Evergreen Post Acute

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that for one (R109) out of seven residents reviewed for accidents, the facility failed to provide adequate supervision and implement safe bed mobility practices to prevent a fall. As a result, R109 fell from the bed, sustained a head laceration, required hospital transfer, and received six sutures causing harm to the resident.

Inspectors wroteBased on record review and interview, it was determined that for one (R155) out of one resident reviewed for hydration, the facility failed to ensure that R155 was offered sufficient fluids to maintain proper hydration. This failure resulted in harm with R155 being transferred to the hospital on [DATE] with diagnoses of dehydration and AKI (acute kidney injury).

Inspectors wroteBased on record review and interview, it was determined that for one (R30) out of five residents reviewed for abuse, the facility failed to report an injury of unknown source to the State Agency within the required timeframe.

Inspectors wroteBased on record review and interview, it was determined that for one (R30) out of three residents reviewed for quality of care, the facility failed to ensure care/treatment in accordance with professional standards of practice. Review of R30's clinical record revealed:4/1/23 - R30 was admitted to the facility. 3/8/26 10:48 AM - An SBAR (provider communication note) documented that R30 was observed with right hip discomfort and swelling noted. The SBAR also documented the provider was notified and awaiting a return call. 3/8/26 3:22 PM - A telephone physician's order for R30 documented diagnostic imaging x-ray of bilateral hips with two views. 3/8/26 8:35 PM - A radiology results report documented that x-ray was obtained and completed at 5:03 PM on 3/8/26. The results indicated and acute fracture of R30's right hip. [...]

Inspectors wroteBased on record review and interview, it was determined that for one (R153) out of six residents reviewed for pharmacy services, the facility failed to provide pharmaceutical services to meet the needs of each resident.

Inspectors wroteBased on observation and interview, it was determined that for two out of three resident units the facility failed to provide a clean and homelike environment.

Inspectors wroteBased on record review and interview, it was determined that for five residents (R91, R119, R120, R130, and R440) out of forty three sampled residents, it was determined that for R440 and R130 the facility failed to implement care plan interventions. For R12, the facility failed to hold a quarterly care plan meeting. For R91, R119, and R120 the facility failted to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings.

Inspectors wroteBased on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in manner that prevents food borne illness to the residents.

Inspectors wroteBased on record review and interview, it was determined that for two (R14 and R639) out of twelve residents reviewed for infection control, the facility failed to initiate and maintain appropriate precautions per CDC guidelines. Additionally the facility failed to follow standard precautions.

Inspectors wroteBased on observation and interview, it was determined that for one (R14) out of forty-three (43) residents in the investigative sample, the facility failed to ensure R14 was treated with respect and dignity.

Inspectors wroteBased on a random observation and interview, it was determined that for four (R37, R69, R72, and R133) residents, the facility failed to protect personal privacy.

Inspectors wroteBased on record review and interviews, it was determined for two (R40 and R50) out of forty-three sampled residents, the facility failed to ensure the MDS was accurate.

Inspectors wroteBased on record reviewed and interview it was determined that for one (R196) out of forty-three residents sampled, the facility failed to ensure the person centered care plan included necessary interventions.

Inspectors wroteBased on interview, observation and record reviews it was determined that for one (R132) out of one resident reviewed for communication the facility failed to provide assistive devices to support communication for R132 who was fluent only in Spanish. 3/8/25 - R132 was admitted to facility for rehabilitation. 3/8/25 - The care plan documented that R132's participation in activities was limited due to a language barrier, as the resident was fluent only in Spanish. R132 had difficulty communicating, as evidenced by a limited understanding and use of English. The care plan goal was to facilitate communication through alternative methods, such as a communication board, to express needs and wants. Interventions included teaching R132 how to use a communication book/board or electronic device and utilizing a Spanish interpreter as needed. [...]

Inspectors wrote2. Review of R73's clinical record revealed: 1/2/20 - R73 was admitted to the facility. 1/4/20 - A care plan documented that R73 required assitance with all ADL's with the following interventions: assist with daily hygiene, grooming, oral care, and eating as needed; encourage to participate in self care; praise all efforts; report any changes or decline to provider. 2/25/25 - A quaterly MDS documented R73 required set up or clean up assistance of one staff member for oral hygiene. Additionally the MDS documented R73had a BIMS score of 15 meaning he was cognitively intact. 4/8/25 8:21 AM - An interview with R73 revealed the need for assistance with ADL's and he feels that staff is not attentive to his needs. 4/10/25 9:37 AM - An interview with R73 confirmed that he brushes his teeth after staff set up breakfast. Also, R73 confirmed he had not been set up at this time to bursh his teeth. [...]

Inspectors wroteBased on interview and record review it was determined that for two (R112 and R644) out of forty three residents reviewed in the investigative sample, the facility failed to ensure received treatment and care in accordance with professional standards of practice and physician orders.

Inspectors wroteBased on observation, record review and interview, it was determined that for one (R35) out of 11 resiedents reviewed for accidents the facility failed to implement a care planned fall intervention.

Inspectors wroteBased on observation and interview, it was determined that for one (R3) out of ten residents sampled for dining, the facility failed to provide the therapeutic diet that was prescribed by the physician. The facility failed to provide R3 large portions.

Inspectors wroteBased on record review and interview, it was determined that for two (R18 & R33) out of five residents reviewed for antibiotic usage, the facility failed to monitor antibiotic usage.

Inspectors wroteBased on record review and interview, it was determined that for two (R33 and R96) out of twelve residents reviewed for pneumococcal vaccines, the facility failed to accurately assess the residents' pneumococcal vaccine status.

Inspectors wroteBased on observation and interview it was determined that for three out of three medication carts observed the facility failed to ensure that opened medications were labeled with an open date.

Inspectors wroteBased on record review and interview, it was determined that for one (R644) out of eleven residents, the facility failed to ensure that R644 was free of medication error. On 9/13/24, R644 was inadvertently given the incorrect medications (amlodopine 10mg, benzapril 40mg, Coreg 25 mg and selevamer 800mg). This medication error resulted in harm as R644's blood pressure significantly dropped and she was sent emergently to the hospital for evaluation and treatment. This harm is being cited as past non-compliance.

Inspectors wroteBased on record review and interview, it was determined that for one (R641) out of the seven residents reviewed for advanced directives, the facility failed to ensure that R641's' representative was included in the advanced directive acknowledgment as R641 had cognitive impairment.

Inspectors wroteBased on record review and interview, it was determined that for one (R188) out of four residents reviewed for Beneficiary Notification Review, the facility failed to ensure the resident was informed in advance of a change that occurred to their bill.

Inspectors wroteBased on record review and interviews, for one (R112) out of five sampled for abuse, it was determined that R112 was not free from involuntary seclusion.

Inspectors wroteBased on record review and interview, it was determined that for one (R79) out of five residents reviewed for hospitalizations, the facility failed to notify R79's responsible party in writing of the reason for transfer to the hospital.

Inspectors wroteBased on record review and interview, it was determined that for one (R136) out of forty-three sampled residents, the facility failed to complete a comprehensive assessment after R136 had a significant change in status.

Inspectors wroteBased on record review and interview it was determined that for one (R188) out of three residents reviewed for discharge the facility failed implement a discharge planning process that prepared the resident/RP to effectively transition to post-discharge care.

Inspectors wroteBased on interview, record review and a review of other facility documentation, it was determined that for one (R1) out of three sampled residents reviewed abuse, the facility failed to report an allegation of abuse.

Inspectors wroteBased on interview, record review and review of other facility documentation, it was determined that for one (R1) out of three sampled residents for investigating an allegation of abuse, the facility failed to protect residents from abuse and investigate an allegation of abuse.

Inspectors wroteREVISED POST IDR Based on observation, interviews and record review it was determined that for one (R110) out of two residents reviewed for pressure ulcers, the facility failed to provide care and services to prevent an avoidable deep tissue injury from developing, causing harm.

Inspectors wroteBased on record review, observations and interviews, it was determined that for one (R106) out of five residents reviewed for bowel and bladder, the facility failed to ensure appropriate treatment and services to restore and/or maintain bladder function were implemented.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure food was stored, prepared, and served in a manner that prevents food borne illness to the residents.

Inspectors wroteBased on record review and interview, it was determined that for five (R2, R32, R55, R88 and R120) out of five sampled residents for care plan timing and revision, the facility failed to have input from all required interdisciplinary team (IDT) members at the residents' care plan meetings.

Inspectors wroteBased on observation and interview, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe and sanitary environment.

Inspectors wroteBased on observation, interview and record review, it was determined that the facility failed to promote R18's dignity by keeping R18's urinary collection bag in a privacy bag.

Inspectors wroteBased on observations, interviews and record review, it was determined that for one (R65) out of one sampled resident reviewed for choices and preferences, the facility failed to accommodate R65's preference for showers.

Inspectors wroteBased on interview and record review, it was determined that for three (R18, R65 and R116 ) out of six residents reviewed for Advance Directives, the facility failed to offer an opportunity to formulate an advance directive.

Inspectors wroteBased on record review and interviews, it was determined that for one (R80) out of two reviewed for Personal Property, the facility failed to maintain evidence demonstrating the result of R80's grievance regarding her missing personal items. The facility grievance policy also lacked documentation a specific process for how the resident/family were informed of the results of the grievance investigation.

Inspectors wrote2. Review of R46's clinical record revealed: 9/11/15 - R46 was admitted to the facility with diagnoses including but not limited to anxiety. 5/7/24 - An quarterly MDS revealed that R46 had no behavioral occurrences during the review period. 5/2024 - A review of the CNA behavior flow sheet revealed that R46 had verbal aggression from 5/1/24 to 5/7/24. 5/16/24 10:35 AM - An interview with E37 (RNAC) revealed that she is not responsible for the section documenting the behaviors in the MDS. 5/16/24 10:42 AM - Interview with E7 (SW) confirmed that social services is responsible for documenting the behavior section of the MDS. E7 confirmed that R46 had documented behaviors and the MDS was inaccurate. 3. Review of R98's clinical record revealed: 7/24/23 - R98 was admitted to the facility. 4/25/24 - A quarterly MDS revealed that R98 had no behavioral occurrences during the review period. [...]

Inspectors wroteBased on interview and record review, it was determined that for four (R2, R28, R46 and R116) out of six residents reviewed for PASARR, the facility failed to ensure that a referral for a PASARR screening was completed.

Inspectors wroteBased on interview and record review, it was determined that for one (R47) out of six residents sampled for PASARR review, the facility failed to provide evidence that a Delaware State PASARR was obtained prior to admission.

Inspectors wroteBased on record review and interview, it was determined that for two (R40 and R106) out of three residents reviewed for bowel and bladder, the facility failed to develop a person centered care plan to address incontinence.

Inspectors wroteBased on record review and interviews, it was determined that for one (R3) out of four residents reviewed for Medication Administration, the facility failed to ensure that R3's care met accepted, professional standards. The nurses documented signing out multiple medications as being administered via the oral route when in fact, the medications were being given via the enteral route due to R3 being NPO.

Inspectors wroteBased on observation and interviews, it was determined that for four (R18, R54, R65, and R79) out of six residents reviewed for ADLs, the facility failed to ensure ADLs were provided to dependent residents.

Inspectors wrote3. Review of R397's clinical record revealed: 10/26/23 - R397 was admitted to the facility with diagnoses including type II diabetes and morbid obesity due to excess calories. 10/27/23 12:30 PM - A physician's order was written for Humalog quick pen inject 25 units intramuscularly three times a day for diabetes. 10/28/23 - A care plan was written for potential/alteration in Nutritional status related to a need for therapeutic, fluid restricted diet secondary to DM, cardiac dx, morbid obesity. Expected weight variances related to diuretic use. Interventions included record percent of each meal and/or supplement consumed and Record weight and notify physician, patient, family or significant other of any significant change as needed. 11/3/23 to 11/7/23 - A review of the CNA task sheet revealed that R397's meal consumption was documented as 0% from 6 PM on 11/4/23 through 6 PM on 11/7/23. [...]

Inspectors wroteBased on record review and interviews, it was determined that for one (R3) out of four residents reviewed for Medication Administration, the facility failed to ensure that R3's monthly medication review was completed.

Inspectors wrote3. Review of R47's clinical record revealed: 12/15/15 - R47 was admitted to the facility. 1/11/16 - A care plan was initiated for R47's use of anticoagulant therapy with an intervention of observing and monitoring for side effects such as blood in urine/stool, gums/nose bleeding, bruising. 10/21/22 - A physician's order for R47 was written for Pradaxa capsule (anticoagulant) one capsule by mouth twice a day related to chronic atrial fibrillation. 8/2023 - A review of the August MAR revealed no documentation related to adverse effects of anticoagulant therapy. 5/20/24 9:27 AM - An interview with E38 (UM) confirmed adverse effects were not being monitored for R47. 4. Review of R98's clinical record revealed: 7/24/23 - R98 was admitted to the facility with a diagnosis of major depressive disorder, concurrent. 4/25/24 - A quarterly MDS revealed R98 is prescribed an antidepressant. [...]

Inspectors wroteBased on observation and interview it was determined the facility failed to receive and document narcotic medications per professional standards of care.

Inspectors wroteBased on record review and interview, it was determined, for one (R79) out of one resident sampled for laboratory services, the facility failed to promptly notify the ordering medical practitioner of laboratory results that fell outside of clinical reference ranges.

Inspectors wroteBased on interview, record review and review of other facility documentation it was determined that the facility failed to ensure, in accordance with professional standards and practices, that medical records for two (R40 and R106) out of five residents of the investigative sampled residents were accurate.

Inspectors wroteBased on record review, observations and interviews, it was determined that for one (R106) out of three residents reviewed for accidents, the facility failed to ensure that R106 received adequate supervision to prevent falls. R106 fell two times due to lack of adequate supervision by staff resulting in harm to the resident, broken ribs and broken nose, which required him to be transferred to the hospital for treatment and evaluation. Additionally, R106 had multiple falls due to the lack of assistance with toileting and on 8/14/23, R106 got up to the bathroom that resulted in R106's fall and broken ribs.

Inspectors wroteBased on interview and record review, it was determined that for one (R399) out of one resident reviewed for hydration, the facility failed to ensure that R399 was offered adequate fluid intake to prevent dehydration. This resulted in harm where R399 was transferred to the hospital with a diagnosis of dehydration and lithium toxicity.

Inspectors wroteBased on record review and interview, it was determined that for one (R294) out of one sampled resident reviewed for reporting of alleged violations, it was determined that the facility failed to identify and immediately report an injury of unknown source.

Inspectors wroteBased on interview, record review, and review of other facility documentation, as indicated, it was determined that for one (R294) out of one sampled resident for investigate/correct alleged violation, the facility failed to thoroughly investigate an injury of unknown source. The facility policy on Abuse, Neglect and Exploitation last reviewed on 4/2/24 indicated the following: B. Written procedures for investigations include: 1. Identifying staff responsible for the investigation .3. Investigating different types of alleged violations; 4. Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; 5. Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and 6. [...]

Inspectors wroteBased on record review and interview, it was determined that for one (R297) out of four residents reviewed for respiratory care the facility failed to properly administer oxygen.

Inspectors wroteBased on record review, interview, and review of other facility documentation, it was determined that for two (R3 and R294) of five sampled residents, the facility failed to ensure the medical care of the resident was supervised by the physician regarding the evaluation of administration of medications by a PEG tube (a feeding tube) and the provision of care for a surgical wound.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that all staff employ hygienic practices, ensure the safe storage of food and beverages, and ensure food storage and preparation equipment is kept clean.

Inspectors wroteBased on interview and observation of one out of two units toured, it was determined that the facility failed to provide a clean and homelike environment.

Inspectors wroteBased on record review and interview, it was determined that for one (R49) out of three residents reviewed for hospitalization, the facility failed to ensure the Ombudsman was notified of the residents transfer to the hospital.

Inspectors wroteBased on observation, interview, and record review, it was determined that for one (R98) out of five sampled residents for ADL's (activities of daily living), the facility failed to provide oral hygiene and grooming of facial hair for a resident that required extensive assistance.

Inspectors wroteBased on interview, record review and review of other documentation, it was determined that for one (R128) out of one resident reviewed for skin conditions, the facility failed to initiate timely treatment to R128's pinky toe.

Inspectors wroteBased on interview and record review, it was determined that for one (R15) out of one resident reviewed for dialysis, the facility failed to monitor the residents dialysis catheter.

Inspectors wroteBased on review of facility documentation and interview, it was determined that for six (E8, E9, E10, E11, E12 and E21) out of six employee evaluations reviewed, the facility failed to ensure that performance evaluations were conducted every 12 months.

Inspectors wroteBased on observation and interview, it was determined that the facility failed to ensure that it was free of a medication error rate of 5% or greater. Medication pass observations identified three (3) errors out of twenty-six (26) opportunities, resulting in a medication error rate of 11.5%.

Inspectors wroteBased on observation and staff interview, it was determined that the facility failed to ensure that one (R116) out of eight (8) sampled residents reviewed for medication (med) review was free from significant medication errors. During a med pass observation, R116 was administered three oral meds in a crushed form that did not follow the manufacturer's instructions to not crush the meds prior to administration.

Inspectors wroteBased on interview and record review, it was determined that for one (R98) out of two sampled residents for dental services, the facility failed to assist the resident in obtaining routine dental services.

Inspectors wroteBased on record review and interview, it was determined that for one (R7) out of five residents reviewed for unnecessary medication administration, the facility failed to properly identify the appropriate indication for which the medication Tamsulosin was being administered.

Inspectors wroteBased on interview and record review, it was determined that the facility failed to provide one (R98) out five sampled residents for immunizations, an informed consent for four administered doses of the COVID-19 vaccine.