Evergreen Health and Rehabilitation Center

Inspectors wroteThis citation pertains to intake: 2809647. Based on observation, interview and record review the facility failed to conduct a thorough investigation for a staff to resident abuse allegation and failed to protect the alleged victim (resident) while the investigation was conducted for one (R303) of three residents reviewed for abuse.

Inspectors wroteThis citation pertains to intake(s): 2966229 & 2803135. Based on interview and record reviews the facility failed to complete Braden assessments per the facility policy, failed to accurately/timely implement wound orders and failed to ensure timely reporting of abnormal changes to wounds for two (R's 304 & 305) of three residents reviewed for pressure wounds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare food in accordance with professional standards for food service safety. This deficient practice has the potential to result in food borne illness among all residents that consume food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure quarterly health care conferences were conducted for one (R154) out of one resident reviewed for care conferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure lidocaine patches were available to administer for one resident (R6) of one resident reviewed for medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure tube feeding and water flushes for hydration were administered per physician's orders for one resident (R23) of one resident, resulting in the potential for unmet nutrition and hydration needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Physican ordered laboratory (labs) were obtained for one resident (R81) of one resident reviewed for laboratory diagnostics.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assistive devices for eating were provided to one resident (R17) of 21 residents reviewed for dining.

Inspectors wroteThis citation pertains to intake: 2581302. Based on interview and record reviews the facility failed to accurately assess, timely report a change in condition to the Physician and timely transfer to a higher level of care, for one (R404) of three residents reviewed for a change of condition/timely transfer to the hospital.

Inspectors wroteThis citation pertains to Intake Number(s): MI00150988. Based on interview and record review, the facility failed to thoroughly evaluate and timely address a foot injury for one (R802) of one resident reviewed for a change in condition, resulting in a delay in diagnosing and treating a moderately comminuted avulsion fracture (bone broken in multiple places) to the resident's heel (calcaneus), increased pain, and the inability to fully participate in physical rehabilitation.

Inspectors wroteThis citation pertains to intake #MI00150776. Based on interview and record review, the facility failed to provide timely incontinence care for one (R801) of two residents reviewed for bowel and bladder.

Inspectors wroteThis citation pertains to intake #MI00150187. Based on interview and record review the facility failed to ensure a consent for psychotropic medications were obtained from a legally authorized resident representative for one resident (R303) of three residents reviewed for rights of legally authorized representatives.

Inspectors wroteThis citation pertains to intake #MI00150047 Based on interview, and record review, the facility failed to follow pest control procedures for one resident (R305) of three residents reviewed for pest control.

Inspectors wroteThis citation pertains to Intake Number MI00147674. Based on interviews and record review, the facility failed to protect the resident's right to be free from physical abuse by a resident for one (R803) of four residents reviewed for abuse, resulting in R804 pushing R803 out of their wheelchair.

Inspectors wroteThis citation pertains to Intake # MI000148791 Based on interview and record review the facility failed to report allegations of neglect to the Administrator/Abuse Coordinator and to the State Agency (SA) for one (R806) out of four residents reviewed for Abuse/Neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure unrestricted, 24-hour visitation for residents. This deficient practice had the ability to affect all 143 residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the ventilation hood filters in a sanitary manner, failed to ensure the dish machine was sanitizing, and failed to maintain the dish machine in a sanitary manner. This deficient practice had the potential to affect all residents that consume food from the kitchen.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an environment that promoted and enhanced residents' dignity for multiple residents, including three (R42, R73, and R85) of residents reviewed for dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure choice of an attending physician was honored for one (R288) of three residents reviewed for choices.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate notice in a dignified manner of a room change for one (R289) of one resident reviewed for room changes.

Inspectors wroteBased on interview and record review, the facility failed to execute a Do-Not-Resuscitate (DNR) Advance Directive order for one resident (R128) reviewed of two residents reviewed for Advance Directives.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a safe and collaborated discharge for one (R29) of three residents reviewed for discharge.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a baseline care plan for tube feeding was provided to one (R287) of one resident reviewed for tube feeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were accurately documented and orders written according to professional standards of practice for two (R27 and R287) residents.

Inspectors wroteThis citation has 2 Deficient Practice Statements. Deficient Practice Statement #1 Based on observation, interview and record review, the facility failed to provide wound care for two (R337 and R120) of two residents reviewed for nonpressure related wound care.

Inspectors wroteBased on observation interview and record review the facility failed to ensure there were wound care orders placed for one resident (R337) of two residents reviewed for pressure ulcers.

Inspectors wroteBased on observations, interview and record review the facility failed assess promptly after a fall for one (R29) resident of reviewed for accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure proper infection control protocols and practices including hand hygiene during meals, transmission-based precautions (TBP) regarding use of personal protective equipment (PPE) and room placement for four (R42, R73, R288, and R289) of four residents reviewed for infection control.

Inspectors wroteThis citation pertains to intake #MI00144802. Based on interview and record review, the facility failed to ensure safe transfer per plan of care (use of a mechanical hoyer lift) and facility policy for one (R901) of three residents reviewed for accidents.

Inspectors wroteThis citation pertains to intake #s MI00143487 and MI00143823. Based on observation, interview and record review, the facility failed to maintain a clean, comfortable, safe, and homelike environment, as evidenced by soiled floors, walls, trash/debris throughout the facility, broken chair and tile, unsecured sharps and chemicals, and visible harborage of pests. This deficient practice has the potential to affect multiple residents throughout the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure a medication cart was locked and secured, resulting in the potential for unauthorized access and diversion of narcotic medications.

Inspectors wroteThis citation pertains to intake: MI00142846. Based on interview and record review the facility failed to ensure staff timely identified a worsening of condition and communicated a change of condition with the nursing staff and physician staff for one (R801) of three residents reviewed for a change of condition.

Inspectors wroteThis citation pertains to Intake(s): MI0014286, MI00143149, MI00142861 & MI00143213. Based on observation, interview, and record review the facility failed to ensure pressure wounds were identified (R801), assessed and monitored by physicians/wound clinicians consistently if at all (R's 801 & 804) , implement effective treatment for identified wounds timely (R803), implement preventive interventions (R802) for four (R's 801, 802, 803 & 804) of four residents reviewed for wounds, resulting in R801 to have developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) coccyx/sacrum wound, R802 to have developed a Deep Tissue Injury (DTI- Intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration due to damage of underlying [...]

Inspectors wroteThis citation pertains to intake: MI00142846 Based on interviews and record reviews the facility failed to ensure professional standards of nursing practice was provided by the nursing staff to administer pain medications as directed by the physician for one (R801) of three residents reviewed for pain.

Inspectors wroteThis citation pertains to intake: MI00142846. Based on interviews and record reviews the facility staff failed to ensure labs were completed as ordered by the medical clinicians for one (R801) of three residents reviewed for a change of condition.

Inspectors wroteThis citation pertains to intake: MI00143149 & MI00142861. Based on interviews and record reviews the facility failed to ensure supervision for an appointment (appt) was provided for a resident who lacked capacity, one R802 of three residents reviewed for accidents.

Inspectors wroteThis citation pertains to intake: MI00142846. Based on interview and record reviews the facility failed to obtain weights per the facility's policy for one (R801) of one resident reviewed for weight loss.

Inspectors wroteThis citation pertains to intake: MI00143213. Based on interview and record review the facility failed to provide therapy services as ordered by the physician for one (R803) of two residents reviewed for rehabilitation services.

Inspectors wroteThis citation pertains to Intake Number(s): MI00141529. Based on interview and record review, the facility failed to assess and treat a resident who expressed pain for one (R804) of two residents reviewed for changes in condition, resulting in unrelieved pain.

Inspectors wroteThis citation pertains to Intake Number(s): MI00142295 and MI00142293. Based on observation, interview, and record review, the facility failed to ensure safe positioning in a wheelchair with access to a call light for one (R801) of two residents reviewed for falls, resulting in a fall from the wheelchair and sustaining a bump to the head.

Inspectors wroteThis citation pertains to Intake MI00139462 Based on interview and record review the facility failed to ensure narcotic medications were documented as administered per professional standards for one (R802) of one resident reviewed for professional standards resulting in the inaccurate representation of the amount given and the effectiveness of pain medications.

Inspectors wroteThis citation pertains to intakes: MI00140611 and MI00140683. Based on observation, interview, and record review, the facility failed to timely obtain, acknowledge and ensure a resident's choice for health care decision making prior to petitioning for a third party guardian for one (R807) of one resident reviewed for resident rights, resulting in expressions of extreme frustration, distress, fear of loss of autonomy and the increased potential for further denial of the resident's right for self-determination under a reasonable person concept for a resident who had appointed a family member as their legal representative prior to the deterioration of their health condition.

Inspectors wroteThis citation pertains to Intake MI00139532, MI00139080 Based on observation, interview and record review, the facility failed to provide food in the prescribed texture/consistency for one (R803) of four residents reviewed for therapeutic diets, resulting in the increased potential for episodes of choking and aspiration to occur.

Inspectors wroteThis citation pertains to Intake #MI00135548 Based on interview and record review the facility failed to initiate necessary treatments for one (R155) of seven resident's reviewed for pressure ulcers, resulting in the worsening of a pressure wound to the spine.

Inspectors wroteThis citation pertains to Intake #MI00134725 Based on observation, interview and record review the facility failed to timely review abnormal lab results for one (R58) out of four residents reviewed for Urinary Tract Infection (UTI) resulting in a delay in treatment for a UTI and hospitilization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a sanitary kitchen; ensure food items were properly labeled, dated, and stored; monitor and maintain refrigerator and freezer temperature logs; and ensure proper functioning of the dish machine, resulting in the increased potential for cross-contamination and foodborne illness. These deficient practices had the potential to affect all residents that consume food from the kitchen. On 6/27/23, during an initial tour of the kitchen with Interim Dietary Manager (Staff 'S') between 8:56 AM - 9:45 AM, the following items were observed: In the dry storage room, there was an opened plastic bag of pecans that were stored on a top shelf. The package was not properly sealed and was open to air, and there was no date of when it had been opened. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a homelike dining experience based on the reasonable person standard for one resident (R94) and multiple other residents with cognitive impairments who ate their meals in the Anna's Place dining room.

Inspectors wroteR153 A complaint was filed with the SA that alleged R153 was not receiving weekly showers two times per week. A review of R153's clinical record documented the resident was admitted to the facility on [DATE] with diagnoses that included: cellulitis, gangrene and type II diabetes. A review of the resident's MDS indicated the resident had a Brief Interview for Mental Status (BIMS)score of 15/15 (cognitively intact) and required extensive one to two person assist for most ADLs. On 6/28/23 at approximately 10:11 AM, the facility was asked to provide any documentation pertaining to R153's showers during their stay at the facility. The following paper shower documents were provided: 1/24/23: R (refused) 2/1/23: Shower not provided 2/10/23: [...]

Inspectors wroteThis citation pertains to intake # MI00134296 Based on observation, interview, and record review the facility failed to ensure over an extended period that residents with limited mobility were assessed timely for appropriate assistive devices to maintain or improve functional mobility for one (R118) of one Residents reviewed for mobility and assistive devices resulting in the potential for a decline their bed mobility/self-care, dissatisfaction, and frustration with care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure appropriate storage and/or labeling of medications and treatments/biologicals in three of five medication carts and one treatment carts reviewed, resulting in the potential for unauthorized entry, misuse, contamination, and diversion of narcotics and controlled substances. This deficient practice has the potential to affect multiple residents in the facility.

Inspectors wroteOn 6/29/23 at 8:23 AM, R55's Family Member was interviewed by phone. When asked about concerns at the facility, R55's Family Member explained the meals are frequently served late, as an example, on 6/28/23, lunch was not served until 1:40 PM and dinner will sometime be served at 6:30 PM, an hour after it is supposed to be served .it is ridiculous because the residents are just sitting in the dining room with nothing to do, they just sit there for hours. Based on observation, interview, and record review, the facility failed to ensure meals were served in a timely manner and per facility scheduled times for residents that resided within the Anna's House (secured unit), resulting in delayed meal service and dissatisfaction with the dining experience.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper infection control practices were followed for one (R148) of three residents reviewed for transmission-based precautions (TBP).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication administration was performed according to professional nursing standards of practice for two (R90 and R253) residents.

Inspectors wroteThis citation pertains to Intake #MI00136649 Based on interview and record review, the facility failed to ensure a resident was adequately prepared for discharge home for one (R156) of three sampled residents reviewed for discharge planning from a total of three

Inspectors wroteThis citation has two deficient practices. Deficient practice #1. This citation pertains to Intake #MI00137787 and MI00137804. Based on interview and record review the facility failed to ensure neuro checks were completed following a resident's fall causing injury to the head for one (R162) of seven residents reviewed for falls/accidents.

Inspectors wroteThis citation pertains to intake #'s MI00136943 and MI00136471. Based on observation, interview, and record review, the facility failed to perform a wheelchair transport in a safe manner and thoroughly investigate the root cause of an injury; and failed to follow the plan of care for two (R4 and R110) of eight Residents reviewed for accidents hazards, resulting in an injury (bruising, redness, swelling, and pain) to R4's ankle and potential for further falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessment and monitoring of hydration for one (R51) of one resident reviewed for hydration.

Inspectors wroteThis citation pertains to Intake #MI134568 Based on observation, interview and record review, the facility failed to ensure consistent communication between the hemodialysis center and the facility for one (R152) of three residents reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two (Nurse 'PP' and Nurse Aide 'N') of 11 nursing staff reviewedf had the skills and competencies necessary to care for residents' needs.

Inspectors wroteThis citation pertains to intake #MI00137804. Based on observation, interview and record review the facility failed to ensure a Physician ordered laboratory diagnostic were completed in a timely manner for one resident (R67) of one residents reviewed for laboratory diagnostics.

Inspectors wroteBased on interview and record review the facility failed to ensure a legally authorized representative signed a binding arbitration agreement (a legal contract that dictates an out-of-court alternate form of dispute resolution) for one resident (R152) of four residents reviewed for binding arbitration agreements.