Evergreen Commons Rehabilitation and Nursing Ctr

Inspectors wroteBased on record review and interviews conducted during a survey, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (Residents #1) of three residents reviewed for accidents. Specifically, for Resident #1 on 02/28/2025, Certified Nurse Aide #5 did not use two-person assistance while providing incontinence care as required in Resident #1' s Comprehensive Care Plan. Resident #1 fell out of bed and sustained a head laceration requiring three staples to close the wound. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.

Inspectors wroteBased on record review and interviews conducted during survey, the facility failed to ensure residents were free from abuse and neglect for one (Resident #2) of three residents reviewed for abuse and neglect. Specifically, for Resident #2, on 01/31/2025, Certified Nurse Aide #1 verbally abused Resident #2 with the use of profanity during care and threatening to hit Resident #2.

Inspectors wroteBased on observations, interviews and record reviews during the Abbreviated Survey (complaint #2656654), the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were reported to the New York State Department of Health as required. This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, a resident was transported to dialysis and returned to the facility and was pronounced deceased shortly after. The facility did not report the events leading to the death of Resident #1 to the New York State Department of Health as required. [...]

Inspectors wroteBased on observations, interviews and record reviews during the survey (complaint #2656654), the facility did not ensure that all alleged violations of resident abuse, neglect, exploitation, or mistreatment were investigated as required. This was evident for 1 of 3 residents reviewed for abuse (Resident #1). Specifically, a resident was transported to dialysis and returned to the facility and was pronounced deceased shortly after. The facility did not thoroughly investigate the events leading to the death of Resident #1. This is evidenced by: A facility policy titled Reporting and Investigating Resident Accident/Incidents, dated [DATE], documented that all occurrences which were not consistent with the routine operations of the facility and care of the residents that had or may have caused physical injury or harm would be reported, reviewed and thoroughly investigated. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the abbreviated survey, the facility did not ensure that each resident received the necessary respiratory care and services that were in accordance with professional standards of practice for 1 (Resident #1) of 3 residents reviewed for oxygen administration. Specifically, Resident #1 did not have a physician's order for oxygen, despite being on oxygen on and off during their admission to the facility. This is evidenced by: A review of the facility's policy and procedure titled Oxygen Therapy - Mask and Nasal Cannula, dated 3/2012, documented that 1. Oxygen administration required a medical order (Medical Doctor, Nurse Practitioner, Physician Assistant), specific to include liter flow, route of administration, as well as frequency. [...]

Inspectors wroteBased on observation, interviews, and record review conducted during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not provide effective housekeeping and maintenance services on five (5) of 5 resident units checked. Specifically, the the facility did not ensure that resident room, resident bathroom, common areas, and closets were clean; and furniture and walls were in good repair. This is evidenced by: The following observations were noted on 01/10/2024 from 10:26 AM through 1:31 PM: Finding #1: Soiled Floors Floors were soiled in corners and next to walls in the following areas: Resident room #s 135, 147, 147, 158, 195, 184, 186, 183, 176, 215, 216, 217, 218, 222, 224, 225, 226, 232, 234, 235, 274, 281, 285, 287, 288, 293, 294, 295, and 296. [...]

Inspectors wroteBased on observation, interviews, and record review during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not ensure safe and appropriate labeling and storage of all medications for 3 of 3 units for medication labeling and storage. Specifically, 5 insulin pens were not labeled with expiration dates after opening, and 1 insulin pen was not labeled with the date opened and the expiration date after opening by facility policy. This was evidenced by: The facility Medication Administration Policy, dated 07/28/2023, documented that the expiration date on the medication label must be checked prior to administering. The facility's Diabetic Management Policy, dated 11/2023, documented that upon opening a new vial of insulin, the nurse must date and initial the vial. Insulin vials were to be discarded after 28 days of the date they were opened. [...]

Inspectors wroteBased on observation, staff interview, and record review during the recertification and abbreviated survey (Case #NY00324857) from 01/03/2024 to 01/11/2024, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and 11 of 11 kitchenettes checked. Specifically, serving utensils, food preparation area floors, and kitchenettes were not clean; and the main kitchen floor was not in good repair. This is evidenced by: During observations in the main kitchen on 01/03/2024 at 9:32 AM: - In the clean utensil rack, a wire whisk, 5 ladles, and one 4 ounce measuring spoon were soiled with food residue. - The stove, front of the logbook drawer, floor behind cooking equipment, doors to storage areas, and fire extinguisher were soiled with food particles and/or dirt. [...]

Inspectors wroteBased on observation and interviews during the recertification and abbreviated survey (Case # NY00315024) from 01/03/2024 to 01/11/2024, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, one hot water heater, the hot water holding tank thermometers, and one shower valve were not maintained in good repair. This is evidenced by: During hot water temperature checks on 01/05/2024 at 1:45 PM, the Two Schodack Square 20s shower hot water temperature was 58-degrees Fahrenheit; and hot water temperatures were between 95 and 113-degrees Fahrenheit on the following resident units: One Greenbush Lane, One Schodack Square, Two Greenbush Lane, Two Schodack Square, and Two Wynantskill Way (3 shower temperatures and 3 resident room sink temperatures taken each unit). [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification and abbreviated survey (Case #NY00315024 and #NY00324857) from 01/03/2024 to 01/11/2024, the facility did not maintain a pest-free environment and an effective pest control program on three (3) of 6 resident units. Specifically, rodent droppings were found in resident rooms and dining areas, and staff were not familiar with the procedure for reporting pest findings. This is evidenced by: During observations on 01/03/2024 at 11:02 AM, rodent droppings were found in the drawers and along the walls in the One Schodack Square serving kitchenette. During observations on 01/09/2024 at 2:10 PM, rodent droppings were found behind the television in resident room [ROOM NUMBER]. During observations on 01/10/2024 at 1:08 PM, rodent droppings were found behind furniture in resident room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, staff and resident interviews, and record review conducted during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not ensure that the development and implementation of comprehensive person-centered care plans included measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs for 4 (Residents #'s 539, 25, 69 and 4) of 35 residents reviewed for comprehensive care plans. Specifically, for Resident #'s 539, 25, 69, and 4, the facility did not include interventions specific to the residents' need for oxygen therapy in accordance with professional standards. This is evidenced by: Resident #539: [...]

Inspectors wroteBased on observation, staff interviews, and medical and facility record review conducted during the recertification and abbreviated survey (Case # NY00310589) from 01/03/2024 to 01/11/2024, the facility did not ensure adequate supervision was provided for one (Resident #195) of 7 residents reviewed for accidents. Specifically, on 2/11/2023, the facility did not ensure Resident #195 was provided adequate supervision to prevent an elopement from the facility. This is evidenced by: The facility's Policy and Procedure titled Resident Elopement, revised on 12/17/2018, documented each employee shall be informed of their responsibility in regard to door alarms and response to same, reporting elopements and reporting behavior of residents. [...]

Inspectors wroteBased on observations, record review, and interviews conducted during the recertification survey from 1/3/2024 through 1/ 11/2024, the facility did not ensure that each resident received the necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the resident's choice for 4 (Resident #'s 539, 25, 69 and 4) of 35 residents reviewed for oxygen administration. Specifically, (a) supplemental oxygen was not provided as ordered by the physician for Resident #'s 539, 25, and 69; (b) portable oxygen tanks ran out of oxygen for Resident #'s 539 and 4; and (c) oxygen delivery was provided by unlicensed personnel for Residents #'s 539, 25, 69 and 4. This is evidenced by: [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Food time/temperature controlled for safety (TCS foods), is to be cooled to 41 degrees Fahrenheit (F) within 6 hours provided the food is cooled from 135F to 70F within the first two hours of cooling, automatic dishwashing machines are to operate in accordance with manufacturer specifications, and food and non-food contact surfaces are to be kept clean. Specifically, TCS foods were not cooled properly, the automatic dish washing machine was not rinsing at the specified water pressure, and floors and equipment were not clean in the main kitchen and 6 of 6 kitchenettes. This is evidenced as follows. The main kitchen and kitchenettes were inspected on 08/26/2021 at 9:09 AM. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors were not clean in resident rooms. This is evidenced as follows. The floors in resident rooms were spot checked on 08/26/2021 at 2:30 PM, 08/30/2021 at 12:30 PM, and on 08/31/2021 at 2:30 PM. The floors in resident rooms #'s 114, 131, 183, 184, 185, 186, 191, 193, 194, 196, 197, 214, 273, 274, and #281 were soiled with dirt and brownish build-up. The Director of Maintenance stated in an interview on 08/30/2021 at 2:30 PM, that the facility will make sure that the floors are cleaned in the resident rooms. The Administrator stated in an interview on 08/31/2021 at 3:05 PM, that the facility will audit the floors in resident rooms to ensure that they are clean. 483.10(i)(2)

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor and surrounding area was not maintained in a sanitary condition. This is evidenced as follows. The trash compactor was inspected on 08/26/2021 at 9:30 AM. The sides of the trash compactor were covered in an oily black substance, and the concrete pad below the compactor was covered in food debris. The Director of Food Services stated in an interview on 08/26/2021 at 1:31 PM, that the trash compactor, and the concrete pad will be cleaned. The Administrator stated in an interview on 08/26/2021 at 3:15 PM, that the facility will pressure wash the trash compactor and concrete pad, and the food debris will be cleaned. 10 NYCRR 415.14(h)

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not provide effective maintenance services. Specifically, on 1 (Greenbush 2 unit) of 3 resident units, a shower floor drain was not in good repair. This is evidenced as follows. Observations of the shower rooms on 08/23/2018 at 11:55 AM, revealed that a shower room floor drain in Greenbush 2 resident unit was leaking onto the suspended ceiling of Greenbush 1 unit. During an interview on 08/23/2019 at 11:58 PM, the Regional Director of Physical Plant and Maintenance stated that he was unaware that the floor drain in shower of Greenbush 2 was leaking onto the drop ceiling of the shower room (80's wing) on Greenbush 1, and he will repair the leak. 483.10(i)(2)

Inspectors wroteBased on record review and interview the facility did not refer residents with newly evident mental illness for a level II review for two (Resident #'s 109 and #230) of two residents reviewed for PASRR (Pre-admission Screening and Resident Review). Specifically, the facility did not ensure Resident #'s 109 and #230, who were newly diagnosed with a mental illness, received a level 1 screen to determine if a level II screen needed to be done. This is evidenced by: Resident #109: The resident was admitted on [DATE] with diagnoses of congestive heart failure (CHF), atrial fibrillation and type 2 diabetes mellitus. The Minimum Data Set (MDS) of 6/27/19, documented the resident had moderate impairment for cognition, was able to understand others, and was able to be understood by others. [...]

Inspectors wroteBased on record review, and interviews during a recertification survey the facility did not ensure that residents who use psychotropic drugs receive gradual dose reductions (GDR's), and behavioral interventions, in an effort to discontinue these drugs, for one (Resident #76) of 5 residents reviewed for psychotropic medications. Specifically, for Resident #76, the facility did not ensure that the resident's behaviors were monitored during a GDR attempt that resulted in a failed GDR and justified the increase in Olanzapine (Zyprexa) (an antipsychotic medication). This is evidenced by: Resident #76: The resident was admitted to the nursing home on 3/8/19 with diagnoses of bipolar disorder, vascular dementia with behavior disturbances, major depressive disorder, Diabetes Mellitus (DM), anxiety disorder, and psychotic disorder with delusions. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, the trash compactor was leaking liquid waste and the door of the compactor was left open. This is evidenced as follows. The trash compactor area was inspected on 08/20/2019 at 9:15 AM. The compactor was leaking liquid waste, and the portal door was left open. The Director of Food Service stated in an interview on 08/20/2019 at 9:15 AM, that he will have the trash compactor serviced, and he will re-educate staff to close the door portal after each use. 10 NYCRR 415.14(h)

Inspectors wroteBased on observation, interview and record review during a recertification survey, the facility did not establish and maintain an infection prevention and control program designed to help prevent the development and transmission of communicable diseases and infections determined for 2 (Resident #'s 135 and 193) of 2 residents. Specifically, the facility did not ensure standard precautions were maintained during a dressing change for Residents #'s 135 and 193. This is evidenced by: Resident #135: The resident was admitted on [DATE], with diagnoses of schizoaffective disorder, chronic pain and morbid obesity. The Minimum Data Set (MDS) dated [DATE], documented the resident had no cognitive impairments, was able to understand others and was able to be understood by others. Dressing Aseptic Technique Policy and Procedure with a review date of 6/13/19 documented: [...]