Health inspection·June 17, 2025

F 0774 Help the resident with transportation to and from laboratory services outside of the facility. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to assist residents in making transportation arrangements to and from their provider appointments for three of seven sampled residents (Residents 24, 29 and 40) when: Residents Affected - Some 1. Residents 24 and Resident 40 missed their scheduled appointments due to the transportation arriving late and was not the preferred transportation company requested by Resident 24. This failure resulted in Resident 24 and Resident 40 having to re-schedule their appointments for later dates and caused anger and frustration to Resident 24 and Resident 40's Responsible Party (RP). 2. Resident 29 was not picked up from his appointment by the scheduled transportation company. On 5/21/25 Resident 29 left for a 1:00 p.m. appointment at 12:45 p.m. and did not return to the facility until 5:30 p.m. due to Resident 29 waiting four hours for another transportation company to pick him up. This failure had the potential to place Resident 29 at risk of being exposed to harm and resulted in Resident 29 waiting an extended period of time to be picked up from his appointment causing extreme anger and stress to Resident 29. Findings: 1. During a concurrent observation and interview on 6/10/25 at 12:23 p.m. with Resident 24, in Resident 24's room, Resident 24 was observed sitting in a wheelchair, dressed and speaking with her roommate. Resident 24 stated she had been at the facility for two years for a fractured back (broken bone in the spine) and broken femur (thigh bone) and knee. Resident 24 stated she has had trouble with her transportation to appointments. Resident 24 stated on two occasions she had missed her appointments when using (name of transport company, [Company A]) transport. Resident 24 stated she did not want to use that company anymore because she had to reschedule her appointments on two occasions. Resident 24 stated they had been late to pick her up on one of those occasions and the other time she asked about using another transport company, so they did not show up to pick her up and said she refused transportation. Resident 24 stated when she informed the Social Services Designee (SSD), she was told she needed to call and complain to her insurance about the transport company [Company A]. Resident 24 stated she used another transport company [Company B] for her dialysis (a treatment to cleanse the blood of wastes and extra fluids artificially through a machine when the kidney[s] have failed) appointments and had no problems with them, and [Company B] was who she wanted to use for her transportation. During a review of Resident 24's admission Record (AR - a document with personal identifiable and Page 1 of 6 555920 555920 06/17/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some medical information), dated 6/12/25, the AR indicated, Resident 24 was admitted to the facility from an acute care hospital on 9/6/23 with diagnoses of end stage renal disease (a condition where the kidneys can no longer function on their own) and type 2 Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing). During a review of Resident 24's Minimum Data Set (MDS - a federally mandated resident assessment tool), dated 4/10/25, the MDS section C indicated, Resident 24 had a Brief Interview for Mental Status (BIMS - an assessment tool used by facilities to screen and identify memory, orientation, and judgement status of the resident) score of 15 out of 15 (a score of 13-15 indicates cognitively intact, 08-12 indicates moderately impaired, and 00-07 indicates severe impairment, 99 indicates unable to complete the interview), which suggested Resident 24 was cognitively intact. During a concurrent interview and record review on 6/12/25 at 10:31 a.m. with the SSD Resident 24's Progress Notes dated 4/16/25 through 5/30/29 for appointments were reviewed. The Progress Notes indicated, on 5/30/25 Resident 24's appointment at the hospital radiology (use of imaging technology) department was rescheduled. The SSD stated residents could requested preferred transportation company, but it was not guaranteed. The SSD stated Resident 24's complaints were for not having a specific company for her transportation. The SSD stated transportation issues had been brought up with the administrator. During an interview on 6/12/25 at 2:22 p.m. with Certified Nursing Assistant (CNA) 3, CNA 3 stated he had not gone with residents to their appointments but had heard of a bus not showing up to pick up residents. During an interview on 6/12/25 at 3:27 p.m. with the Director of Staff Development (DSD)/Infection preventionist (IP), the DSD/IP stated usually a CNA went with residents to appointments. The DSD/IP stated they have had some issues with the transportation company [Company A or B ]. The DSD/IP stated there was no good communication with [Company A], Company A would just leave without ringing the door bell in the front gate of the facility. During an observation on 6/10/25 at 10:29 a.m. in Resident 40's room, Resident 40 was observed asleep in bed, wearing a gown and ear plugs, Resident 40 did not answer questions asked. During a concurrent observation and interview on 6/10/25 at 11:53 a.m. with Resident 40 and Resident 40's family member (FM) in Resident 40's room, Resident 40 was observed in bed, dressed, wearing ear plugs and eating snacks. The FM stated Resident 40's transportation to appointments had been an issue. The FM stated one time the vehicle had a flat tire and Resident 40 missed his appointment. The FM stated Resident 40 was rescheduled and the SSD did not communicate to Resident 40 or his Responsible Party (RP) about him missing his appointment. During a review of Resident 40's AR, dated 6/12/25, the AR indicated, Resident 40 was admitted to the facility from an acute care hospital on [DATE] with diagnoses of hemiplegia (paralysis [the loss of the ability to move and sometimes to feel anything] of one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), cerebral edema (swelling in the brain), speech disturbances, difficulty walking, anxiety disorder (a mental health disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities), and major depressive disorder (a mental health disorder characterized by persistently depressed mood or loss of interest in activities). 555920 Page 2 of 6 555920 06/17/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During a review of Resident 40's MDS, dated 5/13/25, the MDS section C indicated, Resident 40 had a BIMS score of 10, which indicated Resident 40 was moderately impaired. During an interview on 6/11/25 at 9:05 a.m. with Resident 40's RP, the RP stated Resident 40 had been in the facility since December due to a stroke (cerebrovascular accident [CVA]-stroke, loss of blood flow to a part of the brain). The RP stated there was poor communication with the facility. The RP stated she had a lot of trouble with Resident 40's transportation to appointments and one appointment was for the neuroscience facility (study of the nervous system, including the brain and spinal cord). The RP stated transportation was often late for Resident 40's appointments. The RP stated she tried to go with Resident 40 to his appointments. The RP stated Resident 40's appointments had to be rescheduled when he was late because the transportation picked him up late and the facility did not tell her if Resident 40's appointment was rescheduled. The RP stated one appointment Resident 40 missed was in May and she was not notified. The RP stated she found out later that he missed his appointment and the facility rescheduled him. The RP stated one appointment in March that Resident 40 had rescheduled was for surgery on his skull, a skull replacement after his craniotomy (a surgical removal of part of the bone from the skull to expose the brain) that had been planned for one month. The RP stated she was notified by the physician at the hospital. The RP stated Resident 40 has had four to five issues with his transportation. The RP stated Resident 40 was to be transported in his wheelchair, but the transportation driver did not have the right equipment to fit the wheelchair in the vehicle, so they had to reschedule him. The RP stated the transportation driver came and pressed the button to enter facility, and no one at the facility knew Resident 40 had an appointment. The RP stated this happened last month. During a concurrent interview and record review on 6/12/25 at 10:31 a.m. with the SSD Resident 40's Progress Notes, dated 5/21/25 indicated , .(resident name) missed his appointment due to transportation issues. The SSD stated residents were schedule with a diagnosis code which the transportation company used to determine what type of vehicle to transport the resident in. The SSD stated Resident 40 used a special wheelchair that was large and allowed resident to recline. Resident 40 was picked up by transport in a small van which did not accommodate Resident 40 and was not able to transport Resident 40 to his appointment, which needed to be rescheduled. The SSD stated she notified the RP of Resident 40's rescheduled appointments, but did not document her conversations with Resident 40's RP. 2. During a concurrent observation and interview on 6/10/25 at 12:47 p.m. with Resident 29 in Resident 29's room, Resident 29 was observed dressed, sitting in a wheelchair, eating his meal. Resident 29 stated he had been at the facility for six months due to a fall injury to his leg and he could not walk. Resident 29 stated he had a transportation issue when the transport company did not pick him up after his provider appointment. Resident 29 stated he waited to be picked up from 1:00 p.m. until 5:30 or 6:30 p.m. Resident 29 stated the staff at the provider's office were getting ready to close and go home when they noticed he was still there and told him You're still here?. Resident 29 stated he had to call a taxi to get picked up and the facility did not tell him what happened. Resident 29 stated his sister usually took him to appointments but was unable to at that time. Resident 29 stated he felt terrible and was pissed he had to wait so long. Resident 29 stated he had not had any more appointments since then and hoped it did not happen again. During a review of Resident 29's AR, dated 6/12/25, the AR indicated, Resident 29 was admitted to the facility from an acute care hospital on 7/25/24 with diagnoses of Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks), Hydrocephalus (a condition in which fluid accumulates in the brain, enlarging the 555920 Page 3 of 6 555920 06/17/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some head and sometimes causing brain damage), type 2 Diabetes Mellitus, congestive heart failure (CHF-a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling), shortness of breath, and difficulty walking. During a review of Resident 29's MDS, dated 5/6/25, the MDS section C indicated, Resident 29 had a BIMS score of 14, which indicated Resident 29 was cognitively intact. During a review of Resident 29's Progress Notes, dated 5/21/25, the Progress Notes indicated, . Effective date: 5/21/25 12:43 (p.m.) .resident leave of absence (LOA) to scheduled appointment. Resident picked up by (name of independent transport company) and went to appointment alone . effective date: 5/21/25 17:30 (p.m.) . resident arrived to facility at 1730 . During an interview on 6/10/25 at 3:17 p.m. with the Administrator (ADM), the ADM stated he had not had any complaints on the transportation company the facility used. The ADM stated the facility called the residents to see if they were ready to be picked up after their appointments. During a concurrent interview and chart review on 6/12/25 at10:31 a.m. with the SSD, Resident 29's Progress Notes, dated 4/30/25, the Progress Notes indicated, . Effective date: 4/30/25 .(resident name) had an appointment on 5/21/25 at (@) 1:00 p.m. sister will assist with (w/) transportation . author: (SSD) . The SSD stated there were a few ambulatory residents who had a cell phone, and if they went alone and used the independent transportation company, the transportation company would send a link to the resident who needed to open the link to see when the transport would arrive. The SSD stated Resident 29 was normally accompanied by his sister and Resident 29 did not know how to use his phone to open the link. The SSD stated the provider's office called her regarding Resident 29 and informed her Resident 29 was still at their office after Resident 29 should have been picked up. The SSD stated she had to call a private company to pick up Resident 29, but he waited an additional hour. The SSD stated transportation issues had been brought up to the administrator. During an interview on 6/12/25 at 2:41 p.m. with LVN 2, LVN 2 stated he looked at the communication board in the computer to see which residents had appointments. LVN 2 stated he would add a note in LOA Via Transport in the system when the resident left and when the resident returned from the appointment. LVN 2 stated he did not log in the Resident Out on Pass Log. LVN 2 state if the resident was not back from their appointment at the estimated return time, he called the provider's office to verify if the resident was still there. LVN 2 stated if the resident was fully alert and went by themselves to the appointment, he called the cell phone of the resident. LVN 2 stated one resident was ready to return from his appointment in 15 min from his appt time, and they had to call the driver to turn around and pick up the resident, but the resident had to wait. During a concurrent interview and record review on 6/17/25 at 9:09 a.m. with the DON, the Resident Out On Pass Log (LOA), dated 3/30/25 to 5/30/25 was reviewed. The LOA indicated, Time out, Licensed Nurse Initials, Expected Return Time, Time Returned, and Licensed Nurse Initials were not filled in. The [NAME] stated the Charge Nurse was responsible for a resident's timely return. The DON stated an estimated time was given for resident appointments. The DON stated the nurses were responsible for making sure the AOL log was complete for resident's departure and return. The DON stated the LOA log was important to make sure the resident came back at the estimated time, and for the safety of the resident to make sure the resident returned unharmed. The DON stated nurses needed to perform an assessment of the resident when the resident left and when they returned, to be sure the resident was not harmed. The DON stated she did not recommend residents use the independent transportation company to go to appointments. The DON stated communication was not being sent to the SSD and residents 555920 Page 4 of 6 555920 06/17/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had to wait longer to be picked up from their appointments. The DON stated the communication issues and wait times could not be continued. The DON stated if a resident had to wait extended periods of time to be picked up, it could have added more stress to the resident, even if the resident had a high BIMS score. The DON stated the SSD was responsible for resident's transportation to and from appointments, but overall, the DON was responsible for the residents. The DON stated her expectation was for the SSD to notify the resident's RP if the resident missed an appointment. The DON stated it was important for the RP to be notified so they were aware of what was going on with the resident and that proper care was given to the resident. The DON stated if the resident had missed appointments, it could have caused a delay of treatment to the resident. The DON stated the communication with the RP should have been documented in the resident's chart regarding any missed appointments. The DON stated if the communication was not documented, it did not happen. During an interview on 6/17/25 at 9:41 a.m. with the Administrator (ADM) and the Assistant Administrator (AA), the ADM stated his expectation was for transportation to be scheduled through the third-party transportation company. The ADM stated he had not received any complaints regarding using the third-party transportation company. The ADM stated nurses were to assess the resident to see if they could go by themselves to their appointment and if they were able to transfer themselves in and out of the car. The ADM stated if the resident was not self-transferable, a CNA should have gone with the resident for safety. The ADM stated residents were not usually assessed if they were able to use their cell phone for opening texted links from the transportation company. The AA stated they monitored the resident's return time depending on the approximate time given for the appointment and when the resident left the facility. The AA stated the LOA log was not filled out for appointments, but only if the resident was leaving with a family member. The AA stated the LOA log should have been filled in anytime the resident left the facility, even for appointments. The ADM stated the facility called residents to see if they were ready to be picked up after their estimated appointment time frame. The AA stated the nurse was made aware of when the resident came back. The AA stated she was aware of Resident 29 not being picked up timely and had been trying to get another transportation company to go pick up Resident 29. The ADM stated residents could have gotten anxious about not getting picked up from their appointment. The ADM stated the ADM and AA were responsible for resident safety when they left the facility. The ADM stated if a resident regularly went alone to an appointment, then they could have gone by themselves, but it was a risk for the resident's safety if the resident was waiting for a long period of time to be picked up. The ADM stated they were responsible for communication between both parties, the provider's office and the transportation company. The ADM stated usually nurses would have noticed a resident had not returned from their appointment during medication pass and the CNAs should have noticed when they did their rounds to see if the resident was taking a long time at an appointment. The ADM stated staff should have notified the nurse and called the office and resident, if they had a cell phone to see if they were okay. During an interview on 6/17/25 at 11:45 a.m. with the ADM, the ADM stated for department head training they have resource consultants and other building staff that could have come and trained new department heads. The ADM stated the SSD had the previous SSD train her before she left. The ADM stated as a new staff department head, the SSD will need to focus on priorities and have time to get their system down. The ADM stated he felt the SSD needed some more training. During a record review of the Social Services Professional Competency Evaluation (CE), dated 2/10/25, the CE indicated, . (SSD Name) . will need more support and continuing training . needs ongoing education . During a review of the facility's job description titled, SSD dated 2023, the job description 555920 Page 5 of 6 555920 06/17/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0774 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some indicated, .The Social Service Designee will assist residents in obtaining transportation to medical appointments, upon discharge . During a review of the facility's job description titled, Charge Nurse, undated, the job description indicated, .schedules follow up appointments for residents and transportation needs as indicated .reports any incidents or unusual occurrences to the supervisor, unit manager, assistant director or nursing or director of nursing and participates in the investigative process as needed . During a review of the facility's job description titled, Director of Nursing, undated, the job description indicated, .plans, develops, organizes, implements, evaluates and directs the overall operations of the Nursing Services department, as well as its programs and activities .evaluates work performance of all nursing personnel .ensures delivery of compassionate quality care and nursing supervision .collaborates with members of the interdisciplinary team . to identify and resolve issues and improve the quality of services .communicates directly with residents, medical and nursing staff, family members, department heads and members of the interdisciplinary team to coordinate care and services and respond to and resolve complaints and concerns . During a review of the facility's job description titled, Administrator, undated, the job description indicated, .plans, develops, organizes, implements, evaluates and directs the overall operation of the facility as well as its programs and activities .leads and coordinates daily, weekly, bi-monthly or monthly management team meetings to discuss priorities and develop solution with facility leaders such as . customer satisfaction .evaluates work performance of department heads and maintains accountability across all departments .for expected performance outcomes in each respective department .ensures delivery of compassionate quality care and services across an interdisciplinary team approach as evidenced by adequate, and competent facility staff . During a review of the facility's policy and procedure (P&P) titled, Transporting a Resident dated 2025, indicated, .it is the policy of this facility to provide residents safe, non-emergency transportation to doctor's appointments, activity outings, and any other trips the facility deems necessary . facility will ensure that residents who require an escort to appointments, due to cognitive or physical limitations, have arrangements ahead of time . During a review of the facility's P&P titled, Competency Evaluation, dated 2025, indicated, .it is the policy of this facility to evaluate each employee to assure they meet appropriate competencies and skills for performing their job .the knowledge and skills required among staff to meet residents' needs are determined through the facility assessment process .initial competency is evaluated during the orientation process. An employee remains on orientation until all competencies are verified . 555920 Page 6 of 6