Evergreen Living Center at Stagecoach

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and facility document review, the facility failed to ensure that the waste was properly contained in the dumpsters, and the area was free from debris. During a concurrent observation and interview on 06/03/2026 at 10:32 AM of the dumpster area with Dietary Manager (DM) the following was observed:-The dumpster lid was open-A clear bag of trash was lying on the ground in front of the dumpster-The fencing around the dumpster was open- Approximately fourteen pallets were stacked and leaning on the fencing. The DM indicated the lid and gates to the dumpster area were to be closed and the trash needed to be in the dumpster. The DM also stated the area needed to be clean to prevent pests and rodents that would spread the trash. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and facility document review, the facility failed to ensure that the food preparation equipment and environment were maintained in a clean and sanitary condition to prevent contamination and the potential development of food borne pathogens, specifically, not cleaning the drip pans, conveyor toasting system and the oven.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Comprehensive Care Plan contained the necessary information to fully provide and coordinate care and services for a resident with physician's orders for Hospice Services for 1 (Resident #192) of 3 sampled residents that were reviewed for Hospice Services.

Inspectors wroteBased on observation, interview and record review, it was determined the facility failed to ensure staff followed a care planned intervention requiring two staff members to perform a mechanical lift transfer for 1 (Resident # 43) of 4 sampled residents reviewed for accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post and make readily accessible to residents and visitors daily nurse staffing in a clear and readable format to include the facility name, date, total census and total number and actual hours worked by nursing staff. This failed practice had the potential to affect all 98 residents residing in the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure clean dishes and glasses were stored in a manner to prevent cross contamination; thickened liquids were dated when opened to prevent the potential for food borne illness; refrigerator temperature was maintained at 41 degrees Fahrenheit or below to prevent the potential for food borne illness; foods stored in the refrigerator and freezer were covered or sealed prevent the potential for food borne illness and employees washed their hands and changed gloves when contaminated to decrease the potential for food borne illness for residents receiving food from 1 of 1kitchen. The failed practice had the potential to affect 85 residents who received meal trays from the kitchen (total census 89), as identified on the list received from the Dietary Supervisor on 01/11/2024 at 11:20 AM.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure meals were served in a method that maintained the appearance of food items that were acceptable to the residents to improve palatability and encourage good nutritional intake during 1 of 1 meal observed. This failed practice had the potential to affect 58 residents who had regular diets; 20 residents who received mechanical soft diets; and 7 residents who received pureed diets as documented on a list provided by the Dietary Supervisor on 01/11/2024 at 1:58 PM.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure Personal Protection Equipment (PPE) was available to prevent the spread of infection and staff sanitized their hands appropriately when assisting residents with meals. This failed practice had the potential to affect all 89 residents in the facility.

Inspectors wroteBased on record review and interview, the facility failed to coordinate with the State Agency for a Pre-admission Screening and Resident Review (PASARR) to ensure the resident received appropriate mental health services for 2 (Residents #59 and #40) of 2 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive resident centered care plan for 1 (Resident #22) of 1 sampled resident addressed generalized anxiety, and major depression diagnoses and medications.

Inspectors wroteBased on record review and interview, the facility failed to ensure the plan of care was reviewed and revised to address tube feedings for 1 (Resident 43) of 1 sampled resident who had a physician's order for tube feedings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure fingernails were trimmed, cleaned, and free of jagged edges to promote good personal hygiene and grooming for 1 (Resident #18) of 7 (Residents #11, #18, #24, #41, #78, #83 and #191) sampled residents who were dependent on staff for nail care on the 100 Hall according to a list provided by Assistant Director of Nursing on 01/12/2024 at 3:40 PM.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the shower door on the 400 Hall was locked and a cabinet on the 100 was locked to prevent accidental ingestion harmful chemicals contained in both areas.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a residents oxygen tubing was dated for 1 (Resident #10) of 4 sampled residents who required oxygen to reduce the risk of infection.

Inspectors wroteBased on observation and interview, the facility failed to ensure only licensed staff had access to keys to the medication room to prevent the potential of misappropriation of resident property. This failed practice had the potential to affect all 89 residents in the facility that get medications from the medication room.