Avantara Evergreen Park

In the surveyor’s words

From the most serious findings on record at Avantara Evergreen Park, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Jan 23, 2022

  Based on observation, interview, and record review, the facility failed to ensure that agency hired nursing staff (V17) was trained on facility emergency procedures prior to allowing her to work on the unit and provide care to residents. This failure affected one resident (R12) in the sample. As a result of this failure, V17 did not immediately response to call a code and start (CPR) for R12, who was found unresponsive in her bed. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE] and was removed on [DATE]. V1 (Administrator) was informed of the immediate jeopardy on [DATE] at 10:07AM. […]

• Actual harm, widespreadF726Jan 23, 2022

  Based on observation, interview, and record review, the facility failed to ensure that nursing staff had the necessary competencies required to care for a resident during an emergency situation. This failure applied to one of one (R12) residents reviewed for staff competence and has the potential to affect all 122 residents currently in the facility. Findings include: R12 is a [AGE] year old female, admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of medical record, documents that R12's advanced directive lists her as a full code. R12's current care plan includes Focus: Code Status, FULL CODE and Interventions (include): As indicated, document the code status on the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Actual harm, isolatedF689Apr 30, 2026

  Based on observation, interview, and record review, the facility failed to provide adequate supervision and failed to ensure fall precautions were implemented to prevent falls. These failures affected three residents (R12, R91, and R197) in a sample of 67 residents. This failure caused harm to R197, as evidenced by sustaining a right humorous fracture and traumatic hematoma on R197's forehead and contributed to R197's death 2 days after the fall.Findings include: R197's face sheet documents R197 was a [AGE] year-old resident with a prior medical history of chronic obstructive pulmonary disease, dementia without behavioral disturbance, restlessness and agitation, iron deficiency anemia, contusion of the head, and displaced supracondylar fracture of the right humerus. […]

• Actual harm, isolatedF684Sep 7, 2025

  Based on interview and record review, the facility failed to follow their guidelines of promptly transferring a resident who exhibited signs and symptoms of sepsis for six hours prior to transfer. This failure affected one (R1) of three residents reviewed for quality of care. This failure resulted in R1 requiring hospitalization and diagnosed with septic shock and pneumonia. Findings include:R1 is a [AGE] year old resident with diagnoses including but not limited to Benign Neoplasm of Cerebral Meninges, Other Seizures, Spastic Hemiplegia Affecting Right Dominant Side, Encephalopathy, Unspecified, Neoplasm of Unspecified Behavior of Brain, Type 2 Diabetes Mellitus Without Complications, Hyperlipidemia, Unspecified, Depression, Unspecified, Cerebral Edema, Cerebral Infarction, Unspecified,… […]

• Actual harm, isolatedF684May 23, 2025

  Based on interview and record review, the facility failed to ensure that one resident who was on pain medication had an effective bowel regime program to prevent constipation. This affected one of one resident (R18) reviewed for quality of nursing care and prevention of constipation. This failure led to R18 being sent to the hospital with a diagnosis of severe fecal impaction with stool ball measuring over 8 centimeters (CM). Findings include: R18 was admitted to the facility on [DATE] with a diagnosis of dependence on supplemental oxygen, heart failure , spinal stenosis, type II diabetes and atrial fibrillation. R18's brief interview for mental status dated 3/4/25 documents a score of 9 which indicates moderate cognitively impairment. […]