Evergreen Care Center

Inspectors wroteBased on interview and record review the facility failed to report an incident of bodily injury that required hospitalization for one of three sampled residents (Resident 1) when Resident 1 had an alleged fall on 5/13/26 and was sent to the hospital due to a head injury. This failure resulted in an inaccurate investigation and reporting to state agencies of events leading up to and resulting from Resident 1's fall with injury.

Inspectors wroteBased on interview and record review the facility failed to ensure a safe and orderly discharge from the facility for one of two sampled residents (Resident 1) when the facility discharged Resident 1 without needed medical equipment that included oxygen concentrator, wheelchair, and shower chair. This failure placed Resident 1 at risk for an unsafe discharge due to the inability to use medical equipment to prevent possible falls, injuries and respiratory distress.

Inspectors wroteBased 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.

Inspectors wroteBased 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: 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. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on [DATE] and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. This failure resulted in Resident 1 being exposed to triggers that caused her re-traumatization from past experiences with feelings of isolation, depression, lack of sleep and fear.

Inspectors wroteBased on interview and record review the facility failed to designate and employ a full time Director of Nursing (DON) for the facility from 12/2024 to 3/2025. This failure had the potential for all residents to result in inadequate residents ' care planning and supervision of the nursing department which placed all residents ' health and safety at risk.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect and promote the rights of residents' privacy for two of nine sampled residents (Resident 1 and Resident 2) when the facility did not provide a private area for Resident 1 and Resident 2 to discuss their personal health information. This failure had the potential to result in health information for Resident 1 and Resident 2, to have been overheard by other unrelated staff and residents in the facility resulting in lack of confidentiality and privacy.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for Trauma informed Care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1), when the facility's admitting nurse and social services director (SSD) identified Resident 1's history of trauma upon admission and did not create a care plan to recognize trauma and triggers that impacted Resident 1's care. This failure resulted in Resident 1 experiencing triggers that caused her to relive past traumas during her care in the facility.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from free from abuse for one of three sampled residents (Resident 1), when certified nursing assistant (CNA)1 was observed hitting Resident 1 with a closed fist. This failure resulted in Resident 1 being physically harmed on the right thigh causing unnecessary mental trauma and physical pain to the area.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. One of three kitchen personnel, [NAME] (CK) 2 did not use a surface sanitizer with the correct concentration when wiping the food preparation table. 2. One of three kitchen personnel, CK 1 did not take the temperature reading of food items after the items were heated in the microwave before serving it to one of 47 residents. 3. Plates, Plate holders, lids, and cooking pans were not air dried and were stacked and stored wet in the kitchen. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were provided with dignity and respect for two of eight sampled residents (Resident 146 and Resident 243) when: 1. Licensed Vocational Nurse (LVN) 3 checked vital signs (V/S-measurements of blood pressure, pulse rate and temperature) and administered medication to Resident 146 in hallway B and did not provide privacy. 2. LVN 3 checked V/S and administered medication to Resident 243 in Residents' room and did not provide privacy. These failures resulted in Resident 146 and Resident 243 not being treated with respect and dignity while their vital signs were taken and while taking their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure dialysis (procedure to remove wastes and excess fluids from the body) communication forms were completed for two of four sampled residents (Resident 142 and Resident 25) when Residents 25 and 142 did not have documentation of completed post-dialysis assessments of access sites (site used for dialysis) on multiple dates. These failures placed Resident 142 and 25 at risk for delayed detection, reporting, and/or management of complications from the hemodialysis (dialysis done through blood vessels)access sites.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for one of five sampled residents (Resident 142) when Resident 142 was administered heparin (anticoagulant-blood thinner) medication as prophylaxis (prevention) for venous thromboembolism (condition that occurs when a blood clot forms in a vein) and the facility did not initiate a care plan. This failure had the potential for Resident 142 to experience a thromboembolism.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide quality of care and treatment in accordance with professional standards of practice for one of four sampled residents (Resident 18) when fasting blood sugar levels (FBS- A test to determine how much sugar is in blood after an overnight fast) was not performed per physician's orders. This failure resulted in Resident 18's blood sugar level not being monitored which could lead to hypoglycemia (a condition where there isn't enough sugar in the blood) or hyperglycemia (a condition where there is too much sugar in the blood).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which ensured the administration of medication to meet the need for one of eight sampled residents (Resident 20) when Resident 20's Lactulose (brand name-laxative medication taken to treat constipation) was not available for administration for one day (5/15/24). This failure had the potential for Resident 20 to develop constipation which could lead to more serious health condition like stool impaction (the result of severe constipation, unable to regularly pass stool or feces and it backs up inside the large intestine (colon).

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the appropriate food texture was provided for one of six sampled residents (Resident 11) when Resident 11 did not received large portions finger foods as ordered. This failure placed Resident 11 at risk for weight loss due to not being able to utilize utensils.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe and sanitary environment for one of five sampled residents (Resident 34) when brown-colored, fecal stains and remnants (remaining, small amount) was found on the toilet and toilet seat in Resident 34's bathroom. This failure had the potential of cross-contamination from one resident to another.

Inspectors wroteBased on observation and interview during the survey period of 5/13/24 to 5/17/24, the facility failed to provide and maintain minimum square footage for each resident in 12 of 19 rooms (Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19).

Inspectors wroteBased on observation, interview and record review, the facility failed to implement care plan intervention for one of seven sampled residents (Resident 1), when the facility did not provide continuous monitoring as indicated in Residnt1 ' s care plan and Resident 1 eloped (left the health care facility unsupervised and undetected) from the facility on 9/23/23. This failure resulted in Resident 1 leaving the facility unsupervised and had a potential for accident which could lead to serious injury.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteIntakes: CA00855412, CA00856005, CA00856175 Based on interview and record review, the facility failed to implement their Policy and Procedure (P&P) titled, Abuse, Neglect and Exploitation (the act of using someone unfairly for your own advantage) that prohibit and prevent abuse for two of two sampled residents (Resident 1 and Resident 2), when the facility did not provide a safe environment and protection that would prevent Resident 1 from entering Resident 2 ' s room to perform a sexual act and protect Resident 2 from Resident 1 entering his room to perform a sexual act. This failure resulted in nonconsensual (sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur) sexual abuse to Resident 1 and Resident 2.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a comprehensive, person-centered care plan (a plan that provides direction for individualized care of resident) was developed and implemented to meet the identified needs for one of two sampled residents (Resident 1), when Resident 1 did not have a resident-centered care plan developed after Resident 1 performed a nonconsensual (sexual contact is nonconsensual if the resident appears to want the contact to occur but lacks the cognitive ability to consent or does not want the contact to occur) sexual act to Resident 2. This failure had the potential to result in Resident 1 ' s identified care needs, to go unmet and placed Resident 1 at risk of not receiving appropriate, consistent, and individualized care interventions to ensure the safety of Resident 1.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was free from sexual abuse for one of three sampled residents (Resident 15) when on two separate occasions (3/25/19 and 4/3/19) Resident 38 without permission grabbed Resident 15's breasts in the hallway of the facility. For Resident 15, the facility failed to protect her from sexual abuse from Resident 38 on 4/3/19, ten days after a previous incident of sexual abuse occurred on 3/25/19 with Resident 38. This failure had the potential to impact the physical and mental well-being of Resident 15 by increasing her anxiety and depression from potential feelings of disrespect and violation of her personal body space.

Inspectors wroteBased on observation, interview and record review, the facility failed to store food in accordance with professional standards for food safety when: 1. In the small refrigerator in the kitchen, there was unlabeled prepared milk and sugar free juice cups and a pitcher of sugar free orange juice. 2. In the large refrigerator, there was a carton of unlabeled liquid eggs and a bag of shredded lettuce. 3. On the dry food rack there was an unlabeled container of popcorn kernels. 4. In the freezer there was unlabeled frozen waffles and mixed veggies in a bag. These failures resulted in unsafe food handling practices which placed the residents at risk of contracting foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Long Term Care Ombudsman (an advocate for residents) was notified of the emergency transfer for three of three residents (Residents 18, 30, and 51), when Residents 18, 30, and 51 were transferred to a general acute care hospital (GACH). This failure had the potential of not providing Residents 18, 30, and 51 with access to an advocate who could inform them of their options and rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person centered care plan (a plan that provides direction for individualized care of the resident) for three of 21 sampled residents (Residents 7, 18, and 30) when: 1. For Resident 7, the facility failed to implement the care plan for a psychotropic (affecting mental activity, behaviors, and perceptions) medication when Resident 7's olanzapine (an anti-psychotic medication used to treat mental/mood conditions) had no resident specific targeted behaviors identified for monitoring. This failure had the potential to result in Resident 7 not to receiving the appropriate plan of care for the use of psychotropic medication. 2. For Residents 18 and 30, the facility failed to develop a care plan related to the use of side rails. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise care plans for two of 21 sampled residents (Resident 7 and Resident 9) when: 1. For Resident 7, the facility did not revise the care plan to reflect the specific behavior monitoring for the use of an anti-depressant medication, fluoxetine. 2. For Resident 9, the facility did not revise the care plan to reflect the specific behavior monitoring for the use of an anti-psychotic medication, quetiapine. These failures had the potential for Resident 7 and Resident 9's behavior manifestations to be unrecognized by staff for accurate evaluations of the effect of the medication treatments.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide nursing services in accordance with professional standards of practice and facility policy and procedure for two of eight sampled residents (Residents 43 and 46), when the Registered Nurse (RN) left an unlabeled medication cup with medications at the bedside unattended. For Residents 43 and 46, this failure had the potential for an unintended resident to take another residents' medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to perform assessments that identified the risks and benefits of the use of side rails for three of 7 sampled residents (Resident 18, 30, and 41) and failed to obtain informed consent for Resident 18 when: 1. For Residents 18 and 30, the facility failed to assess for entrapment, attempt alternatives, and offer least restrictive measures prior to the use of side rails. 2. For Resident 41, the facility failed to obtain consent, a physician order, assess for entrapment, attempt alternatives, and offer least restrictive measures prior to the use of side rails. These failures had the potential to put Residents 18, 30, and 41 at risk for entrapment and serious injury.

Inspectors wroteBased on interview and record review, the facility failed to complete and transmit a significant change Minimum Data Set (MDS) assessment (required assessment of cognitive and functional abilities) in resident status for one of 21 sampled residents (Resident 18) when Resident 18 was admitted for hospice (end of life care) services. For Resident 18, this failure had the potential for Resident 18 to not have care needs met as related to a change in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two of 21 sampled residents' (Residents 18 and 30) use of side rails were accurately coded when the side rails were coded as restraints on the Minimum Data Set ([MDS] resident assessment tool which indicates physical and cognitive abilities) assessments. This had the potential for the residents' side rails to be used by staff as restraints and restricting Resident 18 and Resident 30's mobility.

Inspectors wroteBased on observation during the survey period of 5/19/19 to 5/23/19, the facility failed to provide and maintain minimum square footage for each resident in 12 of 19 rooms (Rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19).