Evergreen Crossing and the Lofts

In the surveyor’s words

From the most serious findings on record at Evergreen Crossing and the Lofts, in the surveyor’s own words.

• Immediate jeopardy, patternF697Sep 10, 2021

  Based on observation, interview and record review, the facility failed to ensure pain management was provided to 8 residents, (Residents, BC, CX, BG, BD, BF, AH, CR and CT) consistent with professional standards of practice to relieve their pain and honor their residents' preferences for 8 of 8 residents reviewed for pain management. The immediate jeopardy began on 8/31/21 when the Nurse Practitioner (NP) changed the 8 alert and oriented residents' narcotic pain medications. Residents BC, CX, BG, BD, BF, CR and CT were not notified prior to the change in their medication and therefore, did not have the opportunity to participate in making decisions about their medical care. […]

• Immediate jeopardy, isolatedF684Jul 14, 2022

  Based on observation, interview and record review, the facility failed to ensure thorough assessments of residents to identify change in conditions, send residents with change of conditions out the hospital upon residents' request and failed to identify necrotic toes on a resident's foot prior to admission to the hospital emergency room for 2 of 3 residents reviewed for hospitalization (Resident B and C). The immediate jeopardy began on 6/14/22, when Resident B called 911 and requested to be sent to the hospital due to nausea, vomiting, and not feeling right. Resident B arrived at the hospital emergency room (ER) covered in stool and urine, had gangrenous toes, and had open wounds to his heel. On 6/20/22, Resident C was seen by the psychiatrist and was confused. […]

• Immediate jeopardy, isolatedF690Jul 14, 2022

  Based on observation, interview and record review, the facility failed to ensure thorough assessments of residents with urinary catheters to identify a change in condition, to send residents with a change of condition out to the hospital including upon the residents' request for 2 of 2 residents reviewed for urinary catheters/urinary tract infections (Resident B and D) and failed to ensure catheter care for a resident with a indwelling foley catheter to prevent the development of wounds to the penis and scrotum for 1 of 8 residents reviewed for urinary catheters/urinary tract infections (Resident B). The immediate jeopardy began on 6/14/22 when Resident B called 911 to go the hospital emergency room (ER) for nausea, vomiting, and not feeling well. […]

• Immediate jeopardy, isolatedF678Oct 25, 2021

  Based on interview and record review, the facility failed to monitor, assess and had a delay in providing Cardio-Pulmonary Resuscitation (CPR) according to the resident's code status preference, and failed to follow the CPR procedure for unresponsive residents for 1 of 3 residents reviewed for death (Resident J). The Immediate Jeopardy began [DATE], when the facility failed to initiate CPR on a resident found unresponsive. The Executive Director (ED), Administrator in Training (AIT) and Regional Director of Operations (RDCO) were notified of the Immediate Jeopardy on [DATE] at 4:25 p.m. […]

• Immediate jeopardy, isolatedF684Oct 25, 2021

  Based on interview and record review, the facility failed to have a system in place for ordering, obtaining, and tracking of STAT (urgent, rush, immediate) laboratory orders, and failed to ensure assessments and documentation were completed after a change in condition for 1 of 3 residents reviewed for death (Resident J). The Immediate Jeopardy began October 8, 2021, when the facility failed to ensure STAT laboratory orders were obtained and failed to document follow up assessments after the physician noted a change in condition to include a further decline in mental status, and new onset jaundice and bruising. […]