Health inspection·February 26, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure resident rights were exercised for two of four sampled residents (Resident 1 and Resident 2), when Resident 1 and Resident 2 were denied the opportunity to reheat their food brought in by family past 7:00 p.m. This failure resulted in Resident 1 and Resident 2's rights not having access to reheat their food past 7:00 p.m. causing anger by not recognizing Resident 1 and Resident 2's individuality and autonomy. Findings: During a review of Resident 1's admission Record (AR- a summary of information regarding a resident which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the AR indicated, Resident 1 was admitted to the facility on [DATE] with diagnosis for Major Depressive Disorder (intense feeling of sadness), Morbid Obesity (excessive weight), Anxiety (excessive worry and fear), Bipolar disorder (mood swings including sadness and anger). During a review of Resident 1's Minimum Data Set [MDS a resident assessment tool used to identify cognitive (mental processes) and physical functional level assessment] dated 1/15/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 15 out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 1 was cognitively intact. During an interview on 2/26/25 at 11:08 a.m. with Resident 1, Resident 1 stated there was no microwave in the facility to assist in reheating his food. Resident 1 stated the facility staff would use the microwave located in the staff breakroom to heat up residents' foods, but the microwave had since stopped functioning . Resident 1 stated the facility staff informed him they were not supposed to assist him with reheating his food. Resident 1 stated he felt angry when he could not reheat his food while in the facility. During a review of Resident 2's AR, the AR indicated, Resident 2 was admitted to the facility on [DATE] diagnosis for type 2 diabetes mellitus (disease that causes high blood sugar), anemia (low iron in the blood). During a review of Resident 2's MDS dated [DATE], the MDS indicated, Resident 2's BIMS score was 14 Page 1 of 3 555920 555920 02/26/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some out of 15 (0 - 7 indicated severe cognitive impairment [memory loss, poor decision making skills] 8 12 moderate cognitive impairment, (13 -15) cognitively intact) which indicated Resident 2 was cognitively intact. During an interview on 2/26/25 at 11:12 a.m. with Resident 2, Resident 2 stated the facility staff had informed him the microwave that was previously used to reheat resident food was not working . Resident 2 stated he was informed by facility staff that they were no longer allowed to assist in reheating resident foods. Resident 2 stated he felt angry because he did not have the ability to reheat the food himself and the facility was not accommodating his request to reheat his food after dinner. Resident 2 stated he was offered facility snacks at night instead of being allowed to consume his own food due to the lack of resources available to reheat his food. During a review of Resident 1's, Dietary Note, dated 2/26/25, the note indicated, . certified dietary manager (CDM) and assistant administrator were in hall and [Resident 1] had asked how he could heat up his food. Assistant administrator stated that the facility had to remove his personal microwave from his room for safety reasons. CDM explained that foods prepared outside the kitchen could not be re-heated in the kitchen . During an interview on 2/26/25 at 11:34 a.m. with certified nursing assistant (CNA) 1, CNA 1 stated the facility microwave used to reheat residents' food, was broken. CNA 1 stated the facility process was to not reheat residents' food and instead the food would be taken to the kitchen and request for the dietary staff to reheat residents' food. During an interview on 2/26/25 at 12:00 p.m. with the assistant administrator (AADM) the AADM stated the facility did not have a microwave for resident use. The AADM stated the facility process was for the staff to take resident food to the kitchen for reheating. The AADM stated the kitchen staff were in the facility only until 7:00 p.m. and there was no dietary staff present after that time. The AADM stated, she was not comfortable with the facility staff reheating resident food as the staff were not trained on proper reheating of food. The AADM stated residents did not have access to reheating food after 7:00 p.m. During a telephone interview on 3/5/25 at 3:15 p.m. with CNA 2, CNA 2 stated the facility process was for the staff to not reheat any food for residents. CNA 2 stated the facility staff was supposed to take food to the kitchen to be reheated by the dietary staff. CNA 2 stated the facility staff was told not to reheat residents' food and instead give residents the snacks that were provided from the kitchen. CNA 2 stated there was no microwave available to reheat residents' foods. During a telephone interview on 3/7/25 at 11:46 a.m. with the administrator (ADM), the ADM stated the facility did not have a microwave for resident use after 8:00 p.m. The ADM stated the facility process was for the dietary staff to reheat resident food while they were working in the facility. The ADM stated the residents had the opportunity to ask facility staff to reheat their food before 8 p.m. The ADM stated the dietary staff should have been the only staff reheating resident food as the CNAs were not properly trained to reheat resident food. The ADM stated residents did not have the option to reheat food between the hours of 8:00 p.m. and 4:00 a.m. as there was no dietary staff available to assist resident needs. During a record review of the facility's policy and procedure (P&P) titled, Foods brought by Family/Visitors, dated 2001, the P&P indicated, . Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the 555920 Page 2 of 3 555920 02/26/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some nutritional and safety needs of residents. family members and visitors are asked to inform nursing staff when foods are brought for a resident . safe food handling practices are explained to family/visitors in a language and format they understand. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility prepared food . During a record review of the facility's P&P titled, Resident Rights, dated 2025, the P&P indicated, . The resident has the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility . The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice . The resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident . The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely . 555920 Page 3 of 3