds of California vegetable blend, 7.5 pounds of Italian vegetable blend, 12 pounds of corn and black bean fiesta, one bag diced strawberries, half a case of tater tots, one case french fries, 6 chocolate cream pies, one case breadsticks, one case crab cakes, one in a half case of fettucine pasta, half case of ground beef, one pork roast, one case of turkey sausage patty, one case of diced ham, one bag of diced chicken. All food items were frozen. On 5/29/18 at 8:22 AM, during an interview, the Certified Dietary Manager (CDM) stated, "The freezer should be at 0°F or less, let me get the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 64 of 78 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 06/01/2018 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 maintenance supervisor to see what is wrong with the readings on the thermometers ... I had not noticed the temperature was high, this can be a problem if all the food items start to defrost we would not be able to serve them [food items] and it is not safe." On 5/29/18 at 10:15 AM, during an observation in the kitchen the large freezer's internal temperature indicated 14° F and the external temperature indicated at 20° F. On 5/29/18 at 10:26 AM, during an interview, the CDM reviewed the large freezer and refrigerator logs and stated, "Dates 5/26/18 AM [morning] and PM [evening] shift has no temperature logged or initials for the Freezer .... Dates 5/26/18 PM shift has no temperature logged or initial for the large refrigerator ... Dates 5/26/18 AM shift has no temperature logged or initial for the small refrigerator." CDM stated she expects her cook to check the refrigerator and freezer temperatures first thing in the morning and to document it in the temperature log. CDM stated, "I am responsible for making sure cooks are documenting temperatures in the log." On 5/29/18 at 11 AM, during an interview, the Registered Dietician (RD) stated, "Freezer temperature should be at 0°F or lower to prevent a foodborne illness. The cook and certified dietary manager are expected to look at freezer and refrigerator temperatures daily and chart it in the temperature log." The facility policy and procedure titled, "Freezer and Refrigerator Temperatures" undated, indicated, "Freezer temperature will be maintained 0 or below... Procedure: Dietary staff will check temperature of freezer and refrigerator daily am and pm ... the am cook will check the temperatures upon arrival and log in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 65 of 78 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 06/01/2018 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 temperatures, and the pm cook will check the temperatures at the end of shift and log them. Abnormal Reading will be reported to supervisor immediately." 2. On 5/30/18 at 8:11 AM, during an observation in the break room, a brown colored and yellow slime like substance matter was noted on a white paper napkin after wiping the water trough and ice damper inside the ice machine. On 5/30/18 at 8:13 AM, during an interview, the maintenance Supervisor (MS) stated, "The brown stuff on the napkin is dust and the yellow stuff might be water residue." The MS stated, "The ice machine should not be dusty or contain slimy yellow matter ... staff and residents are consuming dirty water if left that way." MS stated, "I follow the Manitowoc manufacturer's instructions when I clean it. I clean the internal parts of the ice machine monthly." On 5/30/18 at 9:13 AM, during an interview, the RD stated, "My expectations are that the ice machine should be cleaned once a month and internally quarterly. If there is no maintenance person the facility should pull out another maintenance person from another facility ... there should not be dark mold or yellow slime on paper towel, it should physically be clean." RD stated, "I did not have [MS] open up the internal parts of the ice machine to make sure it was clean, I just learned in April to do the internal inspection." RD stated, "The outcome can be a foodborne bacteria that can affect the GI [Gastrointestinal] [stomach and intestines]." On 5/30/18 at 1:34 PM, during an interview, Manitowoc Technician (MT) stated, "A sanitized ice machine should not have yellow slime, it could mean a bacterial problem." MT FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 66 of 78 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 06/01/2018 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 stated, "The ice machine should be cleaned and sanitized every 6 months, but also more often as needed. All the parts need to be taken apart and soaked off." MT stated, "The facility's ice machine needs more frequent cleaning if there is yellow slime or dust or they should have their water tested." The manufacturers service manual titled, "Manitowoc" dated 12/4, indicated, "Clean and sanitize the ice machine every six months for efficient operation. If the ice machine requires more frequent cleaning and sanitizing, consult a qualified service company to test the water quality and recommend appropriate water treatment." The facility policy and procedure titled, "Sanitization" dated 10/08, indicated, "Ice machines and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions and facility policy." The facility job description titled, "Maintenance Supervisor/Manager" dated 7/2/97, indicated, " ... Essential Job Functions: ... Ensure equipment and work areas are clean, safe and orderly; and strict adherence to procedures regarding cleaners ..." 3. On 06/01/18 at 02:37 PM, during an observation and concurrent interview in the medication storage room, 14 cans, eight ounces each, of "[Brand name]Therapeutic Nutrition [a liquid nutritional supplement]" sat on the top shelf of the refrigerator. Each of the 14 cans of "Brand name" had a date printed on the bottom of the cans which indicated an expiration date of, "1 Dec 18." Licensed Nurse (LN) 2 counted the number of cans of "Brand name" and stated there were 14 cans of the "Brand name" which had an expiration date of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 67 of 78 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 06/01/2018 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 1 Dec 17. LN 2 stated she didn't know why the cans were in the refrigerator as none of the residents with tube feedings had orders for feedings with the "Brand name."

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) 06/04/2018 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation during the survey period of 5/29/18 to 6/1/18, the facility failed to provide and maintain minimum square footage for each resident in 12 of 19 rooms (Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19). Findings: During an observation of the facility, the following rooms did not provide the minimum square footage as required by regulation: Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19. The residents had a reasonable amount of privacy. Closets and storage spaces were adequate. Bedside stands were available. There was sufficient room for nursing care and for residents to ambulate. Wheelchairs and toilet facilities were accessible. The waiver will not adversely affect the health and safety of residents. Room # Square Feet # Residents 7 203.7 3 8 210.2 3 9 213.3 3 10 209.1 3 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 68 of 78 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 06/01/2018 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) 11 12 13 14 15 16 17 19 203.2 209.5 154.0 152.4 159.2 158.2 154.9 154.7 ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 3 3 2 2 2 2 2 2 Recommend waiver continue in effect. ______________________________ Health Facility Evaluator Nurse / Date Request continuance of waiver. ________________________ Administrator Signature / Date

F917 SS=E Resident Room Bed/Furniture/Closet CFR(s): 483.10(i)(4), 483.90(e)(2)(3)

F917 08/09/2018 §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv) §483.90(e)(2) -The facility must provide each resident with-(i) A separate bed of proper size and height for the safety and convenience of the resident; (ii) A clean, comfortable mattress; (iii) Bedding, appropriate to the weather and climate; and (iv) Functional furniture appropriate to the resident's needs, and individual closet space in the resident's bedroom with clothes racks and shelves accessible to the resident. §483.90(e)(3) CMS, or in the case of a nursing facility the survey agency, may permit FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 69 of 78 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 06/01/2018 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 variations in requirements specified in paragraphs (e)(1) (i) and (ii) of this section relating to rooms in individual cases when the facility demonstrates in writing that the variations (i) Are in accordance with the special needs of the residents; and (ii) Will not adversely affect residents' health and safety. This REQUIREMENT is not met as evidenced by: Based on observation, resident and staff interview and document review, the facility failed to ensure residents' closet space was easily accessible to the residents while protecting it from casual access by others when: 1. Three of 22 sampled residents (Resident 13, Resident 39 and Resident 46) had to walk into another resident's bed space to get their clothes from the shared closet. 2. Three of 19 resident rooms had closets with no doors or other coverings. These failures resulted in the residents feeling bothered, apologetic, and affected their psychosocial well-being. Finidings: 1. On 6/01/18 at 10:04 AM, during an observation in room 8, bed "A's" privacy curtain was pulled closed and covered access to the shared closet. On 6/01/18 at 10:06 AM, during an interview in room 8 "B", Resident 13 stated, "I feel sorry for her [bed A]because in order to get my clothes out of the closet I have to get by her bed area FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 70 of 78 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 06/01/2018 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 ... I feel like I am bothering her every time I have to get into the closet." On 5/31/18 at 10 AM, during an observation in room 9 "B", Resident 39 had 13 shirts were hanging on his privacy curtain and clothes and shoes were being stored on his bed. There was one shared closet in the room near bed "C". Bed "C's" privacy curtain was pulled closed and covered access to the shared closet. The closet had enough space for all three resident's clothing and shoes. On 5/31/18 at 10:02 AM, during an interview, Resident 39 stated, "The three of us share the closet. I have to walk into the other person space [bed C] to get to the closet. I have no choice but to have all my clothes with me on my bed. Everyone steals everything here. So far no has stolen anything but I keep my clothes next to me in case ... I am afraid my clothes will get stolen." On 5/31/18 at 10:05 AM, during an interview, the Certified Nursing Assistant (CAN) 3 stated, "The resident removes his clothes from the closet and hangs his clothes himself on the privacy curtain because he does not want them stolen. He thinks people will steal from him." On 5/31/18 at 11:00 AM, during an interview, the License Nurse (LN) 3 stated she was not aware resident 39 was hanging clothing on his privacy curtain. LN 3 stated, "The resident has to go into bed "C" area to get into the closet but I do not know what to do about the room layout. The closet is shared by all 3 residents and the closet is located by bed "C" space." On 5/31/18 at 11:42 AM during an interview, the Social Service Director (SSD) stated, "The closet is located by C bed, I do not think it is too close to b bed, there is enough space I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 71 of 78 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 06/01/2018 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 think. I need to contact his daughter and encourage daughter to talk to him about not putting his clothes on the privacy curtain ... no plans as of now on what to do about his behavior." On 6/01/18 at 10:02 AM, during an observation in room 10 "A", the privacy curtain was pulled closed and covered access to the shared closet. On 6/01/18 at 10:04 AM, during an interview in room 10 "A", Resident 46 stated, "The closet is by my bed and we share it ... sometimes it bothers me that I have to share it because my roommates go into my space to get to the closet and I am not always in my room." The facility policy and procedure titled, "Personal Property" dated 9/12, indicated, "Each resident's room is equipped with private closet space that includes clothes racks and shelving and the permits easy access to the resident's clothing." 2. On 6/01/18 at 10 AM, during an observation in rooms 13, 14, 15, 17, and 19, the resident closets were located behind the room door. The residents' closets had no doors or coverings exposing the residents' clothing and other belongings. On 6/01/18 at 10:05 AM, during an interview in room 19, Resident 32 stated he had been at the facility for 7 years and the closets never had any doors or coverings. Resident stated "I learned to live with it" Resident 32 stated, "no", he would not want a closet like the one he has in his room in his home. On 6/01/18 at 10: 09 AM, during an interview in room 15, Resident 9 stated she would like to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 72 of 78 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 06/01/2018 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 have doors or a curtain for the closet. Resident 9 stated she would like to have some thing to protect her clothing from dust and dirt. 6/01/18 10:30 AM during an interview and concurrent observation in rooms 13, 14, 15, 17, and 19, the Maintenance Supervisor (MS) and the Environmental Services Supervisor (ESS), the MS and ESS, the MS stated the closets in rooms 13, 14, 15, 17, and 19 had no doors or coverings to protect the resident's belongings from easy access by others. The ESS stated some of the rooms had doors or cloth coverings but did not know why rooms 13, 14. 15, 17, and 19 had none. The facility policy and procedure titled, "Personal Property" dated 9/12, indicated, "Each resident's room is equipped with private closet space that includes clothes racks and shelving and the permits easy access to the resident's clothing."

F921 SS=E Safe/Functional/Sanitary/Comfortable Environ CFR(s): 483.90(i)

F921 06/18/2018 §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide residents and staff a safe, functional, sanitary and comfortable environment when: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 73 of 78 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 06/01/2018 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 1. The exterior wooden fence located on the south of the facility was slanted and damaged. 2. Three beds had broken head and foot boards. 3. Four bedside fall mats (designed to reduce injury if fall occurs) were torn and had exposed foam. 4. Two linen cart covers were torn. 5. Two sharp containers were overfilled with sharps. This failure resulted in an unsafe and unsanitary environment for the residents and staff of the facility. Findings: 1. On 10/9/17 at 1:40 p.m., during an environmental observation of the external facility grounds, a 6 foot tall wooden fence dividing the facility property from the neighboring property was slanted. The wooden fence had areas that were tilting towards the facility walkway and other areas that tilted towards the neighboring property. The fence had an area covered and secured with a tarp like material. On 10/9/17 at 1:41 p.m., during an observation and concurrent interview, Maintenance Supervisor (MS 1) stated the facility wooden fence was weather beaten. MS 1 stated, "The fence looks like it is tilting." MS 1 stated the wooden fence needed to be repaired and perhaps needed to be replaced. 2. On 05/29/18 at 10:50 a.m., during an observation of room 11-A and 11-B, there were two beds with broken head and foot boards. The head board for 11-A had a broken seal and exposing the inside of the frames wooden FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 74 of 78 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 06/01/2018 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 uneven edges. The foot board of 11-B had a torn seal and exposing the inside of the frames wooden uneven edges. On 5/29/18 at 10:51 a.m., during an interview CNA 6 looked at both beds and stated the broken seals on the head boards exposed the wood and the uneven edges. CNA 6 stated, "The beds look like they need to be repaired." On 06/1/18 02:25 p.m., during an observation and concurrent interview, the foot board for 7-A had a hold on the bottom right hand corner and a broken seal. There was exposed wood with uneven sharp edges. CNA 15 stated, "The foot board has a hole and it looks like it needs to be fixed." 3. On 05/29/18 08:05 a.m., during an observation in room 4-A a bedside fall mat was on the floor with ripped and torn edges. The fall mat had exposed foam. CNA 4 stated she had not seen the tears on the mat. On 05/29/18 09:10 a.m., during an observation in room 7 and concurrent interview, there were two fall mats on the ground for 7-A and 7-B, both fall mats were torn from the edges and had exposed foam. CNA 15 stated, "I had not paid attention to the torn fall mats. I don't think it should be torn." On 5/29/18 09:30 a.m., during an observation in room 11 and concurrent interview, 11-C had a fall mat that was torn and had exposed foam. The Environmental Service Supervisor (ESS) stated, the mat was torn and needed to be replaced. 4. On 05/30/18 03:52 p.m., during an observation of the two linen carts located in the A-wing hall way. The carts had torn and frayed covers without a smooth surface. Interview with FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 75 of 78 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 06/01/2018 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 the CNA 2 stated, "The linen carts were torn and looked like they could be replaced." 5. On 05/30/18 02:30 p.m., during an observation in the B-wing shower room, and a concurrent interview, a sharps container was overfilled pass the full line with one razor sticking out. CNA 2 stated the sharps container could not be passed the fill line. She pressed the lever on the sharps container in order to push the razor into the container. On 05/31/18 at 6:50 a.m., during an observation and concurrent interview, Licensed Nurse (LN 7) completed the early morning medication pass. LN 7 stated the sharps container located on the medication cart was overfilled passed the fill line. LN 7 stated, "Oh it should not be like this, we need to replace it, it is every nurses responsibility to notice this and change it. I can't even push anything into it because it is so full." On 6/1/18 at 4:25 p.m., during a joint observation with the Administrator (ADM 2) the Director of Nursing (DON) and the MS 2 of the broken foot board in room 7-A, the torn fall mats and the torn linen cart covers, and concurrent interview, the DON stated they were aware of the items needing repair and were in the process of making the necessary repairs. The DON stated they completed weekly rounds and had identified the items needing repair. The ADM 2 could not produce documentation to indicate when the rounds were completed. ADM 2 stated the ESS notified her during the week about the torn fall mats. The facility policy and procedure titled, "Maintenance Service" dated 12/09, indicated, "Maintenance service shall be provided to all areas of the building, grounds, and equipment...1. The Maintenance Department is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 76 of 78 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 06/01/2018 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 responsible for maintaining the building, grounds, and equipment in a safe and operable manner at all times ...g. Maintaining the grounds, sidewalks, parking lots, etc., in good order ...10. Maintenance personnel shall follow established safety regulations to ensure the safety and well-being of all concerned."

F923 SS=D Ventilation CFR(s): 483.90(i)(2)

F923 06/25/2018 §483.90(i)(2) Have adequate outside ventilation by means of windows, or mechanical ventilation, or a combination of the two. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and administrative document review, the facility failed to provide ventilation and good air circulation when one of two resident shower rooms did not have a working exhaust fan. This failure prevented residents, and staff from being in a ventilated area with good air circulation. Findings: 05/29/18 10:20 a.m., during an observation of the shower room for "A wing", a shower was being given with the shower room door left open. A privacy curtain was available and covered the opened shower room door. 05/30/18 02:30 p.m., during an interview, CNA 2 stated there were two showers in the facility that were available to the residents. CNA 2 stated the shower room door to A-wing shower remained opened while showers were given FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 77 of 78 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 06/01/2018 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 because, "it got too stuffy in [the shower room] when the shower room door was closed." 05/29/18 02:41 p.m., during an observation and concurrent interview, the Environmental Service Supervisor (ESS), stated the shower room ventilation unit was not working. The ESS stated the vent had no suction and would tell the maintenance supervisor the vent had no suction. The ESS stated the vent had spots around the frame that looked corroded, the ESS pointed to corroded spots around the door frame of the shower room. 05/30/18 01:35 p.m., during an interview with the maintenance supervisor (MS 2) he stated the A- wing shower room ventilation system was not working. MS 2 stated the shower room vent needed to be repaired because it was not providing ventilation to the shower room. MS 2 stated the vent had spots around the frame that looked corroded, MS 2 pointed to corroded spots around the door frame of the shower room. MS 2 stated the shower room for A-wing did not have adequate ventilation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: RVJ611 Facility ID: CA040000012 If continuation sheet 78 of 78