Other·July 26, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health, Licensing and Certification, during an ABBREVIATED Survey for Complaints: CA00506068, CA00531944 and CA00534476. Representing the California Department of Public Health by Federal ID: 28531, RN, Health Facilities Evaluator Nurse (HFEN); 35737, RN, HFEN; 37312, RN, HFEN; 38641, RN, HFEN The inspection was limited to the specific complaints investigated and does not represent the findings of a full inspection of the facility. Two deficiencies were issued for Complaint: CA00506068, CA00531944 and CA00534476.

F203 SS=G NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE CFR(s): 483.12(a)(4)-(6)

F203 06/30/2017 Before a facility transfers or discharges a resident, the facility must notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand; record the reasons in the resident's clinical record; and include in the notice the items described in paragraph (a)(6) of this section. Except as specified in paragraph (a)(5)(ii) and (a)(8) of this section, the notice of transfer or discharge required under paragraph (a)(4) of 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: 0PDX11 Facility ID: CA040000036 If continuation sheet 1 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 section must be made by the facility at least 30 days before the resident is transferred or discharged. Notice may be made as soon as practicable before transfer or discharge when the health of individuals in the facility would be endangered under (a)(2)(iv) of this section; the resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (a)(2)(i) of this section; an immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (a)(2)(ii) of this section; or a resident has not resided in the facility for 30 days. The written notice specified in paragraph (a)(4) of this section must include the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident is transferred or discharged; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to provide 3 of 27 sampled residents (Resident 1, Resident 2, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 2 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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) or their Responsible Party (RP) a 30 day notice of discharge that included the right to appeal the discharge to the State. This failure denied Resident 1, Resident 2, Resident 3 and their RP of the right to appeal the discharge and resulted in unsafe discharges when: 1. Resident 1 was discharged into a situation that previously required Adult Protective Services (APS) intervention and experienced emotional and physical distress that required intervention by local police and fire departments and ultimate transfer of Resident 1 to the acute care hospital (ACH) by ambulance. 2. Resident 2 was transferred to a lower level of care without notification of his RP prior to the transfer, and later fell in the less supervised setting and suffered a fractured (broken) hip that required surgical intervention. 3. Resident 3, who suffered from dementia (disorder causing progressive loss of memory, judgement and reasoning ability), and was unable to make reasonable independent decisions, was transferred to a lower level of care without prior notification of an advocate (in the absence of a family member to act as the RP) of the right to appeal the transfer in his behalf, placing Resident 3 at risk of harm and injury. Findings: 1. Resident 1's face sheet (a document containing resident personal information) indicated Resident 1 was admitted to the Skilled Nursing Facility (SNF) 1 on 5/17/16. Resident 1's diagnoses included diabetes (disorder which causes high blood sugar due to insufficient production of the hormone insulin FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 3 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 which regulates blood sugar) and an open wound to the right foot. Resident 1's Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 8/24/16, indicated Resident 1 had no cognitive (memory) impairment. The MDS assessment indicated Resident 1 did not ambulate (walk) and required total staff support in bed mobility, transfers from bed to wheelchair, locomotion while in wheelchair, dressing, toilet use, personal hygiene and bathing. Administrative document review, untitled and dated 10/6/16, indicated a typed written 30 day notice of discharge addressed to Resident 1. The letter indicated, "Hand delivered to [Resident 1] at [the facility]...Copy to [Resident 1's Family Member (FM) 1]...You are hereby given a 30 Day notice of discharge from [facility]...because you have not been paying your share of cost. Your Medical determined share-of-cost is $2,269 per month. Your current bill is $11,649.63. You will be discharged on November 7, 2016 unless your bill is paid in full and/or a satisfactory repayment plan is established prior to that time. Your bill will increase by $2,269 plus interest by that date. You will be discharged to your home with [FM 1]. We will assist you in setting up in-home care if you desire. You have all your mental capacities and even with certain physical limitations you should be able to function at home with some in-home supportive services..." On 11/10/16 at 9:40 a.m., during an interview and concurrent clinical record and administrative document review, the Assistant Administrator (AA) stated Resident 1 was discharged from the facility on 11/7/16. The AA stated, "We provided transportation to her [Resident 1's] home. Her [FM 1] refused to open the gate to let her come in." The AA FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 4 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 she and the facility Administrator (Adm) drove to Resident 1's house after Resident 1's transport driver informed them FM 1 would not let Resident 1 inside the home. The AA stated FM 1 yelled and cursed at them, and refused to open the gate. The AA stated, "We offered to let him pay the bill." The AA stated FM 1 stated he paid the utility bill with Resident 1's money; he took care of her house and could not take care of her. The AA stated while the situation with FM 1 yelling and the facility staff responding took place, Resident 1 complained she didn't feel well so she (the AA) called 911 (the emergency response phone number). The AA stated two policemen and three or four firemen responded to the 911 call and the AA and the Adm then left Resident 1 at her house. The AA stated, "We were told we were free to go. We left. [FM 1] was in the house. The resident [Resident 1] was at the gate with officers, and the paramedics were taking her [Resident 1] to the hospital. She [Resident 1] said she knew the law. She didn't believe she would be kicked out." The AA stated FM 1 had not answered phone calls from the facility prior to Resident 1's discharge and had not participated in Resident 1's discharge planning. On 11/15/16 at 1 p.m., during an interview and concurrent clinical record review, the Social Services Designee (SSD) stated there were allegations of abuse at Resident 1's home prior to her admission to the facility. The SSD stated Resident 1 did not have a "safe discharge" to her home on 11/7/16. The SSD stated there were issues surrounding APS. The SSD stated, "When we talked to her, she wanted to go home...she hadn't seen [FM 1] in six months." The SSD stated FM 1 did not participate in discharge planning. The SSD stated medical equipment was required for home care, which needed to be arranged prior to Resident 1's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 5 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 discharge. The SSD stated Resident 1 was bed and wheel chair bound, and Resident 1 had not walked during her stay at the facility. The SSD stated Resident 1's physician ordered a hospital bed, a wheelchair, a mechanical lift, a bedside commode (portable bedside toilet) and a shower chair for the home. The SSD stated there was no validation the items had been delivered to the house or would be able to be acquired with Resident 1's insurance. The SSD stated, "There was no reason to expect [FM 1] would cooperate. I knew it was an unsafe discharge. I didn't have access to her house. I didn't know if she had medical equipment." The SSD stated, "A 30 day notice was given for failure to pay [her facility bill]." Resident 1's ACH clinical record titled, "ED [emergency department] Provider Notes dated 11/7/16, indicated, "Chief Complaint...patient was kicked out of SNF, PD [police department] states home is unfit for patient to live in...73 year old was left in front of her house and FPD [local PD] stated her house is unfit to live in, therefore was transported to the hospital..." Resident 1's ACH clinical record titled, "Case Manager Addendum" dated 11/7/16, indicated, "...Per medical record review - she [Resident 1] was an APS [Adult Protective Services] case 05/10/16 - APS report filed by PD [police department] due to unsanitary living conditions and suspicion of abuse/neglect. Pt [patient] with a past medical history of CVA [cerebral vascular accident - stroke] x 2 [twice], residual right side weakness, and diabetes... In [ACH] ED [emergency department] pt was noted to have hair soiled with feces, small cockroaches on her, and multiple wounds. Wound on right foot found to have maggots. Report received by APS from PD that pts home is uninhabitable and that [FM 1] appears to have his own medical conditions and cannot care for pt..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 6 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 1's Progress Note entered by the SSD, dated 6/7/16 at 2:13 p.m., indicated, "This writer contacted the Adult Protective Services to confirm if there is an open case. Spoke with [worker's name] and he said yes the case is still open..." An additional Progress Note, entered by SSD, dated 8/23/16 at 11:31 a.m., indicated, "It is uncertain if returning to her home would be a safe discharge. Adult Protective Services were involved. This writer has left many messages for her [FM 1] and he does not return the calls..." On 4/13/17 at 9 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was discharged home on 11/7/16 at 2 p.m. LN 1 stated Resident 1 did not want to sign for her discharge. LN 1 stated Resident 1 looked angry and later began to cry. LN 1 stated the Adm and the AA spoke to Resident 1 about her discharge taking place on 11/7/16 and told her she needed to sign the discharge papers. On 4/18/17 at 10:20 a.m., during an observation and concurrent interview in SNF 2, where Resident 1 was transferred to after discharge from her stay at the ACH. Resident 1 was alert and sitting up in bed. Resident 1's fingers of her right hand were stiff and drawn in toward her palm. Resident 1 demonstrated difficulty moving her fingers and stated she would not have been able to take care of her foot wound at home due to the limited mobility in her hand and fingers. Resident 1 stated, "My [FM] is unable to care for me at home. He has been in and out of the hospital...My house has no electricity and no running water or heat...The manager [Administrator] at the facility accused me of being a thief because I didn't give them my pension...I wanted to explain that my [FM] was using my money to pay for my taxes and my bills plus the utilities. I FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 7 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 was not stealing from them." Resident 1 stated, "I was sad by the entire thing, I was stuck between a rock and a hard place. They were calling me a thief and accusing [FM 1] of stealing from me, but what would they have done. I felt horrible that I was kicked out of the facility and not let into my house, but my [FM] is also ill himself. I wanted to be taken away [by the paramedics to the acute hospital]." On 4/18//17 at 10:55 a.m., during an interview, Resident 1 stated the facility did not offer her the right to appeal the discharge. Resident 1 stated, "They wanted me out of there." On 4/18/17 at 12:05 p.m. during an interview and concurrent administrative document review, the Adm stated the facility gave Resident 1 a 30 day discharge notice on 10/6/16. The Adm stated the discharge notice did not indicate Resident 1's right for an appeal. The Adm stated the discharge notice did not have information on how to request an appeal. The Adm stated, "All I can say is that I'm sure we told her, but we don't have to show that in the letter [30 day discharge notice]." Administrative document review, untitled, dated 4/14/17, indicated "...[Resident 1] postponed the inevitable numerous times as should be apparent by how high we allowed her bill had become. She broke down crying when the time of her discharge became a reality as probably anyone would. The fact that she ultimately had to be issued a 30 day notice naturally brought into play a conflictual situation which came to a head at the moment of her discharge. Staff also reported...about a safe discharge. Naturally a safe discharge is always in everyone's best interest however we have been unable to find a regulation which requires a safe discharge..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 8 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 2. Resident 2's face sheet indicated Resident 2 was 82 years old at the time of discharge from SNF 1. Resident 2 was admitted to the facility on 1/5/15 and resided in the facility a total of 761 days. Resident 2's diagnoses included dementia, fracture of the right hip (7/29/16), diabetes, and psychosis (a mental disorder characterized by behaviors indicating loss of reality). Resident 2's face sheet indicated Resident 2's family member (FM) 2 was the Responsible Party (RP) to be contacted for notifications regarding Resident 2's care. Resident 2's MDS, dated 11/5/16, indicated Resident 2 had moderately impaired cognitive function (poor decision making, cues and supervision required) and was totally dependent on staff for toilet use and bathing. Resident 2's physician's orders, dated 7/29/16, indicated insulin injections four times a day were required to manage his diabetes. Resident 2's care plan, dated 1/5/15, indicated, "Residents condition requires long-term care. Resident requires 24/7 nursing care..." Resident 2 was discharged on 2/3/17 to Room and Board (R & B ) 1, an unlicensed facility that provides meals and lodging but does not provide skilled nursing care or 24 hour supervision and care. Resident 2's care plans from SNF 1 did not indicate an improvement of function or capabilities or improved mental and physical abilities had occurred during his stay in the SNF. On 5/1/17 at 3:10 p.m., Resident 2 was observed in a room at the ACH. The ACH record indicated Resident 2 arrived to the ACH on 4/28/17 at 11:18 a.m., and the reason for admission was "Left Femoral Neck [hip] Fx [fracture]." The record indicated, "Spanish speaking only. Caregiver found pt [patient] on the floor next to his bed [in R & B 2]." The record indicated Resident 2 had undergone surgery 4/29/17, to repair the left hip fracture. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 9 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 ACH Interpreter services were engaged to attempt to communicate with Resident 2. Resident 2 did not make eye contact or make any other recognizable attempts at verbal or nonverbal communication. On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated, "...No 30 day notices [30 day advance notice of discharge including the right to appeal the discharge] were given... a letter was sent to [FM 2], but after the fact [3 days after the discharge from the SNF had taken place]." On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the Director of Nursing (DON) was conducted. The DON stated Resident 2's condition had not significantly improved during his stay in the SNF, and he was not ready for discharge to a R&B on 2/4/17. On 5/11/17 at 8:10 a.m., a telephone interview with FM 2 was conducted. FM 2 stated he understood his father was supposed to be in a skilled nursing facility, but they [the facility] put his father in a group home without his knowledge. FM 2 asked, "Why would they move him without talking to me?" FM 2 stated when he learned his father was no longer at the facility; he waited three days to learn his father's location. FM 2 stated when he was finally able to locate and visit his father; he realized his father was not getting the care he needed and deserved, and that there were no Spanish speaking individuals to communicate with his father. FM 2 started to sob and stated, "I had never in my life seen my father with a beard. I did not know what to do. Then, I heard he fell and hurt himself..." On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 10 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 transferred Resident 2 to R&B 2. The owner of R&B 1 stated Resident 2 fell too much and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, "I kept an eye on [him] for half a month." On 5/16/17 at 1:55 p.m., a telephone interview with Resident 2's physician, MD 1, was conducted. MD 1 stated, "I understood [Resident 2] was discharged to an Assisted Living facility. This patient has dementia, severe dementia. Not able to go to an R&B. R&B residents must be independent. This resident was not independent. The social worker should arrange a safe discharge. Physicians depend on that. We just sign the paperwork." On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated, "We didn't do everything right..." 3. Resident 3's face sheet indicated Resident 3 was 92 years old at the time of discharge from SNF 1. Resident 3 was admitted to the facility on 2/7/13 and resided in the facility a total of 1458 days. The face sheet indicated Resident 3 was his own RP. Resident 3's diagnoses included dementia, prostate cancer (the prostate is a male sexual gland located behind the bladder), depression and dysphagia (difficulty swallowing). Resident 3's physician order, dated 1/14/15, indicated a pureed (modified texture), no added salt diet, due to the diagnosis of dysphagia. Resident 3's MDS, dated 1/15/17, indicated Resident 3's cognitive skills for daily decision making were "moderately impaired - decisions poor; cues/supervision required." The same MDS indicated Resident 3 required extensive assistance for dressing, toilet use, personal FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 11 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 hygiene and bathing. Resident 3's care plan, last revision dated 1/16/17, indicated, "Resident's condition requires long-term care. Discharge to community not feasible, Resident requires 24/7 nursing care ..." Resident 3's discharge to R&B 1 occurred on 2/3/17. Resident 3's care plans did not indicate an improvement of function or capabilities or improved mental and physical abilities had occurred during his stay in the SNF. On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the [name of county] Department of Social Services (SWFDSS) was conducted. The SWFDSS stated Resident 3 was discharged from the SNF to the care of R&B 1 on 2/4/17. The SWFDSS stated the owners of R&B 1 transferred Resident 3 to the care of R&B 2 (owned and operated by different people at another location). The SWFDSS stated the owner of R&B 2 applied for In Home Supportive Services (IHSS) for Resident 3.The SWFDSS stated Resident 3 had dementia and no family or support system available to ensure his needs were met. The SWFDSS stated she had contacted APS regarding concern over the questionable appropriateness of current placement in an R&B On 5/1/17 at 11:15 a.m., R&B 2 was visited. A woman that identified herself as a resident allowed surveyors to enter, and she phoned the owner. There were no care givers present. Resident 3 was observed in the back bedroom, sitting on the side of the bed eating breakfast cereal (Cheerios in milk) and a banana. Resident 3 had milk puddled around his mouth, in his full, bushy beard, and there was a distinct smell of urine about him. Resident 3 did not respond when he was spoken to and did not acknowledge surveyors' presence or make eye contact or make any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 12 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 recognizable attempts at verbal or nonverbal communication. On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated, "No 30 day notices were given... [to Resident 3]." On 5/2/17 at 2 p.m., the Adm stated Resident 3's name was brought up in a morning meeting regarding discharge from SNF 1 to R&B 1 and there was no objection to Resident 3's discharge. The Adm stated the SSD finds placement and the Interdisciplinary Team (IDT, a team of healthcare providers who meet to review and revise resident care plans) has an opportunity to object to the placement. The Adm stated the IDT was made up of the Adm, the AA, the SSD, and the DON. On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the DON was conducted. The DON stated Resident 3's condition had not significantly improved during his stay in the SNF, and he was not ready for discharge to a R&B on 2/4/17. On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he transferred Resident 3 to R&B 2. The owner of R&B 1 stated Resident 3 started hitting people and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, "I kept an eye on [him] for half a month." On 5/16/17 at 2:30 p.m., a telephone interview with Resident 3's physician, MD 2, was conducted. MD 2 stated, "I am not sure what drove the discharge." MD 2 stated [Resident 3] required the same level of care [after discharge as was provided in SNF 1]. MD 2 stated she went with the recommendation of the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 13 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 staff regarding Resident 3's discharge from SNF 1 on 2/3/17. On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated, "We didn't do everything right..." 


F204 SS=K PREPARATION FOR SAFE/ORDERLY TRANSFER/DISCHRG CFR(s): 483.12(a)(7)

F204 06/30/2017 A facility must provide sufficient preparation FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 14 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 orientation to residents to ensure safe and orderly transfer or discharge from the facility. In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency the State LTC ombudsman, residents of the facility, and the legal representatives of the residents or other responsible parties, as well as the plan for the transfer and adequate relocation of the residents, as required at §483.75(r). This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to ensure sufficient preparation and orientation for a safe and orderly discharge from the facility for four of 27 residents (Resident 1, 2, 3, and 7) when: Resident 1 was discharged from the Skilled Nursing Facility (SNF) 1 without family support and into a situation that previously required Adult Protective Services (APS) intervention, without ensuring physician ordered medical services and equipment were in place. Upon discharge, Resident 1's family member refused entry into the home and 911 was called. Resident 1 experienced emotional and physical distress that required intervention by local police and the fire department and subsequent transfer of Resident 1 to the acute care hospital (ACH) by ambulance. Resident 2 was discharged from SNF 1 where he was assessed to require 24 hour nursing care and insulin (hormone that lowers blood sugar levels) injections four times a day to treat his medical condition, to a room and board (R&B, a home that provides food and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 15 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 lodging, and requires residents to be independent) which did not have staff on duty 24 hours a day or staff who could administer injections; the R&B only provided a room and meals. The owner of R&B 1 stated Resident 2 required a higher level of care than what could be provided at R&B 1 and transferred Resident 2 to R&B 2 (also a home which only provides meals and a room). Resident 2 later fell at R&B 2 and suffered a fractured (broken) left hip which required surgical intervention. SNF 1 did not verify the services required on discharge were provided by R&B 1 and incorrectly identified the R&B as a Board and Care (B&Clicensed homes staffed with caregivers 24 hours a day/seven days a week) and as an Assisted Living (housing for elderly or disabled that provides nursing care, housekeeping, and prepares meals). Resident 3, who had resided in SNF 1 for 1458 days and suffered from dementia (disorder causing decline in memory, reasoning and judgement and poor safety awareness) was discharged from SNF 1, where he was assessed to require 24 hour nursing care and extensive staff assistance for all activities of daily living, to R&B 1, where 24 hour care and supervision were not provided, placing Resident 3 at risk of harm and injury. The owner of R&B 1 stated Resident 3 required a higher level of care than what could be provided at R&B 1 and transferred Resident 3 to R&B 2. The facility did not verify the services required on discharge were provided by R&B 1 and incorrectly identified the R&B as a B&C and as an Assisted Living facility.. The survey findings validated an Immediate Jeopardy at the Code of Federal Regulations (CFR) 483.15(c)(7) Orientation for Transfer or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 16 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 Discharge, F204 with a scope and severity of K (more than a limited number of individuals affected; Immediate Jeopardy (IJ), a situation in which immediate corrective action is necessary because the facility's noncompliance with one or more requirements of participation has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident receiving care in a facility). Because of the actual serious harm related to the unsafe discharge of Resident 1 and Resident 2, and the serious potential harm of the unsafe discharge of Resident 3, an IJ situation was called on 5/3/17 at 11 a.m. with the Administrator (Adm), Assistant Administrator (AA), Director of Nursing (DON) and Social Services Designee (SSD). On 5/4/17 at 11 a.m., the Adm presented an acceptable Action Plan addressing the IJ situation. The action plan consisted of the following elements: (1) Establishment of criteria for review by the Interdisciplinary Team (IDT, team of health care providers that plan resident care including licensed nurses, Social Services and facility Administrators) prior to resident discharge. The review would include assessment of resident needs to ensure appropriate placement with adequate services to meet resident needs, ensuring the discharge is safe, obtaining physician orders for durable medical equipment, home health services and follow-up appointments and verifying the required services are in place prior to discharge. IDT to ensure all residents will be provided, educated, and assisted with the appeal process if they do not agree with the discharge and the Ombudsman will be contacted for any resident who is unable to make decisions and has no responsible party. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 17 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 (2) Revision of the facility "Notice Before Transfer" form to include the right to appeal the discharge and the process to appeal a discharge. (3) Establishment of a process to verify the facility residents are discharged to a properly licensed facility that has the ability to meet the needs of the resident. (4) Arrangement for training on the discharge process, IDT process and Quality Assurance process through Health Services Advisory Group. On 5/5/17 at 3:05 p.m., the surveyor met with the Adm, DON, and SSD. The facility demonstrated that all the elements of the Action Plan that addressed the immediacy had been implemented and the IJ was removed on 5/5/17 at 3:05 p.m. with the Adm, DON and SSD present. Resident 7 was discharged into the care of the owner of R&B 1. The owner of R&B 1 was unable to provide care for Resident 7 and transferred Resident 7 to R&B 3 which was owned by a different provider. R&B 1 and R&B 3 were homes that provided a room and meals. No skilled nursing services or 24 hour care givers were available at R&B 1 or R&B 3.The owner of R&B 3 was unable to provide the level of care required by Resident 7. The owner of R&B 3 stated Resident 7's friend removed Resident 7 from R&B 3 and her whereabouts is unknown. The facility did not verify the services required for Resident 7 were available at R&B 2 and placed Resident 7 at risk for harm from inadequate care. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 18 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 1: Resident 1's face sheet (document containing resident personal information) indicated Resident 1 was 73 years old and was admitted to the facility on 5/17/16. Resident 1's diagnoses included diabetes mellitus (disorder which causes high blood sugar due to insufficient production of the hormone insulin which regulates blood sugar), heart failure, and an open wound to the right foot. Resident 1's Minimum Data Set (MDS) (a resident assessment tool) assessment, dated 8/24/16, indicated Resident 1 had no cognitive (memory) impairment. The MDS assessment indicated Resident 1 did not ambulate (walk) and required total staff support in bed mobility, transfers from bed to wheelchair, locomotion while in wheelchair, dressing, toilet use, personal hygiene and bathing. Administrative document review, untitled and dated 10/6/16, indicated a typed written 30 day discharge notice addressed to Resident 1. The letter indicated, "Hand delivered to [Resident 1] at [the facility] ...Copy to [Family Member (FM) 1] ...You are hereby given a 30 Day notice of discharge from [facility] ...because you have not been paying your share of cost. Your Medical [Medi-Cal] determined share-of-cost is $2,269 per month. Your current bill is $11,649.63. You will be discharged on November 7, 2016 unless your bill is paid in full and/or a satisfactory repayment plan is established prior to that time. Your bill will increase by $2,269 plus interest by that date. You will be discharged to your home with your [FM 1]. We will assist you in setting up in-home care if you desire. You have all your mental capacities and even with certain physical limitations you should be able to function at home with some in-home supportive services..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 19 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 11/10/16 at 9:40 a.m., during an interview and concurrent clinical record and administrative document review, the AA stated Resident 1 was discharged from the facility on 11/7/16. The AA stated, "We provided transportation to her [Resident 1's] home. [FM 1] refused to open the gate to let her come in." The AA stated she and the Adm drove to Resident 1's house after Resident 1's transport driver informed them FM 1 would not let Resident 1 inside the home. The AA stated FM 1 yelled and cursed at them, and refused to open the gate. The AA stated, "We offered to let him pay the bill." The AA stated FM 1 stated he paid the utility bill with Resident 1's money; he took care of her house and could not take care of her. The AA stated while the situation with FM 1 yelling and the facility staff responding took place, Resident 1 complained she didn't feel well, so she (the AA) called 911 (the emergency response phone number). The AA stated two policemen and three or four firemen responded to the 911 call and the AA and the Adm then left Resident 1 at her house. The AA stated, "We were told we were free to go. We left. [FM 1] was in the house. The resident [Resident 1] was at the gate with officers, and the paramedics were taking her [Resident 1] to the hospital...She [Resident 1] said she knew the law. She didn't believe she would be kicked out." The AA stated FM 1 had not answered phone calls from the facility prior to Resident 1's discharge and had not participated in Resident 1's discharge planning. Resident 1's ACH clinical record titled, "ED [emergency department] Provider Notes" dated 11/7/16, indicated, "Chief Complaint...patient was kicked out of SNF [SNF 1], PD [police department] states home is unfit for patient to live in...73 year old was left in front of her house and FPD [local PD] stated her house is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 20 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 unfit to live in, therefore was transported to the hospital..." Resident 1's ACH clinical record titled, "Acute Care Physical Therapy Initial Assessment and Discharge" dated 11/8/16, indicated, "...Summary/Analysis of examination: The patient...who presents for placement due to unsafe living conditions at her home. She [Resident 1] demonstrates weakness about all extremities with right hemiplegia [paralysis of one side of the body] consistent with previous stroke 15 years ago. She required maxA [ maximum assistance] to complete bed mobility and transfer tasks...She exhibits excessive extensor tone [muscle tightness] about BLE [both lower extremities] which made stand pivot transfers difficult to complete ...Recommend disposition to long term SNF when medically cleared ...Nursing staff to assist patient with bed mobility ...Most appropriate from 2 person stand pivot transfer versus lift [mechanical device to lift patient out of bed and transfer to chair] transfer for patient and caregiver safety ..." Resident 1's ACH clinical record titled, "Case Manager Addendum" dated 11/7/16, indicated, "...Per medical record review - she was an APS case 05/10/16 - APS report filed by PD due to unsanitary living conditions and suspicion of abuse/neglect. Pt [patient] with a past medical history of CVA [cerebral vascular accident stroke] x2 [twice], residual right side weakness, and diabetes... In [identity of facility] ED pt was noted to have hair soiled with feces, small cockroaches on her, and multiple wounds. Wound on right foot found to have maggots. Report received by APS from PD that pts home is uninhabitable and that [FM 1] appears to have his own medical conditions and cannot care for pt..." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 21 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 1's clinical record titled, "... EMS [emergency medical services]" dated 5/8/16, indicated, "...72 year old female...found laying on the floor by [FM 1], c/o [complaint of] possible fall unknown how long pt [patient] has been on floor...firemen on scene stated, "The inside of the house is not livable, I (captain) called...PD to come out and start an APS case, the pt cannot take care of herself and when you see her inside [home] you'll see what I mean. [FM 1] was on scene in the house, [FM 1] stated, "I have been at the hospital; for the past 4 days...I don't know how long she has been on the floor." Pt...completely soiled head to toe, coffee ground emesis [vomit] inside the pt mouth/on arms/shirt, diaper full leaking out, cockroaches crawling all over the pt..." On 11/15/16 at 1 p.m., during an interview and concurrent clinical record review, the SSD stated there were allegations of abuse at Resident 1's home prior to her admission to SNF 1. The SSD stated Resident 1 did not have a "safe discharge." The SSD stated there were issues surrounding APS. The SSD stated, "When we talked to her, she wanted to go home...she hadn't seen [FM 1] in six months." The SSD stated FM 1 did not participate in discharge planning. The SSD stated medical equipment was required for home care, which needed to be arranged prior to Resident 1's discharge. The SSD stated Resident 1 was bed and wheel chair bound, and Resident 1 had not walked during her stay at the facility. The SSD stated Resident 1's physician ordered a hospital bed, a wheelchair, a mechanical lift, a bedside commode [portable bedside toilet] and a shower chair for home use. The SSD stated there was no validation the items had been delivered to the house or would be able to be acquired with Resident 1's insurance. The SSD stated, "There was no reason to expect [FM 1] would cooperate. I knew it was an unsafe FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 22 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 discharge. I didn't have access to her house. I didn't know if she had medical equipment." The SSD stated, "A 30 day notice [notice of transfer/discharge] was given for failure to pay." The SSD stated Resident 1's discharge "Was up to the Administrator." Resident 1's Progress Note, entered by the SSD, dated 6/7/16 at 2:13 p.m., indicated, "This writer contacted the Adult Protective Services to confirm if there is an open case. Spoke with [worker's name] and he said yes the case is still open..." An additional Progress Note, entered by SSD, dated 8/23/16 at 11:31 a.m., indicated, "It is uncertain if returning to her home would be a safe discharge. Adult Protective Services were involved. This writer has left many messages for [FM 1] and he does not return the calls..." On 4/13/17 at 9 a.m., during an interview, Licensed Nurse (LN) 1 stated Resident 1 was discharged home on 11/7/16 at 2 p.m. LN 1 stated Resident 1 did not want to sign for her discharge. LN 1 stated Resident 1 looked angry and later began to cry. LN 1 stated the Adm and the AA spoke to Resident 1 about her discharge taking place on 11/7/16, and told her she needed to sign the discharge papers. LN 1 stated Resident 1 had wounds on her right foot. LN 1 could not explain what type of wounds. LN 1 stated Resident 1 required daily wound care to her right foot toes. LN 1 stated she did not think Resident 1 could perform her own wound care. LN 1 stated she did not know what date the home health agency would follow up with Resident 1 for the wound care. LN 1 stated she did not think Resident 1 had a safe discharge home. Resident 1's clinical record titled "Surgical Consent" dated 10/27/16, indicated, "Consultation for wound on right medial [inner FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 23 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 side] foot ...Subcutaneous [under the skin] tissue debridement [removal] performed by surgical excision [cutting out] of devitalized [dead] subcutaneous tissue...The pre-op [before procedure] wound area was 1.5 centimeters [cm-metric unit of measurement] X [by] 1.5 cm X .3 cm...The post op [after procedure] was 1.5 cm X 1.5 cm X .3 cm...DRESSING USED: Santyl [topical medication used to remove dead tissue]/ Calcium alginate [absorbent dressing]. The patient has a wound located at the right medial foot...wound debrided today was at the right medial foot. For this wound there was evidence of tissue breakdown requiring aggressive management and may require future debridement...No guarantee for wound healing can be made given the patient risk factors and diagnoses that contributes to the condition of this wound." Resident 1's clinical record titled "Pressure and Vascular Ulcer Log" dated 11/2/16, indicated, "R [right] medial foot wound 2 cm X 1.9 cm X .2..." Resident 1's physician orders dated 11/2/16, indicated, "CLEANSE [RIGHT] MEDIAL FOOT WITH [NORMAL SALINE] PAT DRY, APPLY SANTYL, THEN CALCIUM ALGINATE COVER WITH DRY DRESSING, MONITOR FOR [SIGNS AND SYMPTOMS] OF COMPLICATIONS UNTIL RESOLVED." Resident 1's clinical records titled, "Video Swallow Evaluation" dated 9/28/16, indicated, "History of Silent aspiration [food or fluids enter the lungs] and dysphagia [difficulty swallowing]...With thin liquids, premature spillage [food or liquid swallowed escapes from the mouth and reaches the pharynx (throat) before the swallow starts] is seen into the piriforms [located in the pharynx are narrow FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 24 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 hollowed areas]...Premature spillage is seen which may predispose to future episodes of aspiration...No aspiration or penetration with nectar or dry solids..." Resident 1's clinical record titled, "Order Summary Report" dated 11/7/16, indicated Resident 1 had a physician ordered "Mechanical Soft Diet [diet consisting of easy to swallow foods including ground meats and soft cooked diced vegetables and fruits], Nectar consistency [thick liquids]." On 4/13/17 at 10:40 a.m., during an interview and a concurrent record review, the Director of Nursing (DON) stated Resident 1 was on a mechanical soft diet and required thickened liquids (liquids with an added unflavored powder used to thicken the consistency for those with swallowing problems) due to her dysphagia. The DON stated Resident 1 was seen by the speech therapist (ST) who determined Resident 1 needed to remain on nectar thick liquids to prevent aspiration of liquid into the lungs. The DON stated she did not know if Resident 1 could cook. The DON stated she did not know who would prepare Resident 1's meals at home or if Resident 1 knew how to thicken her liquids. The DON stated she did not know if Resident 1 was discharged with thickener because it was not reflected in Resident 1's clinical notes. The DON stated the SSD made all of the arrangements for the discharge and determined what support system existed for the residents being discharged. The DON stated she did not know FM 1 was not involved in the care of Resident 1. The DON stated she was unsure if Resident 1 demonstrated the ability to perform her wound treatment. The DON stated she was not aware APS was involved prior to Resident 1's admission. The DON stated, "I don't think it was a safe discharge." FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 25 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 4/13/17 at 11:30 a.m., during an interview, the AA stated she believed Resident 1 received a safe discharge. The AA stated Resident 1 wanted to be discharged from the facility. The AA stated Resident 1 was left on her [Resident 1's] property. The AA stated FM 1 was in Resident 1's house and the police officers were present. The AA stated, "We had already lost a lot of money from her [Resident 1] nonpayment." The AA stated she was aware of APS involvement and she couldn't say whether or not it was appropriate for Resident 1 to return to the same previous living arrangements. The AA stated she was not aware of any regulation requiring facilities to ensure a safe discharge. Review of Resident 1's Physician Orders dated, 11/1/16, indicated, "[Resident 1] May be discharged home with [Home Health Agency] for complete evaluation for home safety, medication training, wound care, around the clock companion care, physical therapy, hospital bed, wheelchair, [brand name mechanical] lift, bedside commode, and shower chair." On 11/15/16 at 9:40 a.m., a telephone interview with the Staffing Supervisor (SS) of a company which provided companion care services and activities of daily living assistance was conducted. The SS stated he visited Resident 1 on 10/25/16 at SNF 1 to discuss services that his company could provide to Resident 1 after discharge from the facility. The SS stated the around the clock companion care ordered by Resident 1's physician was not covered by Resident 1's insurance. Resident 1 would have to pay privately for the 24 hour companion services and activities of daily living assistance. The SS stated Resident 1 informed him on 10/25/16 that private pay was an issue FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 26 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 her; she did not have the money to pay for the services. The SS stated Resident 1 did not have 24 hour companion services or activities of daily living assistance arranged for her discharge home due to her refusal of services related to inability to pay. On 11/15/16 at 1 p.m., during an interview, the SSD stated she was aware the 24 hour companion care services and activities of daily living were not covered by Resident 1's insurance and required Resident 1 to pay with private funds. The SSD stated she was not aware Resident 1 had declined the services due to inability to pay for around the clock companion care. On 4/13/17 at 2:45 p.m., during a telephone interview, the home health agency Adm (HHA ADM) stated the agency received orders for physical therapy and a home safety evaluation only. The HHA ADM stated, "When we reviewed it [the orders], it looked like we would require more assistance and a nurse to follow. The nurse was scheduled for visit on 11/9/16 [Two days after the discharge from SNF 1 occurred]." Resident 1's clinical record from the home health agency titled, "Patient Communication" dated 11/6/16, indicated, "Patient referral from [facility] for discharge on 11/7 to home, includes medication training and wound care. Should RN [registered nurse] open to Home health? This patient is scheduled for PT [physical therapy home safety evaluation] on 11/9/16..." On 4/13/17 at 9:55 a.m., during an interview and concurrent record review, the SSD stated home health services were offered to Resident 1 on 10/6/16. The SSD stated, home health would complete an evaluation for home safety, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 27 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 medication training, and wound care. The SSD stated she did not contact the home health agency to coordinate or assist Resident 1 in arranging the first visit to ensure Resident 1 was safe. The SSD stated she did not know when the home health agency would follow up with Resident 1. The SSD stated Resident 1 did not have a supportive family unit working toward Resident 1's discharge. The SSD stated she made no attempt to contact APS prior to Resident 1's discharge to inquire about the previous APS case regarding Resident 1's home situation. The SSD stated she did not review the discharge instructions prior to Resident 1's discharge home. The SSD stated Resident 1 should not have been discharged to the same living conditions that existed prior to her admission to the facility. On 4/19/17 at 10:40 a.m., during a telephone interview, the durable medical equipment assistant (DMEA) stated the facility notified the equipment company by facsimile [fax] on 11/4/16 of the durable medical equipment (DME) need for Resident 1 at home. The DMEA stated, "It looks like they ordered a manual wheelchair, oxygen, commode, hospital bed, a mechanical lift and a shower chair. The wheelchair was not going to be covered [by Resident 1's insurance]. We needed additional documentation, more supporting notes and oxygen levels. The facility never responded, and they didn't call to make any arrangements." The DMEA stated the additional documentation was requested from the facility on 11/14/16 seven days after Resident 1 was discharged from the facility and ten days after the initial durable medical equipment was ordered. On 4/19/17 at 11:05 a.m., during a telephone interview, the DME supervisor (DMES) stated, "It [the DME order] shows that we needed additional documentation to be able to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 28 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 determine if the DME ordered would be delivered. There are strict guidelines and the need [requires] to be supported with documentation. We did not receive it. It also looks like the form was left incomplete. We need patient height, patient weight, length of need and prognosis." Resident 1's clinical record titled, "MULTIDISCIPLINARY DISCHARGE SUMMARY [document that contains resident discharge assessment and plan]" dated 11/7/16, contained an incomplete discharge summary. The document did not list a discharge diagnosis; under "Nutritional Status Special Needs [including Preferences and Restrictions]" did not list Resident 1's mechanical soft diet orders or need for nectar thick liquids. The document indicated an incomplete "Nutritional Intake and Eating Habits." The document lists "weakness" under "Joint Motions Disorders." The document listed "Rt [right] foot open wound" and "Dressing changed q (every) day" under "TREATMENTS AND OR PROCEDURES." The document had incomplete entries under "Procedures, Rehabilitation Potential, Discharge Potential, Activity Interest, Activity Potential and Activity Participation. The document was missing signatures and names of persons who completed the forms. The document was not signed by Resident 1 in the space that indicated, "Resident Signature." On 4/18/17 at 10:20 a.m., during an observation and concurrent interview, Resident 1 was alert and sitting up in bed in SNF 2. Resident 1's fingers of her right hand were stiff and drawn in toward her palm. Resident 1 demonstrated difficulty moving her fingers. When asked about her discharge from SNF 1, Resident 1 stated she had been upset about the discharge. Resident 1 stated she had not FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 29 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 been shown how to take care of her right foot wound. Resident 1 stated she would not have been able to care for her foot wound due to her limited mobility with her right hand and fingers. Resident 1 stated, "[FM 1] is unable to care for me at home. He has been in and out of the hospital...My house has no electricity and no running water or heat...The manager [Adm] at the facility accused me of being a thief because I didn't give them my pension...I wanted to explain that [FM 1] was using my money to pay for my taxes and my bills plus the utilities. I was not stealing from them." Resident 1 stated, "I was sad by the entire thing. I was stuck between a rock and a hard place. They were calling me a thief and accusing [FM 1] of stealing from me, but what would they have done. I felt horrible that I was kicked out of the facility and not let into my house, but [FM 1] is also ill himself. I wanted to be taken away [by the paramedics]." On 4/18/17 at 12:05 p.m., during an interview, the Adm stated, "I feel it was a safe discharge because [Resident 1] was never left in an unsafe situation. The cops were present...she [Resident 1] was on her property and [FM 1] was not letting her in her home. He refused to open the gate." The Adm stated, "You can talk to [SSD] but [FM 1] and [Resident 1] were both in agreement to discharge home. The Adm stated Resident 1, "Complained about being on a mechanical soft diet. I told her that she could go home and eat whatever she wanted." The Adm stated he assumed Resident 1 had a blender to prepare the mechanical soft diet because Resident 1 said she, "had everything at home." The Adm stated he believed Resident 1 could prepare her own meals. The Adm stated he didn't think he called Resident 1 a thief. The Adm stated, "Putting it into perspective, I told her the money belonged in the facility and she was stealing from the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 30 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility." The Adm stated he knew APS had a closed case on Resident 1 involving [FM 1]. On 4/19/17 at 3:10 p.m., during a telephone interview, with APS supervisor (APSS) 1 and APSS 2, APSS 1 stated he was familiar with Resident 1's APS case of 5/10/16. APSS 1 stated Resident 1 should have never been discharged back to "those conditions." APSS 2 concurred with APSS 1's discharge assessment. Administrative document review of a type written letter, untitled, dated 3/30/17, indicated, "We reviewed the regulation, there is no place where it says "Safe Discharge" Please provide us the regulation that requires the policy for safe discharge. Notwithstanding the above we contend that this was a safe discharge in as much as we completed all the requirements for a discharge but when [FM 1] refused to allow her back into her own home a medical transport was summoned to take to the hospital so [Resident 1] was never in an unsafe situation..." The letter was signed by the Adm. Administrative document review of a type written letter, untitled, dated 4/14/17, indicated, "...[Resident 1] postponed the inevitable numerous times as should be apparent by how high we allowed her bill had become. She broke down crying when the time of her discharge became a reality as probably anyone would. The fact that she ultimately had to be issued a 30 day notice naturally brought into play a conflictual situation which came to a head at the moment of her discharge. Staff also reported...about a safe discharge. Naturally a safe discharge is always in everyone's best interest however we have been unable to find a regulation which requires a "safe" discharge. My comment is if you are aware of a "safe" discharge regulation...please FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 31 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 share it with us ...In addition we would like an explanation of how this could be considered an unsafe discharge. For all practical purposes [Resident 1] was actually discharged to the hospital with a visit in between to see her home and her [FM 1], [Resident 1] was never not "safe" ..." The letter was signed by the Adm. Review of facility policy and procedure titled, "Discharge Summary and Plan," dated revised 2010, indicated, "...When the facility anticipates a resident's discharge to a private residence...a discharge summary and a postdischarge plan will be developed which will assist the resident to adjust to his or her new living environment." For Resident 2: Resident 2's face sheet indicated Resident 2 was 82 years old at the time of discharge from SNF 1. He was admitted to the facility on 1/5/15 and resided in the facility a total of 761 days. Resident 2's diagnoses while a resident at SNF 1 included dementia, fracture of the right hip, diabetes mellitus and psychosis (a mental disorder characterized by behaviors indicating loss of reality). The face sheet indicated Resident 2's family member, FM 2, was the Responsible Party (RP) to be contacted for notifications regarding Resident 2's care. Resident 2's MDS, dated 11/5/16, indicated Resident 2 had moderately impaired cognitive function (poor decision making, cues and supervision required) and was totally dependent on staff for toilet use and bathing. Resident 2's physician's orders, dated 7/29/16, indicated insulin injections four times a day were required to manage his diabetes. Resident 2's SNF 1 care plan, dated 1/5/15, indicated, "Residents condition requires longFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 32 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 term care. Resident requires 24/7 [24 hours per day, seven days per week] nursing care..." The care plan, dated 1/29/15, indicated, "Resident is at risk for elopement [leaving the facility without permission or supervision]...wandering with poor safety awareness..." The care plan, dated 1/15/15, indicated, "The resident uses physical restraints WanderGuard (alarmed device to alert staff when resident wandered near an exit door)..." The care plan, dated 1/12/15, indicated the resident was Spanish speaking. Resident 2's Physician's order, dated 1/5/15, indicated Resident 2 was to wear a WanderGuard alarm at all times due to Resident 2's high risk for elopement and a bed alarm was required due to poor safety awareness. Resident 2's physician discharge order, dated 2/2/17, indicated, "May discharge to [R&B 1] on 2/3/17 with medications, home health R.N. evaluation, wheelchair, and P.T [physical therapy]. The physician order for discharge did not include the level of care Resident 2 would require upon discharge. Resident 2's face sheet indicated Resident 2 was discharged on 2/4/17 (to R&B 1). On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the [name of county] Department of Social Services (SWFDSS) was conducted. The SWFDSS stated Resident 2 was discharged from SNF 1 to the care of R&B 1 on 2/4/17. The SWFDSS stated the owners of R&B 1 transferred Resident 2 to the care of R&B 2 (owned and operated by different people at another location). The owner of R&B 2 applied for In-Home Supportive Services (IHSS subsidized in-home care) for Resident 2. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 33 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 SWFDSS stated she was involved in screening residents for IHSS care. The SWFDSS stated she was contacting APS regarding concern of appropriate placement of Resident 2 in a room and board facility. On 4/28/17 at 1:45 p.m., during an interview, the DON stated she was aware the AA made the decision to discharge Resident 2 to a place the AA called an Assisted Living (housing for elderly or disabled that provides nursing care, housekeeping, and prepares meals). The DON stated she was not aware of the difference in the level of services provided by an Assisted Living as opposed to an R&B. The DON stated she did not have any input on deciding resident discharge. The DON stated, "If I said no [to a discharge] because the resident is not medically safe or with wounds, the AA will override my decision." On 4/28/17 at 1:50 p.m., during an interview, the AA referred to R&B 1 as "an Assisted Living facility." The AA stated she was not aware of the care and services provided at R&B 1. The AA stated Resident 2 was discharged from the facility because he was functioning well and able to ambulate. On 4/28/17 at 2 p.m., during an interview, the SSD referred to R&B 1 as "an Assisted Living Facility." The SSD stated she had never been there and did not know the level of care R&B 1 provided. On 5/1/17 at 9:20 a.m., during a telephone interview, the SWFDSS stated Resident 2 had fallen at R&B 2 and was at the ACH for treatment. On 5/1/17 at 11:15 a.m., R&B 2, where Resident 2 resided, was visited. A woman that identified herself as a resident in R&B 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 34 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 allowed surveyors to enter the home. There were no care givers present. Resident 2 was not at R&B 2 on 5/1/17. Resident 2's ACH Emergency Department (ED) record dated 4/28/17, indicated Resident 2 arrived to the ACH on 4/28/17 at 11:18 a.m. The ACH record indicated, "Chief Complaint Patient presents with Pain - Leg ...brought in by ambulance, presents to ED with s/p [status post] unwitnessed fall this morning. Per EMS [emergency medical services] report staff noticed patient on the floor in his bedroom [at R&B 2]. Unknown down time." The ACH ED record dated 4/28/17 at 1:09 p.m., indicated, "Imaging [X-ray] XR [X-ray] bilateral [both] hip ...Lt [left] hip fx[fracture]." The ACH record indicated Resident 2 had undergone surgery 4/29/17, to repair the left hip fracture. On 5/1/17 at 3:10 p.m., during an observation and concurrent interview, Resident 2 was observed in a room at the ACH. The ACH Interpreter services were engaged to attempt to communicate (in Spanish) with Resident 2. Resident 2 did not make eye contact and did not make any recognizable verbal or nonverbal effort to communicate. On 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated she had met the owner of R&B 1. The SSD provided the flier that R&B 1's owner handed out when he visited SNF 1. The flier indicated, "...Our guests are independent and are people who wish to live in a "clean and sober" environment. Our house provides 3 meals per day, laundry, phone and other services ..." The SSD stated she had not visited or otherwise validated the services provided at R&B 1. The SSD stated Resident 2 did not have good safety awareness, was not independent and would FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 35 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 not be safe without supervision at the time of discharge. The SSD stated Resident 2's condition had not significantly improved during his stay in the SNF. The SSD stated there were no resident assessments to verify Resident 2's physical or medical condition drove the need for discharge, nor had the IDT met and determined it was safe to discharge to a lower level of care. The SSD stated the decision to discharge Resident 2 was made by the Adm and AA. The SSD stated the Adm and AA asked her to contact the owner of R&B 1 to inquire if Resident 2 could be placed in his care; it was her (the SSD) responsibility to make the arrangements. The SSD stated, in her opinion, the discharge was unsafe. The SSD stated she did not voice her opinion because she believed the decision to discharge had already been made, and her opinion would not matter. The SSD stated the owner of R&B 1 visited Resident 2 in SNF 1, prior to discharge, conducted record review, and accepted Resident 2 for discharge to R&B 1. The SSD stated the facility left the determination of appropriate placement to the owner of R&B 1. The SSD stated, "I trusted him [the owner of R&B 1] to set up the home health services ... No 30 day notices were given ... a letter was sent to Resident 2's son, but after the fact [on 2/6/17, 3 days after the discharge had occurred]." On 5/2/17 at 1 p.m., during an interview, the DON stated there was no discharge plan documented in Resident 2's clinical record which indicated the IDT met and resident assessments drove the decision to discharge. The DON stated she was told in a morning meeting Resident 2 was being discharged. The DON stated the IDT did not work as a team on the discharge, but they usually would. The DON stated Resident 2 was a long term care resident at SNF 1 and it was unusual to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 36 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 discharge long term care residents. The DON stated it was the AA's decision to discharge the resident. The DON stated Resident 2 needed supervision and nursing care at the time of his discharge. On 5/2/17 at 1:45 p.m., during an interview, the AA stated, "[Adm] decided to discharge [Resident 2]. Discharge takes about a month. It took a long time to get [Resident 2's] funds coming here. We had to get [his] money coming here before we could discharge. The AA stated Resident 2 needed 24 hour care. The AA stated she did not know the level of care R&B 1 offered and she had not been to the R&B homes. The AA stated she thought because Resident 2 could ambulate, it was a safe placement. On 5/2/17 at 2 p.m., the Adm stated Resident 2's name was brought up in a morning meeting and there was no objection to the discharge from SNF 1. The Adm stated the SSD was responsible to find placement for residents upon discharge and the IDT had an opportunity to object to the discharge. The Adm stated the IDT was made up of the Adm, the AA, the SSD, and the DON. The Adm stated he was not aware Resident 2 required insulin which would have made him ineligible for discharge to R&B, but B&C would have been appropriate. On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the DON was conducted. The DON stated Resident 2's condition had not significantly improved during his stay in SNF 1, and he was not ready for discharge on 2/4/17. On 5/11/17 at 8:10 a.m., a telephone interview with Resident 2's family member, FM 2, was conducted. FM 2 stated he understood his FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 37 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 father was supposed to be in a skilled nursing facility, but they [the facility] put his father in a group home without his knowledge. FM 2 asked, "Why would they move him without talking to me?" FM 2 stated when he learned his father was no longer at the facility; he waited three days to learn his father's location. FM 2 stated when he was finally able to locate and visit his father; he realized his father was not getting the care he needed and deserved, and that there were no Spanish speaking individuals to communicate with his father. FM 2 started to sob, and stated, "I had never in my life seen my father with a beard. I did not know what to do. Then, I heard he fell and hurt himself..." On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he accepted Resident 2 at R&B 1 on 2/4/17 but later transferred Resident 2 to R&B 2. The owner of R&B 1 stated Resident 2 fell too much and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, "I kept an eye on [him] for half a month." On 5/16/17 at 1:55 p.m., a telephone interview with Resident 2's physician, MD 1, was conducted. MD 1 stated, "I understood [Resident 2] was discharged to an Assisted Living facility. This patient has dementia, severe dementia. Not able to go to an R&B. R&B residents must be independent. This resident was not independent. The social worker should arrange a safe discharge. Physicians depend on that. We just sign the paperwork." On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated Resident 2's discharge to a B&C probably would have FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 38 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 been fine; but not an R&B. The Adm stated he was not aware Resident 2 required insulin injections. The Adm stated insulin injections would have made Resident 2 unsuitable for B&C placement as well. The Adm stated, "We didn't do everything right. We didn't do our homework." The ADM stated the facility did not validate the type of services or the level of care provided at any of the R&B's. For Resident 3: Resident 3's face sheet indicated Resident 3 was 92 years old at the time of discharge from SNF 1. Resident 3 was admitted to SNF 1 on 2/7/13 and resided in the facility a total of 1458 days. Resident 3's diagnoses included, prostate cancer (the prostate is a male sexual gland located behind the bladder), depression and dysphagia (difficulty swallowing). Resident 3's MDS, dated 1/15/17, indicated Resident 3's cognitive skills for daily decision making were "moderately impaired - decisions poor; cues/supervision required." The same MDS indicated Resident 3 required extensive staff assistance for dressing, toilet use, personal hygiene and bathing. Resident 3's care plan, last revision dated 1/16/17, indicated, "Resident's condition requires long-term care. Discharge to community not feasible, Resident requires 24/7 nursing care ..." Resident 3's care plan, last revised 3/13/13, indicated he had an activity of daily living self-care performance deficit and required staff assistance with personal hygiene, dressing, eating and transfer. Resident 3's care plan dated 11/4/13, indicated a WanderGuard to be worn at all times for wandering and high risk of elopement Resident 3's physician order, dated 1/14/15, indicated a pureed diet (diet consisting of foods FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 39 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 that have been strained or blended and require no chewing), due to the diagnosis of dysphagia. Resident 3's physician order dated 2/7/13 indicated a WanderGuard to be worn at all times for wandering and high risk of elopement. Resident 3's physician discharge order, dated 2/2/17, indicated, "May discharge to [R&B 1] on 2/3/17 with medications, home health R.N. evaluation, and P.T. The physician order did not indicate the level of care. Resident 3's discharge occurred on 2/4/17, and the care plan did not indicate an improvement of function or capabilities or improved mental and physical abilities. On 4/28/17 at 9 a.m., a telephone interview with a Social Worker for the [name of county] Department of Social Services (SWFDSS) was conducted. The SWFDSS stated before Resident 3 was admitted to SNF 1, he was receiving IHSS. The SWFDSS stated prior to placement at SNF 1, APS was involved with Resident 3's care because Resident 3 had memory issues and no family or support system available. The SWFDSS stated Resident 3 was discharged from SNF 1 to the care of R&B 1 on 2/4/17. The SWFDSS stated the owners of R&B 1 transferred Resident 3 to the care of R&B 2 (owned and operated by different people at another location). The owner of R&B 2 applied for IHSS for Resident 3. The SWFDSS stated she was contacting APS regarding concern over the previous APS case for Resident 3 and the questionable appropriateness of current placement in an R&B, as Resident 3 was determined to be unsafe at that level of care prior to placement at SNF 1. The SWFDSS stated the previous APS case was related to Resident 3's need for a public guardian because he didn't have family, but the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 40 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 application was not pursued because he was safely placed at SNF 1. On 4/28/17 at 1:45 p.m., during an interview, the DON stated she was aware the AA made the decision to discharge Resident 3 to a place the AA called an Assisted Living. The DON stated she was not aware of the difference in the level of services provided by an Assisted Living as opposed to an R&B. The DON stated she did not have any input on deciding resident discharge. The DON stated, "If I said no [to a discharge] because the resident is not medically safe or with wounds, the AA will override my decision." On 4/28/17 at 1:50 p.m., during an interview, the AA referred to R&B 1 as "an Assisted Living facility." The AA stated she was not aware of the care and services provided at R&B 1. The AA stated Resident 3 was discharged from the facility because he was functioning well and able to ambulate. On 4/28/17 at 2 p.m., during an interview, the SSD referred to R&B 1 as "an Assisted Living Facility." The SSD stated she had never been there and did not know the level of care R&B 1 provided. On 5/1/17 at 11:15 a.m., R&B 2, where Resident 3 resided, was visited. A woman that identified herself as a resident in R&B 2 allowed surveyors to enter. There were no care givers present. Resident 3 was observed in the back bedroom, sitting on the side of the bed eating breakfast cereal (Cheerios in milk) and a banana. Resident 3 had milk puddled around his mouth, in his full, bushy beard, and there was a distinct smell of urine about him. Resident 3 did not make eye contact, or make any recognizable verbal or nonverbal attempts to communicate. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 41 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 5/2/17 at 11:12 a.m., during an interview and concurrent record review, the SSD stated she had met the owner of R&B 1. The SSD provided the flier that R&B 1's owner handed out when he visited SNF 1. The flier indicated, "...Our guests are independent and are people who wish to live in a "clean and sober" environment. Our house provides 3 meals per day, laundry, phone and other services ..." The SSD stated she had not visited or otherwise validated the services provided at R&B 1. The SSD stated Resident 3 did not have good safety awareness, was not independent and would not be safe without supervision at the time of discharge. The SSD stated Resident 3's condition had not significantly improved during his stay in SNF 1. The SSD stated there were no resident assessments to verify Resident 3's physical or medical condition drove the need for discharge, nor had the IDT met and determined it was safe to discharge Resident 3 to a lower level of care. The SSD stated the decision to discharge Resident 3 was made by the Adm and AA. The SSD stated the Adm and AA asked her to contact the owner of R&B 1 to inquire if Resident 3 could be placed in his care; it was her responsibility to make the arrangements. The SSD stated, in her opinion, the discharge was unsafe. The SSD stated she did not voice her opinion because she believed the decision to discharge had already been made, and her opinion would not matter. The SSD stated the owner of R&B 1 visited Resident 3 while in SNF 1, prior to discharge, conducted record review, and accepted Resident 3 for discharge to R&B 1. The SSD stated the facility left the determination of appropriate placement to the owner of R&B 1. The SSD stated, "I trusted him [the owner of R&B 1] to set up the home health services... No 30 day notices were given FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 42 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 5/2/17 at 1 p.m., during an interview, the DON stated there was no discharge plan documented in Resident 3's clinical record which indicated the IDT met and resident assessments drove the decision to discharge. The DON stated she was told in a morning meeting Resident 3 was being discharged. The DON stated the IDT did not work as a team on the discharge, but they usually would. The DON stated Resident 3 was a long term care resident at SNF 1 and it was unusual to discharge long term care residents. The DON stated it was the AA's decision to discharge Resident 3. The DON stated Resident 3 needed supervision and nursing care at the time of his discharge on 2/4/17. On 5/2/17 at 1:45 p.m., during an interview, the AA stated, "[Adm] decided to discharge [Resident 3]. Discharge takes about a month. It took a long time to get [Resident 3's] funds coming here. We had to get [Resident 3's] money coming here before we could discharge." The AA stated, "Only partial payment [for Resident 3] was coming here. We had to get Social Security to send money here." The AA stated Resident 3 needed 24 hour care. The AA stated she did not know the level of care R&B 1 offered and she had not been to the R&B homes. The AA stated she thought because Resident 3 could ambulate, it was a safe placement. On 5/2/17 at 2 p.m., the Adm stated Resident 3's name was brought up in a morning meeting and there was no objection by the IDT to the discharge of Resident 3 from SNF 1. The Adm stated the SSD was responsible to find placement for residents upon discharge and the IDT had an opportunity to object. The Adm stated no one objected to Resident 3's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 43 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 discharge to R&B 1. The Adm stated he was not aware of the previous APS referral, or that Resident 3 had no family. The Adm stated, "I doubt he [Resident 3] ever needed skilled nursing. He has dementia...We sent him to Assisted Living... I really don't know the level of care..." On 5/2/17 at 4:45 p.m., an interview and concurrent record review with the DON was conducted. The DON stated Resident 3's condition had not significantly improved during his stay in SNF 1, and he was not ready for discharge on 2/4/17. On 5/16/17 at 9:50 a.m., during a telephone interview, the owner of R&B 1 stated he accepted Resident 3 at R&B 1 on 2/4/17 but later transferred Resident 3 to R&B 2. The owner of R&B 1 stated Resident 3 started hitting people and needed a higher level of care than he could provide at R&B 1. The owner of R&B 1 stated, "I kept an eye on [him] for half a month." On 5/16/17 at 2:30 p.m., a telephone interview with Resident 3's physician, MD 2, was conducted. MD 2 stated, "I am not sure what drove the discharge." MD 2 stated Resident 3 required the same level of care (after discharge) that was provided in SNF 1. MD 2 stated she went with the recommendation of the staff (to discharge to R&B 1). On 5/16/17 at 3:35 p.m., an interview and concurrent record review was conducted with the Adm. The Adm stated Resident 3's discharge to a B&C probably would have been fine; but not an R&B. The Adm stated, "We didn't do everything right. We didn't do our homework." The ADM stated the facility did not validate the type of services or the level of care provided at any of the R&B's. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 44 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 Due to the actual serious harm related to the unsafe discharge of Resident 1 and Resident 2, and the serious potential harm related to the unsafe discharge of Resident 3, an IJ situation was called on 5/3/17 at 11 a.m., with the Adm, AA, DON and SSD present. The facility provided an acceptable Action Plan addressing the IJ situation on 5/4/17 at 11 a.m. On 5/5/17 at 3:05 p.m., the IJ was removed upon successful demonstration that all the elements of the Action Plan that addressed the immediacy had been initiated, with the Adm, the DON and the SSD present. For Resident 7: Resident 7's face sheet indicated Resident 7 was 55 years old when discharged from SNF 1. Resident 7 was admitted to the facility on 1/30/17, and resided in the facility a total of 29 days. Resident 7's diagnoses included paranoid schizophrenia (mental illness with loss of reality and hallucinations), cellulitis (swollen, inflamed tissue) and wound care to the left ankle. Resident 7's physician discharge orders dated 2/28/17 at 10:11 p.m., indicated, "May discharge as of 3/1/17 with medications and personal effects, home health P.T." The physician discharge order did not indicate where Resident 7 would be discharged to or the level of care required at discharge. Resident 7's Nurses Notes, dated 3/1/17 at 8:10 a.m. indicated, "[owner of R&B 1] is to transport resident to [R&B 3]. Resident 7's Nurses Notes, dated 3/1/17 at 2:45 p.m., indicated, "...RESIDENT REQUIRES DAILY SKILLED NURSING CARE SECONDARY TO CELLULITIS OF LOWER LEFT LIMB...DISCHARGED WITH ALL FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 45 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 PERSONAL AFFECTS AND UNDER THE CARE OF [owner of R&B 1] GROUP HOME." Nurses Notes, dated 3/1/17 at 3:45 p.m. indicated, "[Resident 7] was discharged from the facility today." The note indicated Resident 7's friend and the owner of R&B 1 were both at the facility. The note indicated the owner of R&B 1 was going to transport Resident 7 to R&B 3. On 5/16/17 at 2:55 p.m., a telephone interview with Resident 7's physician, MD 3, was conducted. MD 3 stated, "I rely on the administrator and social services to arrange safe discharge ...I don't make my own decisions." On 5/17/17 at 7:30 a.m., a telephone interview with the owner of R&B 3 was conducted. R&B 3's owner stated Resident 7 was discharged from SNF 1 on 3/1/17 to the owner of R&B 1. The owner of R&B 3 stated the owner of R&B 1 transported Resident 7 from SNF 1 to R&B 3. The owner of R&B 3 stated she runs an R&B, not an Assisted Living or Group Home. She stated Resident 7 required a higher level of care than she could provide. The owner of R&B 3 stated Resident 7 ran down the street in the middle to the night and tried to hide in neighbors' cars. The owner of R&B 3 stated Resident 7's friend had attempted to find her more suitable placement and took her away. The owner of R&B 3 stated she did not know where Resident 7 went after she left R&B 3. On 5/16/17 at 3:35 p.m., an interview and concurrent record review with the Adm was conducted. The Adm stated, "...We didn't do everything right. We didn't do our homework." The ADM stated the facility did not validate the type of services or the level of care provided at FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 46 of 47 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: _______________ 055423 (X3) DATE SURVEY COMPLETED 06/30/2017 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE MANNING GARDENS CARE CENTER, INC. 2113 E Manning Ave Fresno, CA 93725 (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 of the R&B's, and they should have. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 0PDX11 Facility ID: CA040000036 If continuation sheet 47 of 47