Evergreen Health Services

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 5 residents reviewed for elopement. R1 was at risk for wandering and elopement. On 8/15/25, R1 exited the facility unsupervised and was found lying on the side of the road 0.3 miles from the facility. The facility failed to ensure all exit doors alarmed and did not have a system in place to ensure doors were secure and an audible alarm functioned. The facility's failure to provide adequate supervision for a resident assessed to be at risk for elopement and who exited the facility and was discovered laying on the side of a road and to ensure a properly functioning alarm system led to a finding of immediate jeopardy that began on 8/8/25. Nursing Home Administrator (NHA)-A was notified of the immediate jeopardy on 9/10/25 at 4:30 PM. [...]

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 8 residents (R) (R3, R10, R8, R9, R11, R14, R15, and R13) of 16 sampled residents received timely assistance for activities of daily living (ADLs)R3 and R10 experienced long call light response times and had to wait to be assisted to bed. R8 experienced long call light response times which caused increased incontinence and embarrassment. R9 experienced long call light response times which caused stress and difficulty completing ADLs so R9 could go to bed. R11, R14 and R15 experienced long call light response times which resulted in increased stress and incontinence. R13 experienced long call light response times which resulted in increased incontinence. In addition, R13 had to wait to be assisted to bed.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the transmission of communicable disease and infection. This practice had the potential to affect more than 4 of the 36 residents residing in the facility. The facility was following COVID-19 precautions due to staff exposure. During lunch and supper on 9/8/25, hand hygiene was not offered to residents prior to or after dining.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not provide the necessary enteral feeding services for 2 residents (R) (R2 and R1) of 2 sampled residents. R2 had an order to infuse 920 milliliters (mls) of enteral feeding between 8:00 PM and 4:00 AM. On 8/20/25 at 7:26 AM, R2's pump was running and had infused 990 mls. In addition, the head of R2's bed was not elevated to the proper height during multiple observations. R1 had an order to flush R1's feeding tube with 2000 ml of water per day after tube feeding at a rate of 390 until gone and an order for tube feeding with carbohydrate stability 1.2 (calories) 1422 ml at a rate of 90 for 15 continuous hours during the hours of 8:00 PM and 11:00 AM. [...]

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure meals were served at regular times and per resident preferences for 7 residents (R) (R27, R19, R14, R18, R237, R13, and R23) of 7 sampled residents. On 5/28/25 and 5/29/25, the facility served room trays 30 or more minutes after the posted meal service time for breakfast. On 5/27/25 and 5/28/25, the facility served room trays 30 or more minutes after the posted meal service time for lunch. In addition, R237 did not receive a lunch tray on 5/28/25 until one hour after the posted meal service time.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not provide appropriate respiratory care and services for 3 residents (R) (R237, R187 and R139) of 3 sampled residents. R237, R187, and R139 did not have physician's orders to use, clean, or maintain a continuous positive airway pressure (CPAP) machine.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure 1 resident (R) (R9) of 17 sampled residents was provided safe and accurate administration of drugs and biologicals. On 5/27/25, Surveyor observed a tube of 1% hydrocortisone cream on R9's bedside table. R9 did not have a physician's order for the cream or an order have medication at the bedside.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for 3 residents (R) (R33, R32, and R15) of 3 residents observed during the provision of cares. R33 was on enhanced barrier precautions (EBP). During an observation of care for R33, Certified Nursing Assistant (CNA)-D did not complete appropriate hand hygiene and did not don clean gloves while providing care. Licensed Practical Nurse (LPN)-E did not don a gown while providing care. In addition, R33's uncovered catheter drainage bag was observed on the floor. During wound care for R32, LPN-J did not complete hand hygiene between glove changes. [...]

Inspectors wroteBased on staff interview and record review, the facility did not ensure appropriate care and treatment were provided for 1 resident (R) (R29) of 1 resident reviewed for cardiac monitoring. The facility did not assess R29's ability to follow cardiac monitoring instructions or provide monitoring assessments for R29's cardiac monitor.

Inspectors wroteBased on observation, staff and resident interview, and record review, the facility did not ensure the provision of adequate supervision and assistance devices to prevent accidents for 3 residents (R) (R1, R4, and R3) of 3 sampled residents. On 10/24/24, R1 had a fall with injury while smoking outside without supervision. R1 sustained a head laceration and was transferred to the emergency room (ER). A smoking assessment indicated R1 could smoke independently unsupervised, however, R1 needed assistance with locomotion and could not independently get to or return from the smoking area. In addition, R1 did not have a smoking care plan at the time of the fall. R4 fell from a lift chair on 12/27/24. The facility did not reassess R4 for lift chair safety following the fall. R3 fell on [DATE]. A fall intervention was not implemented or added to R3's care plan in a timely manner.

Inspectors wrote2. On 8/7/24 at 9:35 AM, Surveyor observed LPN-D prepare medication for R4. LPN-D placed vitamin D 1000 units, an iron tablet, atorvastatin 10 mg (milligrams), Jardiance 10 mg, spironolactone 25 mg, furosemide 40 mg, furosemide 20 mg, Eliquis 5 mg, Entresto 24 mg, and carvedilol 3.125 mg in a medication cup. LPN-D then left the cup of medication unattended on top of the medication cart while LPN-D filled a pitcher of water. On 8/7/24 at 9:54 AM, Surveyor interviewed LPN-D who stated LPN-D did not usually leave medication unattended but felt it was okay since Surveyor was there. On 8/7/24 at 4:16 PM, Surveyor interviewed DON-B who verified medication should not be left on top of the medication cart unattended. DON-B stated DON-B expects staff to lock the medication in the cart or carry the medication with them. [...]

Inspectors wroteBased on staff interview and record review, the facility did not revise a plan of care to reflect current care needs for 1 resident (R6) of 12 sampled residents. R6 had chronic gout and gout flare ups which were not included in R6's plan of care.

Inspectors wroteBased on observation, staff interview, and record review, medication was not administered in accordance with the facility's policy for 1 resident (R) (R31) of 4 sampled residents. Staff did not ensure R31's insulin was administered in accordance with the facility's policy for subcutaneous injections.

Inspectors wroteBased on staff interview and record review, the facility did not ensure monitoring for adverse reactions to high-risk medications for 2 residents (R) (R21 and R32) of 5 residents reviewed for unnecessary medications. R21 and R32 were prescribed gabapentin (an anticonvulsant medication) for pain management. The facility did not monitor R21 and R32 for adverse reactions to gabapentin.

Inspectors wroteBased on staff interview and record review, the facility did not ensure hospice services were coordinated for 2 residents (R) (R27 and R15) of 2 residents reviewed for Hospice services. Hospice visit notes were kept in R27's room instead of in R27's medical record or a Hospice binder at the nurses' station. Hospice visit notes were not kept in R15's medical record. The facility did not have a designated person assigned to coordinate care for Hospice services.

Inspectors wroteBased on staff interview and record review, the facility did not ensure vaccines were reviewed, offered, and administered for 1 resident (R) (R20) of 5 sampled residents. The facility did not provide R20 the full pneumococcal vaccine series.

Inspectors wroteBased on staff interview and record review, the facility did not ensure a provider and power of attorney (POA) were notified following the development of a pressure injury for 1 Resident (R) (R1) of 4 sampled residents. R1 developed open areas on the left buttock on 12/21/23. R1's provider and POA were not notified until 12/23/23.

Inspectors wroteBased on staff interview and record review, the facility did not ensure necessary care and services were provided in a timely manner to promote healing for 1 Resident (R) (R1) of 4 resident reviewed for pressure injuries. R1 developed open areas on the left buttock on 12/21/23. R1's wounds were not assessed and treatment was not initiated until 12/23/23.

Inspectors wroteBased on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 42 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not monitor and document food holding temperatures. Staff did not test quaternary sanitizing solution per manufacturer's instructions. The facility did not monitor warewashing temperatures to ensure minimum wash temperatures were reached to prevent the spread of foodborne illness.

Inspectors wroteBased on staff interview and record review, the facility did not ensure the drug regimens for 3 Residents (R) (R26, R1 and R25) of 5 residents reviewed contained adequate monitoring for high-risk diuretic and/or narcotic medications. R26 had a physician's order for furosemide (a diuretic used to remove excess fluid from the body). The facility did not monitor for the effectiveness and side effects of the high-risk medication. R1 had a physician's order for hydrocodone-acetaminophen (a combination narcotic medication used to treat moderate to severe pain). The facility did not monitor for the effectiveness and side effects of the high-risk medication. R25 had a physician's order for furosemide. The facility did not monitor for the effectiveness and side effects of the high-risk medication.