Evergreen Crossing and the Lofts

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure eggs were pasteurized and foods were stored safely during 1 of 3 kitchen observations. This deficient practice had the potential to affect 97 of 99 residents who received food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received showers and bathing per their preference for 1 of 32 residents reviewed for choices (Resident 7).

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's code status and resident representative information was appropriately communicated during a transfer to the hospital for 1 of 5 residents reviewed for hospitalization (Resident 59).

Inspectors wroteBased on interview and record review, the facility failed to code a Minimum Data Set (MDS) correctly when a resident was not taking an antidepressant and failed to code a resident who was edentulous (no teeth or dentures) for 2 of 20 residents reviewed for MDS accuracy (Residents 2 and 7).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were not left at residents' bedside for 2 of 32 residents observed for potential accidents (Residents 60 and 3).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received person-centered dementia specific care and services for 1 of 1 residents reviewed for dementia care services (Resident 72).

Inspectors wroteBased on observation and record review, the facility failed to ensure medications were properly labeled and stored in 3 of 6 carts reviewed for appropriate storage and labeling of medications (Residents 100 and 112).

Inspectors wroteBased on interview and record review, the facility failed to maintain a system for the reconciliation of controlled medications from 4 of 4 nursing units (Health, Heritage, [NAME] 1 and [NAME] 2), resulting in diversion of at least 60 Norco (hydrocodone-acetaminophen - a Schedule II narcotic medication) tablets from 1 of 4 nursing units reviewed for diversion of narcotics (Heritage hallways). This deficient practice was corrected by [DATE] prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' narcotic medications were protected from diversion resulting in 60 missing Norco (a Schedule II narcotic medication) tablets, for 1 of 3 residents reviewed for misappropriation (Resident L). This deficient practice was corrected by [DATE] prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications, painting supplies, and cleaner/degreaser sprays were secured for 3 of 3 random observations for potential accidents. This deficient practice had the potential to affect 2 of 2 residents randomly observed (Residents G and N).

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure insulin was administered in accordance with physician's orders and by manufacturer's instructions for 3 of 3 residents observed for insulin administration (Residents B, H, and T).

Inspectors wroteBased on observation, record review, and interview, the facility failed to identify wounds, and complete skin assessments for 1 of 3 residents resulting in harm when the resident developed skin breakdown on her buttocks that progressed to an unstageable pressure ulcer/injury (a full thickness tissue loss where the extent of the damage is hidden by dead tissue) that required surgical debridement and the facility failed to assess and treat a Deep Tissue Injury (a pressure-related injury to sub-cutaneous tissue under intact skin, as a result of prolonged compression of bony prominences on underlying soft tissue, particularly muscle) to the right heel for 1 of 3 residents reviewed for pressure ulcers (Resident B). This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure care plan interventions were personalized, implemented, and updated to include changes to wound management for 1 of 3 residents reviewed for care plans (Resident B). This deficient practice was corrected by 10/31/25 prior to the start of the survey and was therefore Past Noncompliance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or document showers for 4 of 11 residents reviewed for bathing preferences (Residents C, K, L, and N).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable water temperatures of more than 100 degrees Fahrenheit (F) and less than 120 degrees F in 16 of the 16 residents' bathrooms on the [NAME] 1 hallway reviewed for comfortable temperatures (Rooms 200, 201, 202, 203, 204, 205, 206, 207, 208, 209, 210, 211, 212, 213, 214, and 215) .

Inspectors wroteBased on observation, and interview, the facility failed to maintain a clean and sanitary environment on 4 of 4 hallways (Health Heritage, [NAME] 1, and [NAME] 2 hallways) observed for cleanliness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident rooms and common areas were free of flying and crawling insects, and subsequently into and landing on open food and drinks in the resident's room on 4 of 4 nursing units during random observation of resident rooms (Health, Heritage, [NAME] 1, and [NAME] 2 hallways).

Inspectors wroteBased on observation and interview, the facility failed to ensure resident food was stored in a safe and sanitary manner when resident and staff food were co-mingled and not labeled in 3 of 4 nurse's station refrigerators observed for resident food storage, and failed to ensure resident food was stored in a safe and sanitary manner when food was left open in residents' rooms (Residents C, L, and Q) with visible gnats.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a comprehensive and individualized care plan was developed for a resident with behaviors related to wandering, adjustment to new living conditions and personal hobbies for 1 of 1 residents reviewed for elopement, (Resident 88) and failed to implement a comprehensive care plan for a resident who admitted to the facility with a trans metatarsal amputation (TMA) ( a surgical procedure that involves the removal of the distal portion of the metatarsal bones in the foot) for 1 of 5 residents reviewed (Resident 196).

Inspectors wroteBased on observation, interview, and record review, the facility failed to reassess the effectiveness of interventions and review and revise a resident's care plan (Resident 28 and Resident 241) for 2 of 23 residents reviewed for care plan revision.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the potential for accidents when call lights were observed out of reach, neurological checks were not completed, for 3 of 3 residents reviewed for accidents (Residents 10, 142, and 15), and failed to ensure medications were not left at bedside for 1 of 3 residents reviewed for accidents (Resident 10).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident without teeth or dentures was provided interventions to ensure the resident was able to eat and did not have significant weight loss of 11 percent over 6 months for 1 of 5 residents reviewed for nutrition (Resident 28).

Inspectors wroteBased on record review and interview, the facility failed to hold medications when a resident's vital signs were outside of the ordered parameters for 3 of 5 residents reviewed for unnecessary medications (Resident 196, 59, and 195).

Inspectors wroteBased on observation and interview, the facility failed to date multi-dose vials of tuberculin serum and failed to remove expired insulins from the medication cart for 2 of 3 refrigerators observed for medication storage and 1 of 3 medication carts observed for medication storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the physician was notified of a change in a reesident's condition related to the development of new impairments to their skin for 2 of 3 residents reviewed for pressure ulcers (Resident B and D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development of a new pressure ulcer for a resident with a history of pressure ulcers and ensure timely assessment and treatment of the new pressure ulcer for 1 of 3 residents reviewed for pressure ulcers (Resident B) .

Inspectors wroteBased on record review and interview, the facility failed to ensure residents' discharge instructions accurately reflected their reconciled medications to ensure residents were sent home with an accurate quantity of medications for 2 of 3 residents reviewed for discharge (Resident B and D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure grievances that had been filed on behalf of a resident were documented, followed up with, and resolved for 1 of 1 resident reviewed for grievances (Resident D).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications and wound treatment solutions were secured in the public hallway and in the resident rooms (Resident 11, 18, 5, and 21).

Inspectors wroteA. Based on observation and interview, the facility failed to distribute food under sanitary conditions by performing proper hand hygiene during meal service for 9 of 9 residents in the Lofts dining room (several unidentified residents and Resident 64). B. Based on observation and interview, the facility failed to distribute, serve food, and store used room trays under sanitary conditions and perform proper hand hygiene during meal service for 13 of 13 residents receiving meal tray in their room on the Lofts 2 hallway. C. Based on observation and interview, the facility failed to maintain sanitary conditions for use of an ice chest on the Lofts 2 hallway for 1 of 1 random observation (Resident 13).

Inspectors wroteBased on observation, interview, and record review, the facility failed to care for a resident in a manner that preserved the resident's dignity when she did not receive incontinence care in a timely manner for 1 of 5 residents reviewed for quality of care (Resident F).

Inspectors wroteA. Based on observation, interview, and record review, the facility failed to ensure effective interventions were in place to prevent a resident, (Resident E) from developing new pressure ulcers for 1 of 3 resident reviewed for pressure ulcers. B. Based on observation, interview, and record review, the facility failed to ensure appropriate hand hygiene and application of the correct treatment were provided during a wound treatment observation (Resident 18) for 1 of 3 resident reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident (Resident 41) who had a history of weight loss was provided with the appropriate supplemental health shake and was served meals according to her preferences for 1 of 3 residents reviewed for nutrition.