Evergreen Nursing & Rehab Center

Based 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. The goal for this problem is to be free from injury by next review date of 4/27/26. The interventions for this problem area are: anticipate needs of resident as much as possible, approach resident in a calm manner, calmly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include:R1's Face Sheet documented an admission Date of 6/6/25 and listed diagnoses including Diabetes Type 2 and Hypertension. The Face Sheet also identified V11 as R1's Power of Attorney.R1's Minimum Data Set, dated [DATE] documented that R1 has no deficits in cognition.R1's Care Plan dated 8/25/25 documented a problem area, Resident is at risk for complications due to Diabetes diagnosis, with corresponding intervention, administer meds (medications) as ordered and/or sliding scale.R1's September 2025 Physicians Order Sheet documented orders for Tresiba Flextouch U-100 (insulin degludec) (long acting) insulin pen 100/u (units) per ml (milliliter) administer 30u subcutaneously at bedtime, 7pm to 10pm, and Insulin Aspart (rapid acting) u100 pen give 10 u with meals.R1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.The findings include:R1's Face Sheet documented an admission Date of 6/6/25 and listed Diagnoses including Diabetes Type 2 and Hypertension. The Face Sheet also identified V11 as R1's Power of Attorney.R1's Minimum Data Set, dated [DATE] documented that R1 has no deficits in cognition.R1's Care Plan dated 8/25/25 documented a problem area, Resident is at risk for complications due to Diabetes Diagnosis, with corresponding intervention, Administer meds(medications) as ordered and/or sliding scale.R1's September 2025 Physicians Order Sheet documented orders for Tresiba Flextouch U-100 (insulin degludec) (long acting) insulin pen 100/u (units) per ml (milliliter) administer 30u subcutaneously at bedtime, 7pm to 10pm, and Insulin Aspart (rapid acting) u100 pen give 10 u with meals.R1's Medication Administration Record (MAR) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R3's Resident Face Sheet documents R3 was admitted to the facility on [DATE] with diagnoses that include anoxic brain damage, spastic hemiplegia, psychosis, major depressive disorder, peripheral vascular disease, anemia, osteoporosis, hypertension, acute kidney failure, acute myocardial infarction, dementia, and cellulitis. R3's MDS (Minimum Data Set) dated 07/17/2025 documents a BIMS (Brief Interview for Mental Status) score of 15, indicating R3 is cognitively intact. R3's current Care Plan documents a Focus area of Problem: Resident is at risk for pressure ulcer due to activity limited. This Focus area includes interventions of Weekly skin assessment with notes Start Date 04/17/2023 .Teach or do frequent small shifts of body weight Start Date: 04/17/2023 Consider postural alignment, weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. R2 Face Sheet documents an admission date of 02/11/25 and a discharge date of 02/17/25 with diagnoses including: aftercare following joint replacement surgery, presence of unspecified artificial hip joint, anxiety disorder, peripheral vascular disease, and pain. R2's Minimum Data Set (MDS) dated [DATE] documents a Brief Interview for Mental Status (BIMS) score of 12, indicating R2 has moderate cognitive impairment. R2's Care Plan documents: problem with a start date of 02/13/25: category: falls; (R2) is at risk for falls due to: recent hip surgery with an approach listed as: provide individualized toileting interventions based on needs/patterns dated 02/13/25. R2's Care Plan also documents a problem with a start date of 02/13/25 of (R2) is at risk for alteration in tissue perfusion due to: Dx…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: 1. R1's Face Sheet documented an admission Date of 12/3/24 and listed diagnoses including Displaced Comminuted Fracture of Shaft of Left Femur, Fibromyalgia, Polyneuropathy, Depression, and Anxiety Disorder. R1's Brief Interview for Mental Status Score (BIMS) dated 12/8/24 documented a score of 14, indicating R1 has minimal deficits in cognition. R1's Nursing Progress Note dated 12/3/24 documented, admitted a [AGE] year-old Caucasian female via ambulance from (local hospital). Brought into facility via stretcher and transferred to chair per 2 EMT's (Emergency Medical Technicians) with TTWB (Toe Touch Weight Bearing) status to LLE (Lower Left Extremity) (due to fractured left femur). This note further stated, Resident. States she has chronic pain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings include: R21's Face Sheet documented an admission to the facility on 2/2/24 and listed diagnoses including type 2 diabetes mellitus without complications, pressure ulcer of left heel stage 2, unspecified diastolic (congestive) heart failure and unspecified intellectual disabilities. R21's Physician Order Summary documented an order dated 10/11/2024, metronidazole 500mg. Cleanse area to left heel with NS (normal saline) or wound cleanser and apply betadine, crushed flagyl, calcium alginate and kerlix daily and as needed. R21's Minimum Data Set (MDS) dated [DATE] documents no Brief Interview for Mental Status (BIMS) score. Section C0700, under staff assessment for mental status documented memory problem, showing R21 had severe cognitive impairment. On 10/16/2024 at 2:50…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. R8 stated that he has had to wait 2 hours for his call light to be answered, which he too finds acceptable. R17, R7, R31, R30, R12, and R8 were all observed as being alert and oriented to person, place, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. During this initial tour the reach in refrigerator was found to have a bowl of potato salad that was not labeled with food item/date/time, drinks that were poured in glasses ready for tray assembly that were not covered, a black container that had a lid on it was not labeled with food item/date or time, and a bag of lunch meat on the bottom was not labeled. V11 (Food Service Supervisor) stated that a resident's family…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Review of R5's Resident Face Sheet documents a current admission date to the facility as 3/3/14 and birthdate indicating R5 is [AGE] years of age.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. The Findings include: R32 was admitted to this facility on 02/28/22 with primary diagnoses to include encephalopathy, vascular dementia, and depression according to his facility face sheet. R32's OBRA I (Omnibus Budget Reconciliation Act) dated 02/23/23 indicates he is appropriate for nursing services at this time. R32 was given a new diagnosis of major depressive disorder, recurrent severe without psychotic features on 11/08/22, and again on 07/10/23. R32's face sheet documents a diagnosis of major depressive disorder. R32's record does not contain a referral for a PASARR II screening after either of these diagnoses were added. On 09/01/23 at 10:58 AM, when asked for R32's PASARR II referral, V14 (Social Services) stated a referral for a level II screening had not been submitted because she did not see the new diagnosis…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. A problem area in R135's care plan with a start date of 8/31/23 documents that R135 is at risk for weakness or tiredness due to late effects of Cerebral Vascular Accident. The goal is for the resident to be out of bed daily and able to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.