Evergreen Commons Rehabilitation and Nursing CTR

In the surveyor’s words

From the most serious findings on record at Evergreen Commons Rehabilitation and Nursing CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Jul 3, 2026

  Based on record review and interviews conducted during a survey, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for one (Residents #1) of three residents reviewed for accidents. Specifically, for Resident #1 on 02/28/2025, Certified Nurse Aide #5 did not use two-person assistance while providing incontinence care as required in Resident #1' s Comprehensive Care Plan. Resident #1 fell out of bed and sustained a head laceration requiring three staples to close the wound. This resulted in actual harm to Resident #1 that was not Immediate Jeopardy.Findings include: The policy and procedure titled, Care Plans/Comprehensive (Person Centered), last revised February 2024, documented all staff must abide and follow the resident specific care plan. […]

• No harm, potential for more than minimal, patternF584Jan 11, 2024

  Based on observation, interviews, and record review conducted during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not provide effective housekeeping and maintenance services on five (5) of 5 resident units checked. Specifically, the the facility did not ensure that resident room, resident bathroom, common areas, and closets were clean; and furniture and walls were in good repair. This is evidenced by: The following observations were noted on 01/10/2024 from 10:26 AM through 1:31 PM: Finding #1: Soiled Floors Floors were soiled in corners and next to walls in the following areas: Resident room #s 135, 147, 147, 158, 195, 184, 186, 183, 176, 215, 216, 217, 218, 222, 224, 225, 226, 232, 234, 235, 274, 281, 285, 287, 288, 293, 294, 295, and 296. […]

• No harm, potential for more than minimal, patternF761Jan 11, 2024

  Based on observation, interviews, and record review during the recertification survey from 01/03/2024 to 01/11/2024, the facility did not ensure safe and appropriate labeling and storage of all medications for 3 of 3 units for medication labeling and storage. Specifically, 5 insulin pens were not labeled with expiration dates after opening, and 1 insulin pen was not labeled with the date opened and the expiration date after opening by facility policy. This was evidenced by: The facility Medication Administration Policy, dated 07/28/2023, documented that the expiration date on the medication label must be checked prior to administering. The facility's Diabetic Management Policy, dated 11/2023, documented that upon opening a new vial of insulin, the nurse must date and initial the vial. […]

• No harm, potential for more than minimal, patternF812Jan 11, 2024

  Based on observation, staff interview, and record review during the recertification and abbreviated survey (Case #NY00324857) from 01/03/2024 to 01/11/2024, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the main kitchen and 11 of 11 kitchenettes checked. Specifically, serving utensils, food preparation area floors, and kitchenettes were not clean; and the main kitchen floor was not in good repair. This is evidenced by: During observations in the main kitchen on 01/03/2024 at 9:32 AM: - In the clean utensil rack, a wire whisk, 5 ladles, and one 4 ounce measuring spoon were soiled with food residue. […]

• No harm, potential for more than minimal, patternF908Jan 11, 2024

  Based on observation and interviews during the recertification and abbreviated survey (Case # NY00315024) from 01/03/2024 to 01/11/2024, the facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. Specifically, one hot water heater, the hot water holding tank thermometers, and one shower valve were not maintained in good repair. This is evidenced by: During hot water temperature checks on 01/05/2024 at 1:45 PM, the Two Schodack Square 20s shower hot water temperature was 58-degrees Fahrenheit; and hot water temperatures were between 95 and 113-degrees Fahrenheit on the following resident units: One Greenbush Lane, One Schodack Square, Two Greenbush Lane, Two Schodack Square, and Two Wynantskill Way (3 shower temperatures and 3 resident… […]