Health inspection·July 9, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to provide adequate supervision to ensure safety for one of four sampled residents (Resident 1), when Resident 1 had an order for a one to one staff member supervision due to a physical altercation and the facility did not have staff scheduled on 7/6/25 for the afternoon shift (PM- 2:45 p.m.-11:15 p.m.), 7/6/25 for the night shift (10:45 p.m.-7:00 p.m.) and no staff scheduled for one to one on 7/7/25 afternoon shift.This failure placed Resident 1 at risk for injury from further altercations that could have occurred in the facility.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), Anxiety (excessive worry and fear), Blindness (both eyes), Glaucoma (eye condition that damages the nerves), hearing loss.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 6/12/2025, the MDS indicated, Resident 1's Brief Interview for Mental Status (BIMS screening tool used to assess resident cognitive level) score was 14 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 7/8/25 at 2:21 p.m. with Resident 1, in Resident 1's room, Resident 1 recalled events that transpired in the facility. Resident 1 stated the bathroom was shared with the room next door as it had an entry door in both rooms. Resident 1 stated that on 7/1/25 he went to use the restroom, knocked on the door and since no one answered he proceeded to enter. Resident 1 stated he was pulling up his pants, when suddenly the restroom door leading into Resident 2's room opened. Resident 1 stated he then heard Resident 2 yelling profanity and slammed the restroom door. Resident 1 stated, Resident 2 was then heard yelling profanity and demanding that Resident 1 go to his room. Resident 1 stated he is blind and could not see what was happening and proceeded to tell Resident 2, to come toward him. Resident 1 stated, shortly after he felt punches on his body and began hitting back. Resident 1 stated he felt like he had hit Resident 2 once, but did not know where. Resident 1 stated he proceeded to pull up his pants once again when he suddenly felt two hands on his chest push him back causing him to fall and hit his head on the bathroom counter. Resident 1 stated that since the incident the facility had assigned a one to one staff member to him for safety but stated staff were not present every shift. Resident 1 stated there was no one to one staff assigned at times during the night. Resident 1 stated he would call out for staff prior to going to use the restroom multiple times throughout the night but no one was present to assist him.During a review of Resident 1's, Altercation Care Plan (CP), dated 7/1/25, the CP indicated, . Resident had an altercation with another resident. interventions: 1 to 1 Page 1 of 3 555920 555920 07/09/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few close monitoring.During a review of Resident 1's, Order Summary report, dated 7/3/25, the Order Summary report indicated, . one to one monitoring.During a concurrent observation, interview and record review on 7/8/25 at 3:02 p.m. with the director of staff development (DSD), the facility schedule for staff dated 7/1/25-7/7/25 were reviewed on the DSD's computer documents. The staff schedules were not printed and indicated there was not a one on one staff member scheduled for 7/6/25 for the afternoon shift, 7/6/25 for the night shift and no staff scheduled for one to one on 7/7/25 afternoon shift. The DSD stated the schedules were not printed because they were kept on her computer. The review of the employee schedule on the computer, the one on one staff were not documented on the schedule. The DSD stated there were staff present in the facility for a one on one for the dates indicated but staff were not added to the schedule and staff had not signed in to the shift as working a one to one.During a concurrent interview and record review on 7/8/25 at 3:29 p.m. with licensed vocational nurse (LVN) 1, Resident 1's, Altercation Care Plan (CP), dated 7/1/25 and Order Summary report, dated 7/3/25. The CP indicated, . Resident had an altercation with another resident. interventions: 1 to 1 close monitoring. The Order Summary report indicated, . one to one monitoring. LVN 1 stated Resident was supposed to have a one-to-one staff member at all times. LVN 1 stated the purpose of the one-on-one staff member assigned to Resident 1 was to prevent further altercations and to ensure Resident 1's safety.During an interview on 7/8/25 at 3:35 p.m. with certified nursing assistant (CNA) 1, CNA 1 stated Resident 1 was assigned a one to one staff member at all times. CNA 1 stated the role of the one to one was to remain with the resident at all times and when the staff member assigned needed to step away, another staff member would have to go and stay with Resident 1. CNA 1 stated it was important to follow the one to one order to keep Resident 1 safe and to prevent further altercations with Resident 2.During an interview on 7/8/25 at 3:57 p.m. with the director of nursing (DON), the DON stated Resident 1 had an order for a one-to-one staff member at all times until further notice. The DON stated there was no set schedule for the one to one, the staff was being scheduled on a daily basis through a group text message. The DON stated once a one to one staff member was found for the shifts, the DON would be notified.During a review of the facility's policy and procedure (P&P) titled, Accidents and Supervision, dated 2022, the P&P indicated, . The resident environment will remain as free of accident hazards as is possible. Each resident will receive adequate supervision and assistive devices to prevent accidents. This includes. Implementing interventions to reduce hazard(s) and risk(s). Environment refers to any environment or area in the facility that is frequented by or accessible to residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas, and activity areas. Supervision/Adequate Supervision refers to intervention and means of mitigating risk of an accident. Implementation of Interventions- using specific interventions to try to reduce a resident's risks from hazards in the environment. The process includes. Communicating the interventions to all relevant staff, assigning responsibility. Ensuring that the interventions are put into action. Monitoring is the process of evaluating the effectiveness of care plan interventions. Ensuring that interventions are implemented correctly and consistently. Supervision is an intervention and a means of mitigating accident risk. The facility will provide adequate supervision to prevent accidents. Adequacy of supervision, defined by type and frequency, based on the individual resident's assessed needs and identified hazards in the resident environment.During a review of the facility's policy and procedure (P&P) titled, Abuse, Neglect and Exploitation, dated 2025, the P&P indicated, . it is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect. Abuse means the willful 555920 Page 2 of 3 555920 07/09/2025 Evergreen Care Center 5265 East Huntington Avenue Fresno, CA 93727

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish which can include. certain resident to resident altercations. the facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to. Increased supervision of the alleged victim and residents, room or staffing changes, if necessary to protect the residents from the alleged perpetrator, protection from retaliation. revision of the residents care plan if the residents medical, nursing, physical, mental, or psychosocial needs or preferences change as a result of an incident of abuse. 555920 Page 3 of 3