Evergreen House Health Center

Inspectors wroteBased on surveyor observation, clinical record review, and staff interview, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice. Specifically, the facility did not ensure the resident received a meal prior to departure for a scheduled medical appointment. The resident was transported without breakfast and had not received a meal since dinner the previous evening, an approximate sixteen-hour time period for 1 of 1 resident reviewed, Resident ID #1.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure that the unscheduled implementation of the fire and evacuation plan was reported immediately to the local state agency (Rhode Island Department of Health).

Inspectors wroteBased on record review, and resident and staff interview, it has been determined that the facility failed to ensure that the resident environment remains as free of accident hazards as possible, related to heating devices for 2 of 3 resident rooms observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is served utilizing professional standards for food service safety, relative to the main dining room. Record review of The Rhode Island Food Code 2022 edition 3-501.19 reads in part, .Time/Temperature Control For Safety Food shall have an initial temperature of .41 [degrees] F [Fahrenheit] or less when removed from cold holding temperature control .or 135 [degrees] F or greater when removed from hot holding temperature control . During a surveyor observation on 7/1/2025 at approximately 11:44 AM, whole milk had an internal temprature reading of 52 degrees F. During a surveyor observation on 7/2/2025 at 12:15 PM, a tossed salad with a grilled chicken breast had an internal temperature of 125 degrees F. [...]

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to store drugs and biologicals in accordance with currently accepted professional principles for 1 of 2 medication rooms and 2 of 5 medication carts observed.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide a dietary menu that meets the nutritional needs of residents, in accordance with established national guidelines, as evidenced by a planned menu which failed to follow standardized recipes.

Inspectors wroteBased on record review, resident and staff interview, it has been determined that the facility failed to keep a resident free from abuse for 1 of 3 residents reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure that food is stored, prepared, distributed, and served in accordance with professional standards for food service safety, relative to the main kitchen.

Inspectors wroteBased on surveyor observation, record review, resident and staff interview, it has been determined that the facility failed to ensure that services being provided meet professional standards of practice relative to following a physician's order for 1 of 2 residents reviewed with diabetic ulcers and for the use of off-loading boots, Resident ID #87.

Inspectors wroteBased on record review, resident, and staff interview, it has been determined that the facility failed to follow their policy relative to weights. Additionally, the facility failed to ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range for 1 of 3 residents reviewed for weight loss, Resident ID #28.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 8 residents reviewed whose medications were reconciled following the medication administration task, Resident ID #40, and 1 of 2 residents reviewed with diabetic foot wounds requiring offloading boots, Resident ID #87.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to maintain an infection prevention and control program (IPCP) to help prevent the transmission of communicable diseases and infections for 2 of 2 residents reviewed for contact precautions, Resident ID #s 32 and 64. Additionally, the facility failed to conduct appropriate infection control practices relative to the storage of a nebulizer mask for 1 of 1 resident reviewed with a nebulizer machine (a device for producing a fine spray of liquid, used for inhaling a medicinal drug), Resident ID #12.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure each resident receives the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 resident's reviewed, Resident ID #1.

Inspectors wroteBased on surveyor observation and staff interview, it has been determined that the facility failed to ensure that the facility stores, prepares, distributes, and serves food in accordance with professional standards for food service safety relative to the main kitchen.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to ensure the services provided by the facility meet professional standards of quality relative to following physician's orders for 1 of 2 residents reviewed with fluid restrictions, Resident ID #74, and 1 of 5 residents reviewed for weights, Resident ID #116.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to provide necessary treatment and services, consistent with professional standards of practice, to promote wound healing and prevent new ulcers from developing for 1 of 6 residents reviewed for pressure ulcers, Resident ID #93.

Inspectors wroteBased on surveyor observation, record review, and staff interview, it has been determined that the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to prevent further decrease in range of motion relative to the use of bilateral hand roll splints for one of three residents reviewed for range of motion, Resident ID #90.

Inspectors wroteBased on record review and staff interview, it has been determined that the facility failed to maintain medical records that are accurately documented in accordance with professional standards and practices for 1 of 1 residents reviewed for inaccurate documentation, relative to the use of bilateral hand roll splints, Resident ID #90.

Inspectors wroteBased on surveyor observation, staff interview and record review, it has been determined that the facility has failed to follow standard precautions to prevent the spread of infections for 1 of 2 sample residents observed for wound care, Resident ID #48.

Inspectors wroteBased on surveyor observation, record review, resident, and staff interview, it has been determined that the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 of 26 residents observed to have their call lights placed out of their reach, Resident ID #s 14, 43 and 323.