Evenglow Lodge

In the surveyor’s words

From the most serious findings on record at Evenglow Lodge, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Nov 29, 2023

  Based on observation, interview, and record review the facility failed to ensure proper food storage by failing to label foods with a date, ensure the walk-in cooler contained a thermometer, and ensure foods were not expired prior to serving. These failures have the potential affect all 32 residents residing in the facility. Findings include: On [DATE] from 8:00 AM until 8:18 AM an initial tour of the kitchen was conducted. The walk-in cooler did not contain a thermometer inside the cooler. The temperature gauge on the wall located outside of the cooler next to the door was not functioning and read 0 degrees Fahrenheit (F.) The walk-in cooler contained a plastic container of mixed fruit that was covered with plastic wrap and was not labeled with a date. […]

• No harm, potential for more than minimal, widespreadF880Nov 29, 2023

  Based on record review and interview the facility failed to implement their infection control program by failing to complete infection control logs and by failing to track, trend, and analyze infection data within the facility. This failure has the potential to affect all 32 residents that reside within the facility. Findings include: The Infection Prevention and Control Program dated 5/18/2018 documents it will include a system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents. […]

• No harm, potential for more than minimal, widespreadF880Nov 20, 2021

  Based on observation, interview, and record review the facility failed to properly contain COVID-19 by failing to minimize airflow into the hallway, failing to wear appropriate PPE (Personal Protective Equipment) and failing to wear PPE correctly. This failure affects 24 of 25 residents (R1, R3, R4, R5, R7-R16, R18-R27) reviewed for infection control in the sample list of 25. Findings include: The facility's Outbreak Guidance policy dated 11-17-21 documents, During an outbreak (one case is considered an outbreak): Staff must wear an N95 respirator and eye protection on all units until there are no new positive cases for 14 days. […]

• No harm, potential for more than minimal, patternF761Sep 5, 2024

  Based on observation, interview, and record review the facility failed to store resident's medications separately from food, failed to maintain a pharmacy label on medications and failed to discard/return medication for someone who was not a resident in the facility. This failure affects four residents (R11, R6, R8, R18) with medication in the medication room refrigerator in the sample list of 24. Findings include: The facility's Medication Storage Policy updated 11/1/16 documents, Medications and biologicals that are dispensed by a licensed nurse are stored in a locked cabinet/cart or locked in the medication room. On 9/3/24 at 2:38 PM, V3 (Registered Nurse) opened the medication storage room refrigerator and confirmed there is food stored in the refrigerator with resident's medications. […]

• No harm, potential for more than minimal, patternF607Jun 16, 2021

  Based on interview and record review, the facility failed to implement their abuse prohibition policy by failing to immediately report an allegation of abuse, failed to protect residents from the alleged perpetrator and failed to document resident injury and communication with family in a resident's (R5) medical record for 10 of 11 residents (R4,R5,R6, R8, R9, R10, R11, R12, R13 and R14) reviewed for abuse allegations on the sample list of 14. Findings Include: The facility Abuse and Neglect Prohibition Policy dated June 2020 documents, all residents have the right to be free of abuse, neglect, misappropriation of resident property, and exploitation as defined in this subpart. […]