Evergreen Nursing & Rehab Center

Inspectors wroteBased on interview and record review the facility failed to provide adequate supervision for 1 of 5 (R1) residents reviewed for elopements in a sample of 5. The Findings Include;R1's face sheet documents an admission date of 1/27/2026. This same document includes the following diagnosis: unspecified dementia, mild intellectual disabilities and anxiety disorder. R1's elopement assessment was completed on 5/7/26. This assessment documents that R1 is cognitively impaired/has poor decision making skills and has pertinent diagnosis, he displays behaviors indicate of an attempt to leave (body language, etc) that an elopement is forthcoming and that an elopement care plan is initiated. R1's care plan has a problem area with an initiation date of 1/27/26 as follows: resident exhibiting wandering behaviors and is at risk for injury related to impaired safety awareness. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that dialysis services were provided within the professional standards of practice for 1 of 3 residents (R1) reviewed for appointments in a sample of 7. This resulted in R1 experiencing fluid overload and being hospitalized .

Inspectors wroteBased on interview and record review, the facility failed to promptly notify a residents Physician and resident representative of a medication error for 1 of 3 residents (R1) reviewed for notification of changes in the sample of 9.

Inspectors wroteBased on interview and record review, the facility failed to administer insulin according to physicians' orders for 1 of 9 residents (R1) reviewed for medication errors in the sample of nine.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure treatments were administered as ordered by the physician for 1 of 3 (R3) residents reviewed for wounds in the sample of 28.

Inspectors wroteBased on interview and record review the facility failed to position residents properly to prevent injury for 1 of 3 residents (R1) reviewed for accidents in a sample of 11. This injury resulted in R1 sustaining a closed displaced fracture of right femoral neck. This past non-compliance occurred between 01/19/25 and 01/23/25.

Inspectors wroteBased on observation, interview, and record review the facility failed to place resident's call lights within reach for 3 of 11 residents (R2, R9, and R10) reviewed for call lights in a sample of 11.

Inspectors wroteBased on observation, interview, and, record review the facility failed to treat residents with dignity by answering call lights in a timely manner for two residents of nine residents (R1,R6) reviewed for resident rights in the sample of nine. This failure resulted in R1 and R6 experiencing feelings of embarrassment and humiliation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to formulate a Care Plan to address a resident's pain and to provide as needed pain medication in a timely fashion for one resident of nine residents (R1) reviewed for quality of care in the sample of nine. This failure resulted in R1 experiencing unresolved excruciating pain from a femur fracture, with accompanying feelings of fear and anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide timely ADL (Activities of Daily Living) assistance for residents who are dependent on staff for two of six residents (R1, R6) reviewed for ADL care in a sample of nine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain aseptic technique while performing a dressing change during wound treatment for 1 (R21) of 2 residents reviewed for infection control in the sample of 23.

Inspectors wroteBased on interview and record review the facility failed to ensure staffing levels were sufficient to meet resident needs in a timely manner. This failure has the potential to affect all 35 residents residing in the facility. Findings Include: On 08/29/23 at 01:55 PM, R17, R7, R31, R30, R12, and R8 stated that their needs are not tended to in a timely manner by staff. All agree that the staff do the best they can with the amount of people they have working, but there just doesn't seem to be enough to tend to everyone when needed. R17 and R7 stated that staffing levels and response times seem to be worse on weekends. R12 stated that previously she has had to wait for 30 minutes for her call light to be answered, as evidence by watching the clock. R12 stated she finds that amount of time to be unsatisfactory because, when ya gotta go, ya gotta go, referring to using the restroom. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to appropriately date and label refrigerated food items and store foods to maintain food quality in the freezer. This failure has the potential to affect all 35 residents. The Findings Include: On August 29th, 2023, from 9:00 AM-9:45 AM the initial tour of the kitchen was conducted, and the following items were found in the freezer: There were items that were opened for use and not labeled with date and time of opening and were not tied up to prevent freezer burn. Two bags of undetermined food products in clear plastic bags were loosely twisted at the top and not secured to prevent freezer burn. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 5 of 5 (R3, R5, R7, R21, and R26) residents reviewed for immunizations in the sample of 32, received the education addressing the benefits and risks and/or had the opportunity to receive the 20-valent pneumococcal conjugate vaccine (PCV20 or Prevnar 20). Findings Include: 1. Review of R3's Resident Face Sheet documents an admission date to the facility as 10/29/18 and documents a birthdate indicating R3 is [AGE] years of age. Diagnoses on this same document include, but are not limited to: Chronic Kidney Disease, stage 5; Diabetes Mellitus; Cerebral Infarction; Essential Hypertension. Review of R3's Clinical Record did not indicate that R3 had received the education addressing the benefits and risks or had the opportunity to receive or decline a dose of the 20-valent pneumococcal conjugate vaccine. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to refer 1 (R32) of 2 residents for a PASARR (Preadmission Screening and Resident Review) level II screening after receiving a new mental health diagnosis in a sample of 32 residents reviewed for assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents with limited mobility were properly assessed for assistive devices for 1 of 1 (R135) resident reviewed for assistive devices in a sample of 32. The Findings Include: R135's resident face sheet documents an admit date of 8/25/23. This same document includes the following diagnosis: frontal lobe and executive function deficit following non traumatic intracerebral hemorrhage, alcohol dependence, bipolar disorder, major depressive disorder, generalized anxiety disorder, post traumatic disorder, epilepsy, and cerebral infarction due to cerebral venous thrombosis, and functional quadriplegia. R135 is alert to person, place, and time. R135's care plan documents that he has a BIMS (Brief Interview of Mental Status) of 15 indicating that R135 is fully cognitively intact. [...]