Evergreen Center for Health & Rehabilitation

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure the resident's side-rail was locked into place prior to directing the resident to turn onto their left side in bed resulting in a fall with injury.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident # 1) reviewed for medication administration, the facility failed to prevent a medication error when a licensed nurse administered medications to an incorrect resident and failed to notify a Registered Nurse and the provider of the medication error once discovered.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one (1) of two (2) residents (Resident # 1) reviewed for medication administration, the facility failed to prevent a medication error when a licensed nurse administered medications to an incorrect resident.

Inspectors wroteBased on review of the infection control program, observations, review of facility policy and staff interviews, the facility failed to ensure all staff members were knowledgeable in identifying residents requiring Enhanced Barrier Precautions (EBP) and proficient in utilizing proper personal protective equipment while providing care for residents requiring EBP.

Inspectors wroteBased on clinical record reviews, facility documentation, review of policy and staff interviews 1 of 2 residents reviewed for limited range of motion (Resident #27), the facility failed to ensure physical therapy was made aware of a resident's change in condition regarding the comfort and fit of a prosthetic device for 1 of 1 resident who utilized a Foley catheter, the facility failed to document the diagnosis for the utilization of urinary catheter and for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to assess the resident's left lower hand bruise area according to facility practice and

Inspectors wroteBased on observations, review of facility policy and staff interviews, the facility failed to ensure staff followed the hot water temperature monitoring requirements by checking and logging the mixing valve daily, testing to be done at different times throughout the month at varied testing locations and weekly calibration of the tester and recording the results to ensure a safe environment.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 2 sampled residents (Resident #194) reviewed for abuse, the facility failed to implement policies that ensured allegation(s) of feeling unsafe and being fearful of retaliation were reported.

Inspectors wroteBased on clinical record reviews, review of policy and interviews for 1 of 1 resident reviewed for urinary catheter (92), the facility failed to ensure staff developed a comprehensive care plan related to the urinary tract condition and urinary catheter and for 1 of 1 sampled resident (Resident #76) reviewed for Communication/ Sensory, the facility failed to create person centered care plan to reflect sensory needs.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 5 sampled resident (Resident #342) reviewed for Comprehensive Resident Centered Care Plan, the facility failed to update the resident's care plan to reflect resident preferences.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy and interviews for 1 of 4 sampled residents (Resident #194) reviewed for abuse, the facility failed to ensure medications were administered according to professional standards of practice and for 1 of 5 resident who required assistance with medication administration (Resident # 74), the facility failed to follow the five rights when administering the resident's medication.

Inspectors wroteBased on clinical record review, observations, resident interviews, and staff interviews for 1 of 3 residents reviewed for pressure ulcers (Resident #6), the facility failed to ensure the resident was turned using the appropriate offloading device per the plan of care.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for 1 of 3 residents (Resident # 136) reviewed for accidents, the facility failed to provide the necessary supervision to prevent a resident from eloping.

Inspectors wroteBased on review of the clinical record, facility documentation, and interviews for 1 of 5 residents (Resident # 101) for Unnecessary Medication Review, the facility failed to ensure the pharmacist recommendations were provided to the physician for review and response.

Inspectors wroteBased on clinical record reviews and staff interviews for 2 of the 4 residents (Residents # 12 and # 91) reviewed for hospice, the facility failed to ensure the resident's hospice notes were complete.

Inspectors wroteBased on clinical record review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to ensure the resident was seen by social service within three days after an allegation of mistreatment per facility practice and failed to report the allegation of mistreatment to other state agency.

Inspectors wroteBased on review of clinical record reviews and staff interview for 3 of 4 residents reviewed for hospice ( Residents # 12, # 91, the facility failed to ensure staff coded the resident's MDS assessment to accurately reflect the significant change in status.

Inspectors wroteBased on clinical record review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to ensure the resident was free from mistreatment.

Inspectors wroteBased on clinical record review, facility documentation, review of policy and staff interviews for 1 of 4 resident (Resident # 135) reviewed for abuse, the facility failed to report an allegation of mistreatment to the state agency timely.

Inspectors wroteBased on clinical record review, facility documentation review, facility policy review, and interviews for one of three residents (Resident #15) reviewed for abuse, the facility failed to ensure a resident was treated with respectt and dignity.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one resident (Resident #11) reviewed for Activities of Daily Living, the facility failed to document and follow up on resident grievances accurately and timely.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for two of five residents, (Resident # 1 and #4), reviewed for abuse or neglect, the facility failed to ensure a resident was free from abuse or neglect.

Inspectors wroteBased on clinical record reviews, facility documentation, facility policy, and interviews for three of five residents reviewed for allegation of abuse (Resident #4, #5 and #20), the facility failed to ensure that complete and correct information was reported to the state agency after a staff member was terminated for pushing the resident. Additionally, for two residents the facility failed to ensure a staff member reported an allegation of abuse to the supervisor in a timely manner and for one sampled resident the facility failed to immediately report the allegation of abuse to the state agency no later than two (2) hours after being notified of the alleged abuse in accordance with facility policy.

Inspectors wroteBased on review of the clinical record and interviews for 2 of 23 residents (Resident #11) reviewed for accuracy and completion of assessments, the facility failed to ensure admission assessments were complete or accurately code a Minimum Data Set (MDS) assessment.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy and interviews for one resident (Resident #11) reviewed for bowel and bladder, the facility failed to implement a person-centered care plan on a resident who was identified as needing assistance with toileting.

Inspectors wroteResident #15 had diagnosis that included personality disorder, anxiety disorder, depressive episodes, chronic obstructive pulmonary disease and chronic systolic congestive heart failure. Review of the clinical record, the care plan dated 3/4/2022 identified Focus: Behavior and mood patterns, and the resident becomes loud, yells and swears at the staff when agitated, easily upset and mood changes quickly with the intervention for two NA's for care. Review of the NA care card dated 3/10/2022 identified two NA's or staff for care. Review of the progress notes identified the following: : -2/25/2022 documented by RN#8: the resident became belligerent, pointing he/his finger at the nurse aide (NA) when the NA explained that the order the resident requested was already called into dietary. [...]

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one sampled resident (Resident #18) reviewed for elopement and four of four residents (Resident #6, # 7, # 11 and #13) reviewed for accidents, the facility failed to prevent a cognitively impaired resident from exiting the facility without staff supervision and failed to implement interventions to reduce hazards and risks following a fall, and failed to implement a person-centered care plan on a resident who was identified as at risk for falls.

Inspectors wroteBased on clinical record review, review of facility policy and procedure and interviews with facility staff for 3 of 3 residents (Resident #12, #13 and #16) who had physician orders that directed obtaining resident weights, or physician orders that directed intake and output monitoring, or who experienced weight loss, the facility failed to obtain a weight, monitor intake and output, or reweigh when ordered.

Inspectors wroteBased on review of clinical records, review of the facility policy and procedure, and interviews for 2 of 2 residents reviewed for pain management (Resident #14 and #23), the facility failed to identify and intervene timely for complaints of pain.

Inspectors wroteBased on review of personnel files for 3 of 5 Nurse Aides (NA #7, NA #11, and NA #12), facility policy and interviews, the facility failed to complete annual performance evaluations.

Inspectors wroteBased on review of the clinical record, review of facility documentation, review of facility policy, and interviews for one sampled resident reviewed for psychosocial services and follow up (Resident #1), the facility failed to ensure a resident received appropriate treatment and services to correct an assessed problem to support attaining the highest practicable mental and psychosocial well-being.

Inspectors wroteBased on review of the clinical record, review of facility documentation, and interview with facility staff for one resident (Resident #16) who had an order for a laboratory test, the facility failed to obtain the specimen timely in accordance with physician orders.

Inspectors wroteBased on review of the clincial record, review of facility documentaion and interview with facility staff for one resident who had a signficant change in condition (Resident #16), the facility failed to ensure documentation was completed to reflect the resident's condition.

Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for (1) one of (3) three residents, (Resident #1), reviewed for medication management, the facility failed to reassess a resident whom had a change in status, to ensure continued capability of self administration of medication.

Inspectors wroteBased on clinical record review, facility documentation, facility policy, and interviews for one (1) of three (3) residents, (Resident #1), reviewed for discharge planning, the facility failed to ensure that the discharge instructions/paperwork included the use of a specialized device used to deliver medication .

Inspectors wroteBased on clinical record, facility documentation, facility policy, and interviews for one (1) of (3) three residents, (Resident #1), reviewed for medication management, the facility failed to ensure medical device maintenance was provided in accordance with manufacturer's guidance.

Inspectors wroteBased on clinical record review, interviews, and facility policy review for reviewed for medication management, the facility failed to ensure facility staff were trained and competent in managing and monitoring a specialized medical device.

Inspectors wroteBased on clinical record review, facility policy review, and interviews for one of three residents (Resident #1) reviewed for pressure wounds, the facility failed ensure the responsible party was notified timely of a change in condition.

Inspectors wroteBased on observation, clinical record review, facility documentation review, facility policy review, and interviews for two of three residents (Resident #1 and #2) reviewed for pressure wounds, the facility failed to ensure the clinical record was complete and accurate to include weekly pressure wound assessments.

Inspectors wroteBased on observation, review of the clinical record, facility documentation, facility policy, and interviews for 1 resident (Resident #29) reviewed for positioning, the facility failed to ensure the leg rests and calf pad were on the adaptive wheelchair for positioning per therapy recommendations.

Inspectors wroteBased on review of the clinical record, facility documentation, facility policy, and interviews for one of three sampled resident (Resident #29) reviewed for Physicians Orders, the facility failed to ensure the monthly physicians orders were signed by the physician and progress notes were legible.

Inspectors wroteBased on observation, clinical record review, review of facility documentation, facility policy and interview for 1 of 3 residents reviewed for pressure ulcers (Resident #112) the facility failed to ensure weekly skin assessments were consistently conducted on a resident at risk for developing a pressure ulcer .

Inspectors wroteBased on review of the clinical record, facility policy/procedures and interviews for 1 of 3 residents reviewed for accidents (Resident #61), the facility failed to ensure a fall was reported by the Nurse Aide's (NA) to ensure an assessment could be completed by the Registered Nurse (RN) and for 1 of 1 sampled resident reviewed for an altercation (Resident #104), the facility failed to conduct and document an assessment, consistently complete and document every 15 minute observational safety checks and/or provide documentation of timely behavioral health follow up as per the plan of care subsequent to a resident to resident altercation.

Inspectors wroteBased on clinical record review, review of facility policy and interviews for 1 of 3 sampled residents reviewed for nutrition and weight loss (Resident #150), the facility failed to implement measures to address a weight loss with variable intake in a timely manner as recommended by the Dietician.

Inspectors wroteBased on observations, interviews and review of the facility policy for medication storage, the facility failed to store a medication in a safe manner.