Evergreen Post Acute

In the surveyor’s words

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

• Actual harm, isolatedF760Aug 15, 2022

  Based on interview and record review it was determined the facility failed to ensure a resident was not administered a discontinued medication for 1 of 5 sampled residents (#10) reviewed for unnecessary medications. This failure resulted in the resident experiencing diaphoresis (heavy sweating), shortness of breath and diminished lung sounds which required emergency medical services and treatment at the hospital. Findings include: Resident 10 was admitted to the facility in 2/2019 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A 2/24/20 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . A 4/18/22 physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of a 4/2022 MAR indicated [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF761Aug 7, 2026

  Based on observation and interview it was determined the facility failed to ensure medications and biologicals were stored in locked compartments and maintained in a safe and secured manner for 3 of 3 halls reviewed for medication storage and labeling. This placed residents at risk for unsafe medication storage. Findings include:1. On 8/3/26 at 1:22 PM a medication cart was observed to be unlocked and unattended next to the nurse's station. No staff were observed in the immediate vicinity of the medication cart. On 8/3/26 at 1:24 PM Staff 21 (Med Aide) stated he had left the medication cart unlocked and unattended. 2. On 8/5/26 at 3:39 PM a treatment cart was observed to be unlocked and unattended on the west hall. […]

• No harm, potential for more than minimal, widespreadF880Aug 7, 2026

  Based on observation, interview, and record review, it was determined the facility failed to maintain an infection prevention and control program, as evidenced by staff not performing required hand hygiene during resident care, failing to clean and store resident care equipment appropriately, and not following Enhanced Barrier Precautions (EBP) for 1 of 1 facility reviewed for infection control practices. This placed residents at risk for communicable disease transmission and infections. Findings include:The facility's 9/1/24 Hand Hygiene Facility policy indicated hand hygiene is the primary means of preventing and transmission of infection and should be performed as soon as possible after hands become contaminated and frequently during the workday. […]

• No harm, potential for more than minimal, widespreadF880Oct 23, 2023

  1. Based on observation, interview and record review it was determined the facility failed to transport clean laundry to prevent cross contamination for 1 of 1 facility reviewed for infection control. This placed residents at risk for cross contamination for spread of infection. Findings include: The facility's 4/2019 Laundry Handling Policy and Procedure indicated laundry personnel were to transport clean linens in a covered cart. On 10/18/23 at 8:57 AM Staff 16 (Housekeeping/Laundry Manager) was observed to transport and distribute clean laundry to residents using an uncovered wire basket on wheels. […]

• No harm, potential for more than minimal, widespreadF730Aug 15, 2022

  Based on interview and record review it was determined the facility failed to complete nurse aide performance reviews at least every 12 months and provide regular in-service education based on the outcome of these reviews for 5 of 5 CNAs (#s 9, 12, 20, 22 and 23) reviewed for sufficient and competent nurse staffing. This placed residents at risk for lack of care by competent staff. Findings include: On 8/10/22 at 10:01 AM facility staff records for Staff 9 (CNA), Staff 12 (CNA), Staff 20 (CNA), Staff 22 (CNA) and Staff 23 (CNA) were reviewed with Staff 16 (HR/Payroll/Staffing) and revealed no information related to annual CNA performance reviews being completed and no regular in-service education was done based on the outcome of the reviews. […]