Evergreen Nursing Home

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for five (#5, #7, #4, #2 and #3) of ten residents reviewed for abuse out of 12 sample residents. Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease with behavioral disturbances. Resident #6 had a history of wandering and physical aggression. Resident #6 was admitted on [DATE] with diagnoses of dementia. Resident #5 had a history of physical aggression. On [DATE], Resident #6 and Resident #5 had a physical altercation, where the nurse observed Resident #6 push Resident #5. Resident #5 lost his balanced and fell and hit his head on a chair before he landed on the floor. The nurse observed Resident #5 bleeding from his head. The nurse progress note revealed Resident #5 was transferred to the emergency department for evaluation and treatment. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one (#5) of the three residents reviewed for accidents out of 12 sample residents remained free from accidents. Specifically, the facility failed to timely implement person centered fall interventions for Resident #5, who had multiple falls with major injury. Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia. Resident #5 sustained a fall on [DATE] and on [DATE]. On [DATE] Resident #5 had a physical therapy evaluation that determined Resident #5 required supervision or touching assistance for ambulation. The change in level of assistance for ambulation was not communicated to nursing staff until [DATE]. During that time, Resident #5 sustained two more falls on [DATE] at [DATE]. [...]

Inspectors wroteBased on observations and interviews, the facility failed to provide a functional, comfortable and homelike environment for residents on two of two units. Specifically, the facility failed to: -Ensure the residents residing in room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were provided with appropriate hot water in the bathroom sinks; and, -Ensure high back dining room chairs in the secure unit dining room and the main dining room were free from cracks and tears.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#18) of three residents out of 26 sample residents reviewed for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, for Resident #18, the facility failed to: -Ensure a wheelchair positioning device was care planned; and, -Ensure the wheelchair positioning device was positioned appropriately and consistently to keep the resident from leaning in her wheelchair.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#4) of two residents reviewed for pain out of 26 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences. Specifically, the facility failed to ensure Resident #4 was offered effective pain management to include non-pharmacological interventions and as needed (PRN) pain medications for breakthrough pain.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of one medication storage rooms. Specifically the facility failed to: -Ensure expired medications were removed from the medication refrigerator; and, -Ensure medications were labeled with open dates.

Inspectors wroteBased on observations, record review and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections. Specifically, the facility failed to ensure Resident #33's catheter drainage bag was not touching the floor.

Inspectors wroteBased on record review and interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for two (#33 and #346) of five residents reviewed for immunizations out of 26 sample residents. Specifically, the facility failed to offer Resident #33 and Resident #346 additional recommended doses of the pneumococcal vaccination.

Inspectors wroteBased on record review and interviews, the facility failed to ensure licensed nurses and certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for three out of three registered nurses (RN), two out of two licensed practical nurses (LPN) and five out of five CNAs reviewed for competencies.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -Cutting boards were free from deep scratches and stains; -Beard restraints were worn in kitchen areas while serving food; and, -To ensure the food was stored and labeled properly.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#40 and #10) of four residents reviewed for abuse out of 18 sample residents. Specially, the facility failed to prevent a resident to resident altercation between Resident #10 and Resident #40.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who displayed or was diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#10) of 10 residents reviewed for dementia care out of 18 sample residents. Specifically, the facility failed to -Develop and implement effective dementia management focused interventions to prevent Resident #10 form unsafe wandering and engaging in physically abusive resident to resident altercations; -Consistently document and assess Resident #10's wandering and physically aggressive behavior in order to determine the cause of behavior and ensure intervention effectiveness; [...]

Inspectors wroteBased on record review and interviews the facility failed to ensure for one (#38) of one resident who required dialysis received such services, consistent with professional standards of practice out of 19 sample residents. Specifically, the facility failed to for Resident #38: -Obtain a physician's order for hemodialysis (HD); -Obtain a physician's order to monitor the HD port; -Obtain a physician's order for dressing changes on the port; -Update the dialysis care plan with the HD port; and, -Identify the resident was receiving dialysis services on the minimum data set (MDS).