Health inspection·December 1, 2023

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm Based on interview and record review, the facility failed to ensure residents were provided care and services according to acceptable standards of clinical practice for one of seven sampled residents (Resident 6), when Resident 6 was admitted with Pressure ulcers (an injury that break down the skin and underlying tissue) on 9/21/2023. The admission skin assessment indicated the skin was intact and the treatments for pressure ulcers did not start till 9/27/2023. Residents Affected - Few This failure resulted in a delay of treatment and care for Resident 6 ' s pressure ulcers which had the potential for worsening, developing infections and death. Findings: During a review of Resident 6 ' s Face Sheet (FS- a document that gives a Patient ' s information at a quick glance) dated 9/21/23, the FS indicated, .Pressure ulcer sacral region (area by the tailbone), stage 3 (a stage of pressure ulcer development where the top two layers of skin down to the fatty areas are opened and exposed) . Pressure ulcer left ankle, unstageable (cannot be staged), Pressure-Induced Deep Tissue Damage (a form of pressure ulcer or pressure sore) of Right Heel, Pressure Ulcer of Left Heel, Unstageable . During a review of Discharge Note (DN) from the General Acute Care Hospital (GACH) dated 9/21/23, the DN indicated, .Wounds .Coccyx (tailbone) . Wound Heel Left .Wound Heel Right . Wound Ankle Anterior, Left . During a record review on 11/9/23 at 4:20 p.m. of Resident 6 ' s admission Assessment Record (AR), dated 9/21/23 at 7:34 p.m. was reviewed. The AR indicated, .Coccyx-red, blanchable (to turn pale) no open area. Discoloration (lighter in color). Left Heel-Red, blanchable dry flaky skin no open area. Right Heel-red, blanchable dry flaky skin no open area. Other-scattered bruising to BUE (bilateral upper extremity) dry flaky skin throughout . During a record review of Resident 6 ' s Weekly Nursing Summary (WNS), dated 9/22/23 at 9:44 p.m., the WNS indicated, .No new skin issues since recent admission . During a record review of Resident 6 ' s WNS, dated 9/24/23 at 10:41 p.m., the WNS indicated, .Pressure ulcer to coccyx . During a record review of Resident 6 ' s Interdisciplinary-Baseline Care Plan (IDT- a group of health care professional who work together toward the goals of their patients), dated 9/25/2023, on the IDT ' s Skin Concerns Area, the IDT indicated, Skin intact. Page 1 of 8 555920 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a concurrent interview and record review on 11/9/23 at 4:30 p.m. with DON, Resident 6 ' s Weekly Pressure Ulcer BWAT Report (WPUBR), dated 9/27/23 at 5:21 p.m. was reviewed. The WPUBR indicated, .Coccyx-Pressure .Stage III . The DON stated a wound consult for the coccyx and heel was ordered on 9/27/23. During a telephone interview on 12/1/23 at 4:00 p.m. with the DON, the DON stated, the initial assessment done by the nurse that was documented on the AR dated 9/21/23 was inaccurate. The DON stated, accurate assessments should have been done at the beginning so that proper treatment plans could be developed without delay. During a record review of Resident 6 ' s Order Summary (OS), dated 9/27/23, the OS indicated, Medihoney (a medication made of honey) Wound/Burn/Dressing External Gel- Apply to Sacrococcygeal (area on and around the tailbone) ulcer in the evening, everyday. The OS indicated, Pressure ulcer of left heel .Apply heel protector and float heels while in bed. During a record review of Resident 6 ' s Integumentary Assessment Sheet (IAS), dated 9/29/23, the IAS indicated, a diabetic ulcer (a open sore caused by diabetes [a disease where sugar in the blood is too high]) on the left ankle, a stage III ulcer wound on the sacrococcygeal area, and a diabetic ulcer on left heel. During a review of the facility ' s policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated, 4/2018, indicated, P&P indicated, .The nursing staff and practitioner will assess and document an individual ' s significant risk factors .the nurse shall describe and document/report .full assessment of pressure sore including location, stage, length, width and depth .and all active diagnoses .the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure or other skin conditions . During a review of Lippincott Nursing Center, dated 09/09, .All patients should be assessed on admission and re-assessed at least every 24 hours, and with any changes in their clinical status . During a review of document titled Pressure Ulcers: Prevention, and Evaluation and management dated 11/15/2008, from website https://www.aafp.org/pubs/afp/issues/2008/1115/p1186.html, indicated, .documenting each ulcer (i.e. size, location, stage) .are essential to wound assessment . Based on interview and record review, the facility failed to ensure residents were provided care and services according to acceptable standards of clinical practice for one of seven sampled residents (Resident 6), when Resident 6 was admitted with Pressure ulcers (an injury that break down the skin and underlying tissue) on 9/21/2023. The admission skin assessment indicated the skin was intact and the treatments for pressure ulcers did not start till 9/27/2023. This failure resulted in a delay of treatment and care for Resident 6's pressure ulcers which had the potential for worsening, developing infections and death. Findings: During a review of Resident 6's Face Sheet (FS- a document that gives a Patient's information at a quick glance) dated 9/21/23, the FS indicated, .Pressure ulcer sacral region (area by the tailbone), stage 3 (a stage of pressure ulcer development where the top two layers of skin down to the fatty areas are opened and exposed) . Pressure ulcer left ankle, unstageable (cannot be staged), 555920 Page 2 of 8 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Pressure-Induced Deep Tissue Damage (a form of pressure ulcer or pressure sore) of Right Heel, Pressure Ulcer of Left Heel, Unstageable . During a review of Discharge Note (DN) from the General Acute Care Hospital (GACH) dated 9/21/23, the DN indicated, .Wounds .Coccyx (tailbone) . Wound Heel Left .Wound Heel Right . Wound Ankle Anterior, Left . During a record review on 11/9/23 at 4:20 p.m. of Resident 6's admission Assessment Record (AR), dated 9/21/23 at 7:34 p.m. was reviewed. The AR indicated, .Coccyx-red, blanchable (to turn pale) no open area. Discoloration (lighter in color). Left Heel-Red, blanchable dry flaky skin no open area. Right Heel-red, blanchable dry flaky skin no open area. Other-scattered bruising to BUE (bilateral upper extremity) dry flaky skin throughout . During a record review of Resident 6's Weekly Nursing Summary (WNS), dated 9/22/23 at 9:44 p.m., the WNS indicated, .No new skin issues since recent admission . During a record review of Resident 6's WNS, dated 9/24/23 at 10:41 p.m., the WNS indicated, .Pressure ulcer to coccyx . During a record review of Resident 6's Interdisciplinary-Baseline Care Plan (IDT- a group of health care professional who work together toward the goals of their patients), dated 9/25/2023, on the IDT's Skin Concerns Area, the IDT indicated, Skin intact. During a concurrent interview and record review on 11/9/23 at 4:30 p.m. with DON, Resident 6's Weekly Pressure Ulcer BWAT Report (WPUBR), dated 9/27/23 at 5:21 p.m. was reviewed. The WPUBR indicated, .Coccyx-Pressure .Stage III . The DON stated a wound consult for the coccyx and heel was ordered on 9/27/23. During a telephone interview on 12/1/23 at 4:00 p.m. with the DON, the DON stated, the initial assessment done by the nurse that was documented on the AR dated 9/21/23 was inaccurate. The DON stated, accurate assessments should have been done at the beginning so that proper treatment plans could be developed without delay. During a record review of Resident 6's Order Summary (OS), dated 9/27/23, the OS indicated, Medihoney (a medication made of honey) Wound/Burn/Dressing External Gel- Apply to Sacrococcygeal (area on and around the tailbone) ulcer in the evening, everyday. The OS indicated, Pressure ulcer of left heel .Apply heel protector and float heels while in bed. During a record review of Resident 6's Integumentary Assessment Sheet (IAS), dated 9/29/23, the IAS indicated, a diabetic ulcer (a open sore caused by diabetes [a disease where sugar in the blood is too high]) on the left ankle, a stage III ulcer wound on the sacrococcygeal area, and a diabetic ulcer on left heel. During a review of the facility's policy and procedure (P&P) titled, Pressure Ulcers/Skin Breakdown-Clinical Protocol, dated, 4/2018, indicated, P&P indicated, .The nursing staff and practitioner will assess and document an individual's significant risk factors .the nurse shall describe and document/report .full assessment of pressure sore including location, stage, length, width and depth .and all active diagnoses .the staff and practitioner will examine the skin of newly admitted residents for evidence of existing pressure or other skin conditions . 555920 Page 3 of 8 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0658 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During a review of Lippincott Nursing Center, dated 09/09, .All patients should be assessed on admission and re-assessed at least every 24 hours, and with any changes in their clinical status . During a review of document titled Pressure Ulcers: Prevention, and Evaluation and management dated 11/15/2008, from website https://www.aafp.org/pubs/afp/issues/2008/1115/p1186.html, indicated, .documenting each ulcer (i.e. size, location, stage) .are essential to wound assessment . 555920 Page 4 of 8 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure appropriate treatment and services were provided for two of seven sampled residents (Resident 2 and 5 ) when: 1. Resident 5 ' s tube feeding container and water bag (a bag filled with water attach to the feeding tube to clear the tube) was not labeled with name of the resident, the type of formula and the rate per physician ' s order. This failure placed Resident 5 at risk for receiving the wrong formula resulting in malnutrition and dehydration. 2. Resident 2 ' s G-tube (gastrostomy tube-a tube that is connected to the stomach or intestines used provide nutrition to a person) was observed to have brown, beige matter build up around the connection port. This failure placed resident 2 at risk for infection where bacteria (microscopic organisms) from the matter build up on the connector sites of the G-Tube travel down to the insertion site and into the stomach. Findings: 1. During a concurrent observation and interview on [DATE] at 12:56 p.m. with the Director of Staff Development (DSD), inside Resident 5 ' s room, no stickers or labels were observed on the Jevity (a fiber-fortified tube-feeding formula) container and water bag for the resident. The DSD validated there were no labels on the feeding bag and water bag. DSD stated, the labels should have been placed when the feeding and tubing were changed. During an interview of on [DATE] at 4:16 p.m. with the Licensed Vocational Nurse/Infection Control (LVN/IP), the LVN/IP stated nurses should make sure the labeling reflected Physician ' s orders. The LVN/IP stated the tube feeding container and water bag should be labeled with resident name, physician ' s order, and flush (water needed to clear the G-tube) that reflects the physician ' s orders. The LVN/IP states, it was important to provide proper labeling to make sure the residents were getting the correct formula, volume, and rate per physician ' s order. During an interview on [DATE] at 5:35 p.m. with the Director of Nursing (DON), the DON stated, the Jevity bag needed a label which includes name, date, and the kind of formula the resident should be receiving. The DON states, it was not an acceptable practice for nurses to start the feeding without labeling the container because nurses would not know when the feeding was started which could lead to Resident 5 receiving expired formula. The facility did not provide Policy and Procedure (P&P) on management of tube feed labeling procedures. During a review of the American Society for Parenteral and Enteral Nutrition (ASPEN), dated [DATE], ASPEN indicated, .Practice Recommendations 1. Include all the critical elements of the EN (Enteral Nutrition- nutrition delivered directly into the stomach or intestines) order on the EN label: 555920 Page 5 of 8 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few patient identifiers, formula type, enteral delivery site (route and access), administration method and type, and volume and frequency of water flushes .EN products must be labeled to identify the intended patient, date of feeding, and duration of feeding . 2. During a concurrent observation and interview on [DATE] at 12:00 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 2 ' s room, Resident 2 ' s G-tube was observed to have dark, brown matter build up around the connector sites. CNA 1 stated, there ' s dark, brown build up. CNA 1 stated it should be cleaned. During an interview on [DATE] at 4:16 p.m. with the LVN/IP, the LVN/IP stated, The tube looks like it didn ' t get properly flushed. LVN/IP validated the shade of beige and brown build up on Resident 2s G-tube was from tube feed. The LVN/IP stated, this is not acceptable. The LVN/IP stated, the tube must be flushed after each feeding to ensure the bacteria would not grow from the remaining tube feed which could cause infection from bacterial growth. The LVN/IP stated the tube should be cleaned with a damp 2x2 gauze. During an interview on [DATE] at 5:35 p.m. with the DON, the DON validated the brown build up on the connector port of the G-tube might be dry feeding formula. DON stated, It should be cleaned. The DON stated this could cause infections if the tube was not clean. During a record review of the facility ' s policy and procedure (P&P) titled, Enteral Nutrition, dated [DATE], the P&P indicated, .Staff caring for residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube . During a review of the National Library of Medicine article titled, Enteral Tube Feeding and Infection Control: how safe is our practice?, dated [DATE], the article indicated, .poor .handling procedures are still identified as the main source of contamination indicating that there is a gap between practice and recommended standards of care. Nurses have a vital role to play implementation appropriate standards of care and in minimizing risks of bacterial contamination in enteral feeding systems . Based on observations, interviews, and record reviews, the facility failed to ensure appropriate treatment and services were provided for two of seven sampled residents (Resident 2 and 5 ) when: 1. Resident 5's tube feeding container and water bag (a bag filled with water attach to the feeding tube to clear the tube) was not labeled with name of the resident, the type of formula and the rate per physician's order. This failure placed Resident 5 at risk for receiving the wrong formula resulting in malnutrition and dehydration. 2. Resident 2's G-tube (gastrostomy tube-a tube that is connected to the stomach or intestines used provide nutrition to a person) was observed to have brown, beige matter build up around the connection port. This failure placed resident 2 at risk for infection where bacteria (microscopic organisms) from the matter build up on the connector sites of the G-Tube travel down to the insertion site and into the stomach. 555920 Page 6 of 8 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0693 Findings: Level of Harm - Minimal harm or potential for actual harm 1. During a concurrent observation and interview on [DATE] at 12:56 p.m. with the Director of Staff Development (DSD), inside Resident 5's room, no stickers or labels were observed on the Jevity (a fiber-fortified tube-feeding formula) container and water bag for the resident. The DSD validated there were no labels on the feeding bag and water bag. DSD stated, the labels should have been placed when the feeding and tubing were changed. Residents Affected - Few During an interview of on [DATE] at 4:16 p.m. with the Licensed Vocational Nurse/Infection Control (LVN/IP), the LVN/IP stated nurses should make sure the labeling reflected Physician's orders. The LVN/IP stated the tube feeding container and water bag should be labeled with resident name, physician's order, and flush (water needed to clear the G-tube) that reflects the physician's orders. The LVN/IP states, it was important to provide proper labeling to make sure the residents were getting the correct formula, volume, and rate per physician's order. During an interview on [DATE] at 5:35 p.m. with the Director of Nursing (DON), the DON stated, the Jevity bag needed a label which includes name, date, and the kind of formula the resident should be receiving. The DON states, it was not an acceptable practice for nurses to start the feeding without labeling the container because nurses would not know when the feeding was started which could lead to Resident 5 receiving expired formula. The facility did not provide Policy and Procedure (P&P) on management of tube feed labeling procedures. During a review of the American Society for Parenteral and Enteral Nutrition (ASPEN), dated [DATE], ASPEN indicated, .Practice Recommendations 1. Include all the critical elements of the EN (Enteral Nutrition- nutrition delivered directly into the stomach or intestines) order on the EN label: patient identifiers, formula type, enteral delivery site (route and access), administration method and type, and volume and frequency of water flushes .EN products must be labeled to identify the intended patient, date of feeding, and duration of feeding . 2. During a concurrent observation and interview on [DATE] at 12:00 p.m. with Certified Nursing Assistant (CNA) 1 in Resident 2's room, Resident 2's G-tube was observed to have dark, brown matter build up around the connector sites. CNA 1 stated, there's dark, brown build up. CNA 1 stated it should be cleaned. During an interview on [DATE] at 4:16 p.m. with the LVN/IP, the LVN/IP stated, The tube looks like it didn't get properly flushed. LVN/IP validated the shade of beige and brown build up on Resident 2 s G-tube was from tube feed. The LVN/IP stated, this is not acceptable. The LVN/IP stated, the tube must be flushed after each feeding to ensure the bacteria would not grow from the remaining tube feed which could cause infection from bacterial growth. The LVN/IP stated the tube should be cleaned with a damp 2x2 gauze. During an interview on [DATE] at 5:35 p.m. with the DON, the DON validated the brown build up on the connector port of the G-tube might be dry feeding formula. DON stated, It should be cleaned. The DON stated this could cause infections if the tube was not clean. During a record review of the facility's policy and procedure (P&P) titled, Enteral Nutrition, dated [DATE], the P&P indicated, .Staff caring for residents with feeding tubes are trained on how to 555920 Page 7 of 8 555920 12/01/2023 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0693 recognize and report complications associated with the insertion and/or use of a feeding tube . Level of Harm - Minimal harm or potential for actual harm During a review of the National Library of Medicine article titled, Enteral Tube Feeding and Infection Control: how safe is our practice? , dated [DATE], the article indicated, .poor .handling procedures are still identified as the main source of contamination indicating that there is a gap between practice and recommended standards of care. Nurses have a vital role to play implementation appropriate standards of care and in minimizing risks of bacterial contamination in enteral feeding systems . Residents Affected - Few 555920 Page 8 of 8