Other·December 16, 2019

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health Licensing and Certification during an ABBREVIATED SURVEY of Entity Reported Incidents CA00642928. Representing the California Department of Public Health - Licensing and Certification: Federal ID 39227, RN, HFEN. The ABBREVIATED SURVEY was limited to the specific incidents investigated and does not represent the finding of a full inspection of the facility. One deficiency was issued for Facility Reported Incident CA00642928.

F689 SS=G Free of Accident Hazards/Supervision/Devices F689 CFR(s): 483.25(d)(1)(2) 11/16/2019 §483.25(d) Accidents. 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 interview and record review, the facility failed to ensure residents received adequate supervision to prevent falls for one of three sampled residents (Resident 1) when Resident 1 was assessed as high risk for falls and nursing staff did not provide the toileting 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: ZT0B11 Facility ID: CA040000012 If continuation sheet 1 of 9 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 11/05/2019 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 assistance and monitoring frequency in accordance with Resident 1's assessed needs. The Interdisciplinary team (IDT) (a facility group composed of a physician, a registered nurse, a social worker and additional appointed facility staff) did not provide specific care plan interventions to Resident 1 to prevent falls. These failures resulted in Resident 1 having avoidable falls on 5/25/19, 6/15/19 and 6/23/19. Subsequent to the fall on 6/23/19 Resident 1 suffered an avoidable fracture to his cervical (neck) spine, required transportation to the acute care hospital emergency department, hospitalization and surgical repair to correct the cervical spine fracture and experienced pain and suffering . Findings: During an interview with Director of Nursing (DON) 1, on 7/29/19, at 9:15 a.m., she stated Resident 1 tried to get up by himself to the bathroom and fell on the morning of 6/23/19. The DON stated Resident 1 was transferred to the acute care hospital (ACH) on 6/23/19 at 9:59 a.m. after Resident 1 complained of neck pain. During a review of Resident 1's face sheet (a document with demographic, personal and medical information) dated 7/9/19, the record indicated Resident 1 was admitted to the facility on 4/23/19. Resident 1's diagnoses included Benign Prostatic Hyperplasia (BPH) (a condition of blocking the urine that leads to urinary retention in the bladder ), generalized body weakness, difficulty in walking, anxiety (feelings of uneasiness and fear) disorder, and repeated falls. During a review of the clinical record for Resident 1, the "Progress Notes" dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 2 of 9 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 11/05/2019 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 5/25/19, at 10:05 p.m., indicated, " ...Found resident [Resident 1] sitting on the floor with his back leaning against the footboard of the bed ...he [Resident 1] was trying to go to the bathroom and fell ...sustained skin issues: superficial abrasion to left lower elbow measuring 2 cm [centimeters-unit of measure] x 1.75 cm, 2 superficial abrasions to left lower outer knee measuring 1.0 cm x 1.2 cm, and 1.0 am x 1.25 cm." During a review of the clinical record for Resident 1, the "Progress Notes" dated 6/15/19, at 4:15 a.m., indicated, " ...at 0400 [4 a.m.] CNA [Certified Nursing Assistant] and LN [Licensed Nurse] responded promptly to a loud noise directed from resident's room ...he [Resident 1] was on his way to the bathroom and fell ...resident sitting on the dry floor by the foot of his bed ...noted a 2.75 x 1.25 cm superficial abrasion on resident's lower mid back area." During a review of the clinical record for Resident 1, the "Progress Notes" dated 6/23/19, at 7:02 a.m., indicated, "At 0615 [6:15 a.m.] LN and CNA responded promptly to resident's room following a loud noise from resident room, resident did not use his call light, resident observed with non-witnessed fall lying on his Lt [left] side on the dry floor, close to the wall across from the foot board of his bed. Resident alert, verbally responsive ...when questioned if he is injured, resident alleged, he got up to go to the bathroom but he did not have to go, c/o[complained of] he stumbled and fell, resident alleged he bumped his head, assessed by LN ...resident c/o a mild headache to the Lt side of his head ...Full body assessment ...superficial skin tears observed on resident Lt lower outer arm less than 1.5 cm both areas ... superficial skin tear to residents Lt outer elbow 1.0 cm. areas ...with minimal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 3 of 9 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 11/05/2019 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 bleeding subside, covered by a dry dressing ..." During a review of the clinical record for Resident 1, the "Progress Notes" dated 6/23/19, at 9:57 a.m. indicated the facility transported Resident 1 by ambulance to the acute care hospital on 6/23/19, at 8:59 a.m. During a review of the clinical record for Resident 1, the Minimum Data Set (MDS) (assessment of healthcare and functional needs) assessment, dated 5/1/19, indicated Resident 1 had short and long term memory impairment. The MDS assessment indicated Resident 1 was moderately impaired in decision making during activities of daily living and required one person assistance with mobility. During a review of the clinical record for Resident 1, the initial, "Fall Risk Observation/Assessment" (a health assessment by licensed nurses to evaluate risk of fall) dated 4/23/19, indicated Resident 1's fall risk score was 28 (the document indicated a score of 10 or higher was considered high risk for falls), had an unsteady gait (a person's manner of walking) with a history of multiple falls; a diagnosis of BPH caused Resident 1 to have frequent urination. During a review of the clinical record for Resident 1, the initial nursing admission assessment dated 5/1/19, indicated Resident 1 required one-person physical assistance of a staff member for Activities of Daily Living (ADL), support in bed mobility, transfers, personal hygiene and toilet use. During an interview with DON 1, on 7/9/19, at 9:18 a.m., she stated Resident 1 required limited assistance (guided maneuvering of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 4 of 9 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 11/05/2019 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 limbs) of one staff member and needed supervision when transferring and assistance to and from the bathroom. She stated Resident 1 should have been placed on one on one supervision (a staff member with him at all times) to keep him safe and prevent him from falling. During an interview with CNA 1, on 8/5/19, at 1:47 p.m., she stated she was assigned to Resident 1 on the morning of 6/23/19 when Resident 1 tried to get up and go to the bathroom by himself and fell. CNA 1 stated Resident 1 was non-compliant with the use of call lights and would often call for assistance by shouting "Hey!" CNA 1 stated she heard a loud noise across the hallway and proceeded to Resident 1's room where she saw CNA 2 assist Resident 1 in the room. During an interview with CNA 1, on 8/5/19, at 1:50 a.m., she stated Resident 1 had poor safety awareness and he would sometimes get up two to three times by himself on her shift. She stated Resident 1 was placed on 15minute monitoring every shift (CNA to observe the resident on an every 15 minute basis) for safety measures to prevent Resident 1 from falling. She stated she did not remember if she did Resident 1's 15-minute monitoring on 6/23/19. CNA 1 stated she provided setup help only [resident is provided with devices necessary to perform ADL independently] for toilet use to Resident 1 on 6/15/19 and 6/23/19. She stated, "I never had to do too much for him [Resident 1]. I am trying to keep up my normal duties." CNA 1 stated she had three residents on 15-minute monitoring on 6/23/19 and she was aware the three residents needed more supervision than the rest of her assigned residents. During a concurrent interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 5 of 9 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 11/05/2019 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE EVERGREEN CARE CENTER 5265 E Huntington Ave Fresno, CA 93727 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE review with the MDS Coordinator (MDSC), on 8/5/19 at 2:09 p.m., she reviewed Resident 1's MDS, dated 5/1/19, under the section for functional status, stated Resident 1 was not steady in balance during transferring and walking. The MDSC stated CNA 1 should have assisted and supervised Resident 1 to the bathroom to prevent his fall. She stated Resident 1 should have been placed on one on one monitoring for more effective supervision to prevent falls. During a concurrent interview and record review with Licensed Vocational Nurse (LVN) 2, on 8/5/19, at 3:45 p.m., at the nurses' station, she reviewed the 15-minute monitoring binder and was unable to locate Resident 1's 15-minute monitoring record on 6/23/19. LVN 2 stated Resident 1's 15-minute monitoring sheets from 6/1/19 to 6/22/19 were filed in the monitoring binder but no monitoring sheet was found in the binder for 6/23/19. LVN 2 validated the findings. During a concurrent interview and record review with the DON, on 8/5/19, at 3:50 p.m., she was unable to locate Resident 1's 15minute monitoring record for 6/23/19. During a phone interview with LVN 1, on 8/5/19, at 11:35 p.m., she stated she was assigned to Resident 1 on the morning of 6/23/19 when Resident 1 attempted to ambulate to his bathroom unassisted and fell. She stated she was aware Resident 1 was a high-fall risk resident and should have been assisted to the bathroom by a staff member. During a concurrent interview and record review with Director of Staff Development (DSD) on 8/23/19, at 10:30 a.m., she reviewed Resident 1's Follow Up Question Report (a resident's record of ADL support provided by FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 6 of 9 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 11/05/2019 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 CNAs) dated 5/25/19, 6/15/19, and 6/23/19, indicated, " ...TOILET USE: SUPPORT PROVIDED ...Setup help only [resident is provided with devices necessary to perform ADL independently]." The DSD stated CNA 1 should have provided assistance to Resident 1 in walking to the bathroom the day the resident fell. During an interview with CNA 2, on 8/23/19, at 11:50 a.m., she stated she was assigned to Resident 1 on the morning of 6/23/19 (date of Resident 1's fall). CNA 2 stated she was aware of Resident 1's 15 minutes monitoring status every shift and she had not received the monitoring sheet of Resident 1 from CNA 1 or LVN 3 on her morning shift of 6/23/19. During a review of the ACH clinical record for Resident 1, the CT (Computerized Tomography- a computerized form of imaging) dated 6/23/19, indicated a fracture through the right C6 [Cervical {neck} facet (sixth cervical disc joint located between each bone). During a review of the ACH clinical record for Resident 1, the "Discharge Summary Report" dated 6/28/19, indicated, "... Admit date: 6/23/19 Discharge date: 6/28/19 ...Problems and Discharge Diagnoses: C6 [cervical (neck) sixth vertebrae, facet (present on admission) ...Fracture of 6th cervical vertebra, right facet fracture, closed fracture as a result of ground level fall/slip s/p [status post] C5-C6 [cervical 5 to cervical 6] posterior fusion (a surgical procedure that joins two or more bones together) ..." During a concurrent phone interview and record review with DON 2, on 8/23/19, at 3:47 p.m., she reviewed the facility policy and procedure titled, "Safety and Supervision of Resident" dated 7/17, indicated, "...1. Our FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 7 of 9 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 11/05/2019 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 individualized, resident-centered approach to address safety and accident hazards for individual residents. 2. The interdisciplinary care team shall analyze information ...5. Monitor the effectiveness of interventions ..." She stated CNA 1 should have provided a one person assist with ADLs to prevent Resident 1 from falling and CNA 1 did not. During a concurrent interview and record review with the MDSC, on 8/5/19, at 2:15 p.m.., she reviewed Resident 1's IDT document on 6/19/19 and 6/24/19. She stated Resident 1's falls did not identify the root cause of the fall in the IDT on 6/19/19 and 6/24/19. The MDSC reviewed Resident 1's fall care plan and indicated, "...Alert charting QS [every shift], monitor for changes or any delayed trauma ... notify MD/RP ...Tx [treatment] as ordered by MD to mid lower abrasion, notify MD of any s/s of worsening ..." The MDSC stated the cause of Resident 1's falling was trying to ambulate to the bathroom unassisted and the care plan interventions did not document a residentcentered care approach to prevent falls and should have been specific to the identified root cause of the fall. During a concurrent phone interview and record review with DON 2, on 8/23/19, at 3:47 p.m., she reviewed the facility policy and procedure titled, "Assessing Falls and Their Causes' dated 3/18, indicated, " ...1. Review the resident's care plan to assess for any special needs of the resident ...try to identify possible or likely causes of the incident ...6. Appropriate interventions taken to prevent future falls." She stated the IDT should have reviewed Resident 1's fall assessment and care plans to identify and implement a residentcentered approach to prevent falls and did not. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 8 of 9 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 11/05/2019 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, "Care Plans. Comprehensive Person-Centered" dated 12/16, indicated, "... 9. Areas of concern that are identified during the resident assessment will be evaluated before the interventions are added to the care plan ...a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers ..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: ZT0B11 Facility ID: CA040000012 If continuation sheet 9 of 9