Inspection Reports for
Avantara Evergreen Park

The facility failed to promptly transfer a resident exhibiting signs of sepsis, resulting in hospitalization for septic shock and pneumonia. The survey detailed the resident's clinical course and facility responses.

The facility failed to maintain resident room temperatures within a comfortable range of 71 to 81 degrees Fahrenheit, affecting multiple residents and areas of the building. The facility acknowledged the issue and planned to install portable AC units and repair broken fan belts.

The survey identified multiple deficiencies including failure to follow electronic monitoring consent policies, inaccurate resident assessments, inadequate care plan implementation, failure to provide timely incontinence care, ineffective bowel management, pressure ulcer prevention failures, unsafe resident transfers, oxygen therapy without orders, improper use of side rails, medication storage and labeling issues, infection control lapses, lack of antibiotic monitoring, and failure to maintain a clean environment.

The facility failed to ensure care plans reflected the resident's transfer needs and failed to follow safe transfer procedures, resulting in a resident fall and hip fracture. The facility did not consistently use gait belts or mechanical lifts as required.

The facility failed to document a resident's fall in the medical record and notify the family timely. The nurse on duty did not complete required risk management forms or follow fall notification protocols.

The facility failed to follow the Abuse and Neglect Policy by not reporting an allegation of rough handling to the Administrator immediately for one of three residents reviewed.

The facility failed to follow protocol requiring two staff members for mechanical lift transfers, resulting in a resident fall with minimal harm. The facility suspended the responsible CNA and confirmed the lifts passed inspection.

Complaint #145734: Investigation of alleged financial mismanagement and multiple fall incidents resulting in injuries.

The facility failed to ensure proper management of resident R3's funds and failed to implement adequate fall prevention interventions for six residents, resulting in injuries including fractures and lacerations.

The facility was found to have multiple deficiencies related to failure to follow notification policies after a fall, failure to follow physician wound care orders, inadequate pressure ulcer prevention and care, failure to implement effective fall interventions, and failure to ensure adequate hydration for a resident with a gastrostomy tube.

Complaint involving financial abuse and theft of resident R1's purse and debit card, substantiated with police arrest of staff member.

The facility failed to prevent financial abuse and theft for one resident. A staff member was identified via video footage, arrested, and is no longer employed by the facility.

The facility was found to have multiple deficiencies including failure to provide appropriate pressure ulcer care, restorative services, fall prevention interventions, catheter care, food labeling, and infection control practices.

The facility was found to have deficiencies in residents' rights, pressure ulcer care, and fall prevention management. The facility failed to ensure resident representative rights, implement pressure ulcer prevention interventions, and provide adequate fall prevention care plans and supervision.

The facility failed to follow policies regarding indwelling urinary catheter care, including failure to identify and promptly treat a catheter-related laceration for one resident and failure to document catheter care and maintain care plans for residents with indwelling catheters.

Two deficiencies were cited related to resident safety and medication documentation. The facility failed to ensure safe mechanical lift transfers for one resident and failed to accurately document controlled medication administration for another resident.

The facility failed to ensure that a resident's fall risk plan of care was implemented, resulting in a fall with injury to one resident. The chair alarm was found to be nonfunctional and staff were unaware of the resident's fall risk status.

The facility failed to ensure a resident was transferred using a mechanical lift as required, resulting in a closed fracture and severe pain. The investigation confirmed improper transfer by two CNAs contrary to care plan and facility policies.

The facility failed to complete an accurate Minimum Data Set (MDS) assessment regarding the skin condition of one of six sampled residents (R3), specifically not documenting the presence of a stage 4 pressure ulcer and the use of a pressure reducing device as required.

The facility failed to change 1 of 7 residents reviewed for Activities of Daily Living in the sample of 8, as evidenced by soaked linens and delayed care.

The facility failed to notify the physician timely of a resident's change in condition, failed to notify a resident's family of admission, failed to prevent mental abuse and adequately investigate abuse allegations, failed to document and communicate code status resulting in delayed CPR, and failed to provide adequate supervision and fall prevention interventions for residents at risk of falls.

The facility was found to have multiple deficiencies including failure to maintain equipment, inadequate care by agency staff, delayed response to call lights, failure to assess and treat pain, improper medication management, inadequate infection control practices, and failure to maintain a working call light system. The facility committed to retrain staff on policies and procedures and to improve monitoring and documentation.

The facility failed to ensure proper medication self-administration evaluation, provide wheelchairs for residents, implement adequate fall prevention interventions, and maintain sufficient toilet paper supplies for residents.