Evergreen Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Evergreen Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 25, 2023

  Based on observation, staff interview, facility document review, and clinical record review, the facility staff failed to provide care and services to prevent and treat pressure ulcers/injuries for three of 20 residents in the survey sample, Residents #6, #1, and #7. For Resident #6, who was admitted with a pressure/ulcer injury, the facility staff failed to initiate treatment to the pressure ulcer/injury for 20 days. The pressure ulcer/injury worsened, which resulted in harm. The findings include: 1. For Resident #6 (R6), who was admitted on [DATE], with a stage three pressure injury (2) to the sacrum, the facility failed to initiate treatment for the pressure injury until 4/20/23. […]

• Actual harm, isolatedF689Jun 15, 2021

  Based on observation, staff interview, facility document review, clinical record review, and in the course of a complaint investigation, it was determined the facility staff failed to provide supervision, assistive devices, and environment free of hazards to prevent injury for two of ten residents in the survey sample, (Resident #1 and Resident #7). 1. The facility staff failed to ensure Resident #1, with diagnoses including dementia and a stroke, who was mobile in a wheelchair, with wandering behaviors and a wander guard in place, and coded as severely impaired for cognition, was not able to exit the facility unsupervised through the front doors. […]

• No harm, potential for more than minimal, widespreadF865Jan 10, 2024

  Based on staff interview and facility document review it was determined that the facility staff failed to evidence a continuous Quality Assurance and Performance Improvement (QAPI) program that monitored its performance and ensured that improvements were sustained, which had the ability to affect all Residents within the facility during quarter two (Q2) to quarter four (Q4) of 2022. The findings included: The facility staff failed to evidence QAPI sign-in sheets for meetings held between Q2 through Q4 of 2022. On 1/8/2024 at 12:05 p.m. […]

• No harm, potential for more than minimal, widespreadF880Jan 10, 2024

  Based on observation, staff interview, facility document review and clinical record review, it was determined the facility staff failed to maintain an effective infection control program for two of 42 residents in the survey sample, Residents #124 and #122, and failed to maintain the infection control tracking logs. The findings include: 1. For Resident #124 (R124), the facility staff failed to put on PPE (personal protection equipment) when entering the room as the resident was on droplet isolation for influenza. Observation of dining was conducted 1/8/2024 at 5:11 p.m. of CNA (certified nursing assistant) #5 was passing meal trays on the 100 unit. She picked a tray off the dietary cart and proceeded to walk in to R124's room without donning PPE. […]

• No harm, potential for more than minimal, widespreadF812Apr 14, 2022

  Based on observation, staff interview and facility document review, it was determined that the facility staff failed to store food in a sanitary manner in 1 of 1 facility kitchens. The findings include: On 4/12/22 at approximately 12:15 PM, the kitchen tour was conducted with OSM #7 (Other Staff Member) the Dietary Manager. The reach-in fridge was identified to contain a pan of bacon and sausage, a pan of beef patties, a pan of ground beef, a pan of tomato soup, and a pan of creamed corn, all which were not labeled and dated. This reach-in fridge also contained a pan of pancakes and toast and a pan of scrambled eggs, neither which were properly covered. […]