Avantara Evergreen Park

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure eye drops were available for administration as ordered, failed to administer medications timely in accordance with prescriber orders, and failed to ensure the prescriber was notified when medication was not available for administration. This failure affected 5 of 5 (R3, R6, R7, R8, R9) residents reviewed for medication administration in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is dependent with staff assistance for ADL (Activities of Daily Living) was checked and changed every two hours and as needed in accordance with facility's incontinence policy. This failure affected 1 (R4) of 3 residents reviewed for incontinence care in the sample of 9.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is dependent on staff assistance with ADL (Activities of Daily Living) care had a functioning call device. This failure affected 1 (R4) of 1 resident reviewed for call device in the sample of 9 residents. The Findings Include: On 06/26/2026 at 10:39am, R4's call device cord was wrapped on the right-side rail. R4 stated she had been calling but nobody seemed to notice. When R4 to activated the call device; no light illuminated on the call device box attached to the wall or on the overhead indicator box outside of R4's room. On 06/26/2026 at 10:47am, V5 (Assistant Director of Nursing) pushed R4's call device. V5 stated there was no light that was lit on the call device box and on the overhead light indicator outside of R4's room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision and failed to ensure fall precautions were implemented to prevent falls. These failures affected three residents (R12, R91, and R197) in a sample of 67 residents. This failure caused harm to R197, as evidenced by sustaining a right humorous fracture and traumatic hematoma on R197's forehead and contributed to R197's death 2 days after the fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide evening snacks to residents. This failure affected four (R91, R101, R102, 125) out of four residents reviewed for evening snacks. This failure has the potential to affect all residents residing in the facility.

Inspectors wroteBased on observation, interview, and record review, facility failed to dispose of garbage and refuse appropriately, failed to ensure dumpster lids were covered, failed to ensure garbage, including food/drink waste and medical waste were properly contained. This failure affected all 164 residents that reside within the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure; failed to ensure staff appropriately doff appropriate personal protective equipment (PPE) after performing high contact care on one resident; failed to ensure staff don appropriate PPE when performing high contact resident care for one resident; failed to ensure the EBP (enhanced barrier precaution) sign was posted on one resident's door; and failed to implement appropriate measures for the transport and containment of clean linen throughout the facility. These failures affected three residents (R17, R65, and R165) residents reviewed for infection control and have the potential to affect all 164 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure dryer lint traps were clean and without damage to provide a safe environment for the residents. These failures affect all 164 residents residing at the facility.

Inspectors wroteBased up observation, interview, and record review the facility failed to follow policy procedures, failed to provide (R85) required feeding assistance and failed to ensure that call lights were within reach for five of 43 residents (R1, R26, R85, R99, R177) in the sample reviewed for accommodation of needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that staff provide grooming (nail care and shaving) for residents who were dependent on staff for Activities of Daily Living (ADL). This failure affected five (R16, R59, R69, 165 and R176) of six residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the medication pass policy and failed to administer medications within regulatory requirements (within 1 hour before and 1 hour after the scheduled time) therefore failed to maintain a medication error rate below 5%. There were 6 medication errors out of 27 opportunities resulting in a 22.22% medication error rate. Two of four residents (R89, R144) in the medication administration sample were affected.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to ensure that (R1, R17, R49, R74, R105, R136) medications were labeled appropriately, failed to ensure multidose medication were dated when opened, failed to ensure medication carts were lock, failed to ensure medications were stored in locked storage areas, failed to ensure narcotic medications were double locked, and failed to ensure (R25, R133) refrigerated medications and six (6) emergency box insulins were stored within the required temperature range. These failures have the potential to affect 164 residents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident's refrigerators maintained temperature parameters for food safety; failed to properly log residents' refrigerator temperatures; failed to date outside open food items; and failed to ensure residents refrigerators were clean. These failures affect four residents (R17, R50, R78, and R89) reviewed for safety of personal food items, in a total sample of 67 residents.

Inspectors wroteBased on observation, interview and record of review, the facility failed to develop a baseline care plan and failed to provide the resident with a copy/summary of the baseline care plan. This failure affected one resident (R202) in a sample of three residents reviewed for baseline care planning.

Inspectors wroteBased on interview and record review, the facility failed to ensure that staff revise and update resident's (R197) care plan after a fall to address a newly acquired fracture and head injury and failed to update a resident's (R16) care plan to reflect the correct advance directives. These failures affect two (R16 and R197) of two residents reviewed for care plan revision in a sample of 67 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy procedures, failed to ensure that multiple linen layers were not on the LALM (Low Air Loss Mattress) while in use, failed to implement preventive interventions, and/or failed to identify skin integrity impairment for one of 43 residents (R174) in the sample reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow policy procedures, failed to follow physician orders, failed to ensure that designated times were specified for applying/removing restorative devices, failed to include all required device(s) in Nursing Rehab tasks, and failed to ensure that staff provide and/or document restorative care/devices for two of 43 residents (R1, R59) in the sample reviewed for range of motion/mobility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow provider order for continuous oxygen, failed to ensure the nebulizer mask was labeled with the date it was changed, and failed to ensure the respiratory equipment was contained when not in use. These failures affected two (R101 and R129) residents reviewed for respiratory care in the total sample of 67 residents.

Inspectors wroteBased on interview and record review, the facility failed to document post-fall charting and neurological checks (neurocheck) charting in a timely manner, in accordance with professional standards. This failure caused R197's medical records not to be readily accessible or accurate for up to 9 days after R197's fall. This failure affected one (R197) of 67 residents reviewed for resident records. R197's face sheet documents R197 was a [AGE] year-old resident with a prior medical history of chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and displaced supracondylar fracture of the right humerus. R197's minimum data set ([DATE]) documents R197 had a brief interview of mental status summary score of 3, indicating R197 had severe cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the required daily nurse staffing information was accurately completed. These failures have the potential to affect all 164 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to follow requirements by failing to submit an initial and final report, for an injury of unknown origin (of serious bodily injury), to the State Agency in a timely manner. This failure affected one (R1) of three residents reviewed for abuse. R1 sustained a displaced right hip fracture that required an emergency surgical fixation of right basicervical femoral neck with cephalomedullary nail.

Inspectors wroteBased on interview and record review, the facility failed to follow up in a timely manner for Grievance/concerns and provide Dental services. This failure affects one (R7) of three residents reviewed for resident rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a working call light for one (R4) of five residents reviewed for call lights. This failure resulted in a delay of staff helping R4.

Inspectors wroteBased on interview and record review, the facility failed to follow their guidelines of promptly transferring a resident who exhibited signs and symptoms of sepsis for six hours prior to transfer. This failure affected one (R1) of three residents reviewed for quality of care. This failure resulted in R1 requiring hospitalization and diagnosed with septic shock and pneumonia.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain resident's room temperatures within a comfortable range of 71-to 81- degree Fahrenheit. This affected seven of seven residents (R1 - R7) reviewed for comfort environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that the resident environment remains comfortable and homelike with cooling system in proper working order to maintain acceptable temperature within 71- to 81-degree Fahrenheit. This failure affected 100-unit and 200-unit wings in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure that one resident who was on pain medication had an effective bowel regime program to prevent constipation. This affected one of one resident (R18) reviewed for quality of nursing care and prevention of constipation. This failure led to R18 being sent to the hospital with a diagnosis of severe fecal impaction with stool ball measuring over 8 centimeters (CM).

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to consistently and accurately assess, monitor, and implement interventions to prevent skin breakdown, and failed to ensure the intervention of the low air loss mattress was implemented per manufacture guidelines. This affected two of three residents (R62, R176) reviewed for pressure sore and pressure sore prevention. This failure resulted in R62 being admitted to the facility on [DATE] with skin in tact and developing a facility acquired pressure sore ( unstageable) wound to the sacrum area by 4/25/25.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its side rail policy and assess residents for the need of side rails use and/or obtain consent prior to the use of side rails for four residents (R26, R150, R159, and R161) of seven in a sample of 49.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their medication labeling, Storage of medications and insulin administration policies by not discarding medication for discharge residents, ensuring open date and expiration dates were labeled on insulin pens, ( R80, R136, R33, R59, R172) of five of five residents reviewed for medication storage.

Inspectors wroteBased on observations, interviews, and record review this facility failed to follow their infection prevention and control policy and perform appropriate hand hygiene before entering and after exiting resident room, failed to follow their infection control policy for donning appropriate PPE (personal protective equipment) prior to entering resident rooms in enhanced barrier precautions to perform resident care. This affected four of four (R26, R150, and R137) residents reviewed for infection control practices

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its electronic monitoring policy and post signage regarding electronic monitoring in use on facility entry and the resident's room, failed to obtain informed consent from residents and resident representatives before initiating video monitoring and audio monitoring for residents. This affected two of two residents (R83 and R159) reviewed for resident rights in a sample of 49.

Inspectors wroteBased on observation, interview the facility failed to ensure the call light was in reach for a dependent resident. This affected one of three residents (R146) reviewed for call light accessibility.

Inspectors wroteBased on record review and interviews, facility staff failed to accurately code a Minimum Data Set (MDS). This affected three of three residents (R130, R81, R43) reviewed for accurate assessment.

Inspectors wroteBased on interview and record review the facility failed to ensure care plans reflect the patients care needs for safe transfer status to include mechanical lift. This affected one of eight residents (R52) reviewed for implementation of care plan interventions in the sample of 49 residents.

Inspectors wroteBased on observations, interviews, and record reviews, this facility failed to provide incontinence care/checks at least every two hours. This affected one of three (R150) residents reviewed providing incontinence care for dependent residents in the sample of 49 residents.

Inspectors wroteBased on observation, interviews, records reviews the facility failed to follow the identified mechanical lift transfer status while transferring onto the toilet and failed to follow their policy and use a gait belt to perform a safe transfer from bed to wheelchair for one resident. This affected one of three residents (R52) reviewed for safety during staff assisted transfers. This failure resulted in R52 falling during the bed to wheelchair staff assisted transfer and sustaining an acute impacted right femoral fracture.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their oxygen therapy and administration policy by failing to ensure residents have physician orders for oxygen use and ensure the oxygen concentrator is in working order. This affected one of one (R18) resident reviewed for oxygen use.

Inspectors wroteBased on interviews and records reviewed the facility failed to develop and implement protocols and a system to monitor antibiotic use for one resident with a history of Clostridium difficile currently on antibiotics. This failure affected one of eight (R28) residents reviewed for infection control practices.

Inspectors wroteBased on observation, interview and record review the facility failed ensure that the resident was provided a clean homelike environment for one residents (R7) reviewed for home like environment.

Inspectors wroteBased on interview and record review, the facility failed to document in residents electronic health record and notify family regarding a resident's fall. This failure affected one resident (R4) out of eight residents reviewed for quality of care.

Inspectors wroteBased on interview and record review, the facility failed to follow the Abuse and Neglect Policy by not reporting an allegation of rough handling to the Administrator immediately for one of three residents (R1) reviewed for Improper Nursing Care on the total sample list of three.

Inspectors wroteBased on interview and record review the facility failed to follow the facility protocol to safely operate a full body mechanical lift by failing to use 2 staff persons when transferring a patient to a wheelchair from bed. This affected one of three resident (R1) reviewed for mechanical lift. This failure resulted in the full body mechanical lift tipping onto the floor and R1 falling to the floor, while still hooked by the sling to the lift.

Inspectors wrote4. R1 diagnosis include but not limited to Alzheimer's Disease, History of Falling, Unsteadiness On Feet, Repeated Falls, Scoliosis, Age Related Osteoporosis, Dementia, Mood Disorder, Generalized Anxiety Disorder. Fall with Injury report dated 9/17/24 stated R1 observed laying on floor. Facility Final Incident Report stated 9/25/24 states R1 transported to hospital for evaluation. R1 return to the facility with 8 sutures to forehead and a closed nondisplaced fracture of second metacarpal bone of right hand. R1 fall without injury dated 7/16/2024 notes R1 on the floor. R1 stated she was trying to transfer herself from wheelchair to bed. Root cause analysis states R1 was trying to get back in bed. On 10/5/24 at 10:41AM R1 in regular wheelchair, no pommel cushion, R1 wearing black slacks. [...]

Inspectors wroteBased on interviews and records reviewed the facility failed to ensure one resident's (R3) money was managed from her monthly portion paid to the facility. The facility collected a balance of $5,504.06 from R3's facility managed account and did not present an itemized record of services for the amount taken. This failure affected 1 of 3 residents reviewed for finances.

Inspectors wroteBased on interview and record review, the facility failure to develop an effective pressure sore prevention plan to reduce the risk of developing wound infection, failed to ensure wound dressings were replaced after being soiled and failed to ensure the air loss mattress were set for according to resident weight. This affected three of three residents (R2 - R4) reviewed for pressure sore protocols. This failure resulted in R2 developing an infected pressure hand wound due to contracted fingernails pressing into the palm of her hand. Findings Include: 1. R2's diagnosis include Vascular Dementia and adult failure to thrive. On 9/25/24 at 1:30pm, V7 (wound director) said, R2 did not a treatment for her hand nor did R2 have a splints or carrot to prevent contraction. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their fall policy by not implementing new and effective fall interventions, completing an incident report/fall investigation following a fall for one resident who was identified as high risk for falls. This affected one of three (R1) reviewed for falls. This failure resulted in R1 sustaining three falls within 30 days and being transferred to the hospital with a diagnosis of a subacute subdural hematoma.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident prescribed a mechanical soft diet with thin liquids and gastrostomy tube received enough water to prevent dehydration. This affected one of three residents (R2) reviewed for dehydration. This failure resulted in R2 having a calculated free water deficit of 1.9L (liters), a high sodium level and according to the hospital record a large amount of colonic stool with large amount of stool in rectum compatible with fecal impaction. Findings Include: R2 had the diagnosis of Vascular Dementia, Metabolic Encephalopathy, Severe Protein- Calorie Malnutrition, Adult Failure to Thrive and Encounter for Attention to Gastrostomy (G-tube). Physician order sheet dated 8/1/24 documents diet: [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their notification for change in condition policy by failing to notify the family and physician following a fall for one resident (R1) for one of three residents reviewed for falls.

Inspectors wroteBased on observation and interview, the facility failed to follow physician orders for no-pressure wound treatment for one resident. This affected one of three residents (R4) reviewed for non-pressure wound orders.

Inspectors wroteBased on interview and record review, the facility failed to prevent financial abuse and theft for one resident (R1) in a sample of 8 residents reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement fall prevention intervention to R53 who has history of fall. The facility also failed to ensure individualized fall prevention care plan interventions are in place upon admission for a resident who has history fall and fracture of left femur. This deficiency affects two (R53 and R229) of three residents in the sample of 32 reviewed for Fall Prevention Management. This failure resulted in R229 having an unwitnessed fall and sustained acute comminuted left ischial pubic and tuberosity fractures that required hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to label foods being thawed inside the refrigerator. This failure has the potential to affect all 159 residents currently residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to exercise the right of the resident representative to choose a Long-Term Care Facility of their choice in one of four (R329) residents reviewed for residents right in a sample of 32.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure implementation of pressure ulcer prevention interventions and manufacturer recommendation for using low air loss mattress for resident with Stage 4 pressure ulcers. This deficiency affects one (R48) of three residents in the sample of 32 reviewed for Pressure Ulcer Prevention and Treatment Management.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure appropriate restorative services consistent to resident's functional need is provided to a resident with a limitation of range of motion to both upper extremities. This deficiency affects one (R30) of three residents in the sample of 32 reviewed for Restorative Nursing Program.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure ongoing assessment and implementation of catheter care to resident with indwelling urinary catheter. This deficiency affects one (R48) of three residents in the sample of 32 reviewed for Catheter Care Management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate use of Personal Protective Equipment (PPE) during high contact care activities on a resident with urinary catheter and on Enhanced Barrier Precaution (EBP). This facility also failed to perform hand hygiene before donning new pair of gloves after incontinence care. These failures affect 2 of 5 residents (R137, R140) reviewed for infection control in a sample of 32.

Inspectors wroteBased Based on interview and record review, the facility failed to follow their policies regarding indwelling urinary catheter care by failing to identify and promptly treat a catheter related laceration for one resident (R1). This failure applies to one (R1) of one resident reviewed for catheter care.

Inspectors wroteBased on interview and record review the facility failed to follow their policies by not documenting catheter care and cleaning every shift (R1 and R3) failed to ensure a care plan was in place for residents with indwelling urinary catheters (R1 and R4). This failure applied to three (R1, R3 and R4) of four residents reviewed for catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were transferred in a safe manner for 1 of 3 residents (R3) reviewed for safety and supervision in the sample of 18.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately document the administration of a controlled medication on a resident's Medication Administration Record and Controlled Drug Administration Form for 1 of 3 residents (R15) reviewed for controlled medications in the sample of 18.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident's plan of care related to falls was carried out accordingly and failed to ensure that staff were aware of resident fall risk status in order to implement fall risk interventions, for a resident assessed to be at high risk for falls. This failure applied to one (R1) of three residents reviewed for falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident was transferred into bed with the use of a mechanical assistance machine as required. This failure affected one resident (R1) reviewed for accidents and resulted in R1 obtaining a closed fracture of right tibial plateau and experiencing severe pain.

Inspectors wroteBased on interviews and record reviews, the facility failed to complete an accurate MDS regarding the skin condition of resident for one of six sampled residents (R3)