Inspection Reports for
Evergreen Commons Rehabilitation and Nursing Center
1070 Luther Road, East Greenbush, NY, 12061
Back to Facility ProfileDeficiencies (last 5 years)
Deficiencies (over 5 years)
7.4 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
45% worse than New York average
New York average: 5.1 deficiencies/yearDeficiencies per year
24
18
12
6
0
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Jan 11, 2024
Visit Reason
The survey was a recertification and abbreviated annual inspection conducted from 01/03/2024 to 01/11/2024 to assess compliance with regulatory requirements for nursing home operations and resident care.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, development and implementation of comprehensive care plans for oxygen therapy, supervision to prevent resident elopement, respiratory care, medication labeling and storage, food service safety and sanitation, maintenance of essential equipment, and pest control.
Deficiencies (8)
F 0584: The facility did not provide effective housekeeping and maintenance services on five resident units, with soiled floors, cobwebs, soiled toilets, and maintenance issues with walls, furniture, and showers.
F 0656: The facility failed to develop and implement complete care plans with measurable objectives and timeframes for oxygen therapy for 4 residents, lacking specific interventions and documentation.
F 0689: The facility did not ensure adequate supervision to prevent elopement for one resident who removed a Wanderguard bracelet and left the facility unsupervised.
F 0695: The facility failed to provide safe and appropriate respiratory care for 4 residents, including failure to provide supplemental oxygen as ordered, portable oxygen tanks running empty, and oxygen delivery by unlicensed personnel.
F 0761: The facility did not ensure safe and appropriate labeling and storage of medications; specifically, 5 insulin pens were not labeled with expiration dates after opening, and 1 insulin pen was missing date opened and expiration date.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards; multiple kitchenettes and the main kitchen had soiled surfaces, food residue, and missing grout on floors.
F 0908: The facility did not maintain all essential equipment in safe operating condition; one hot water heater and hot water holding tank thermometers were not functioning properly, and one shower valve was not maintained in good repair.
F 0925: The facility did not maintain a pest-free environment and an effective pest control program; rodent droppings were found in resident rooms and dining areas, and staff were unfamiliar with pest reporting procedures.
Report Facts
Residents reviewed for comprehensive care plans: 35
Residents affected by care plan deficiencies: 4
Residents reviewed for accidents: 7
Residents affected by inadequate supervision: 1
Insulin pens not labeled with expiration dates: 5
Insulin pens missing date opened and expiration date: 1
Kitchenettes inspected: 11
Rodent sightings documented: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Licensed Practical Nurse | Stated they would determine insulin expiration date by looking it up on the internet |
| Licensed Practical Nurse #3 | Licensed Practical Nurse | Unable to identify insulin expiration date and stated no insulin administration training upon hire |
| Licensed Practical Nurse #5 | Licensed Practical Nurse | Overlooked filling in insulin date opened and expiration date |
| Licensed Practical Nurse #8 | Licensed Practical Nurse | Discussed oxygen administration practices and monitoring |
| Licensed Practical Nurse #9 | Licensed Practical Nurse | Discussed oxygen administration and care plan responsibilities |
| Certified Nurse Assistant #3 | Certified Nurse Assistant | Removed resident from portable oxygen tank and initiated oxygen concentrator |
| Certified Nurse Assistant #4 | Certified Nurse Assistant | Hooked up residents' oxygen and set liter flow |
| Certified Nurse Assistant #6 | Certified Nurse Assistant | Stated they are not supposed to adjust oxygen machines |
| Registered Nurse Educator #1 | Registered Nurse Educator | Provided education on oxygen therapy and handling oxygen equipment |
| Director of Nursing | Director of Nursing | Discussed care plan setup and oxygen administration policies |
| Director of Maintenance | Director of Maintenance | Discussed maintenance issues including hot water heaters and pest control |
| Regional Manager of Dietary | Regional Manager of Dietary | Discussed food service cleaning and pest control training |
| Administrator | Administrator | Discussed corrective actions for housekeeping, maintenance, and pest control |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 10
Date: Jan 11, 2024
Visit Reason
Complaint Survey with 8 standard health citations and 2 life safety code citations, all Level 2 severity, mostly corrected by March 2024.
Findings
Complaint Survey with 8 standard health citations and 2 life safety code citations, all Level 2 severity, mostly corrected by March 2024.
Deficiencies (10)
Develop/implement comprehensive care plan
Essential equipment, safe operating condition
Food procurement, store/prepare/serve-sanitary
Free of accident hazards/supervision/devices
Label/store drugs and biologicals
Maintains effective pest control program
Respiratory/tracheostomy care and suctioning
Safe/clean/comfortable/homelike environment
Subdivision of building spaces - smoke barrier
Vertical openings - enclosure
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jan 11, 2024
Visit Reason
The inspection was conducted as a recertification and abbreviated annual survey to assess compliance with regulatory requirements and facility standards.
Findings
The facility was found deficient in multiple areas including housekeeping and maintenance services, supervision to prevent resident elopement, medication labeling and storage, food service safety and cleanliness, equipment maintenance, and pest control. Corrective actions and staff re-education were planned or underway for these issues.
Deficiencies (6)
F 0584: The facility did not provide effective housekeeping and maintenance services on five resident units. Floors, bathrooms, closets, and common areas were soiled, and furniture and walls were in disrepair.
F 0689: The facility failed to provide adequate supervision to prevent elopement for one resident who removed a Wanderguard and left the facility unsupervised.
F 0761: The facility did not ensure safe and appropriate labeling and storage of medications. Five insulin pens were not labeled with expiration or opening dates as required by policy.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. Serving utensils and kitchenettes were soiled, and the main kitchen floor was not in good repair.
F 0908: The facility did not maintain all mechanical, electrical, and patient care equipment in safe operating condition. One hot water heater, hot water holding tank thermometers, and a shower valve were not maintained in good repair.
F 0925: The facility did not maintain a pest-free environment and an effective pest control program. Rodent droppings were found in resident rooms and dining areas, and staff were unfamiliar with pest reporting procedures.
Report Facts
Resident units checked for housekeeping: 5
Residents reviewed for accidents: 7
Insulin pens not labeled: 6
Kitchenettes checked: 11
Hot water temperatures measured: 9
Pest sightings log dates: 42
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | Mentioned in relation to insulin pen labeling observation and interview. | |
| Licensed Practical Nurse #3 | Mentioned in relation to insulin pen labeling observation and interview, and additional training. | |
| Licensed Practical Nurse #5 | Mentioned in relation to insulin pen labeling interview. | |
| Director of Nursing | Provided statements regarding medication cart cleaning and insulin pen training. | |
| Regional Housekeeping Director | Interviewed about housekeeping issues and recruitment efforts. | |
| Director of Maintenance | Interviewed about maintenance issues, hot water system, and pest control. | |
| Administrator | Interviewed about corrective actions and audit plans. | |
| Regional Manager of Dietary | Interviewed about food service cleanliness and pest control. | |
| Receptionist #1 | Interviewed about elopement risk procedures. | |
| Receptionist #2 | Mentioned in elopement incident and termination for job abandonment. | |
| Licensed Practical Nurse #1 | Interviewed about resident behaviors and elopement risk. | |
| Activities Aide | Interviewed about dementia and elopement training. | |
| Registered Dietician | Interviewed about education on wandering and elopement. | |
| Regional Administrator | Interviewed about incident reporting and staff termination. | |
| Regional Housekeeping Manager | Interviewed about pest control and housekeeping challenges. |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
Complaint Survey with one Level 2 standard health citation for nutrition/hydration status maintenance, corrected by May 2023.
Findings
Complaint Survey with one Level 2 standard health citation for nutrition/hydration status maintenance, corrected by May 2023.
Deficiencies (1)
Nutrition/hydration status maintenance
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: Apr 4, 2023
Visit Reason
The abbreviated survey was conducted to assess compliance with nutritional monitoring and documentation standards for residents at Evergreen Commons Rehabilitation and Nursing Center.
Findings
The facility failed to ensure proper documentation and monitoring of residents' weights and meal intakes for 3 of 5 residents reviewed. There were multiple instances of missing weights, lack of reweighs after significant weight changes, and incomplete meal intake documentation.
Deficiencies (1)
F 0692: The facility did not ensure residents' weights and meal intakes were documented and monitored according to professional standards. Residents #1, #5, and #6 lacked timely weights, reweighs after significant weight changes, and had numerous undocumented meal intake opportunities.
Report Facts
Meal intake documentation missing: 13
Meal intake documentation missing: 18
Meal intake documentation missing: 17
Meal intake documentation missing: 10
Meal intake documentation missing: 13
Meal intake documentation missing: 13
Meal intake documentation missing: 14
Meal intake documentation missing: 7
Meal intake documentation missing: 19
Weight loss: 24.5
Weight loss: 13
Weight loss: 7.8
Weight gain: 6.6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #3 | Described weight monitoring procedures and documentation responsibilities | |
| Certified Nursing Assistant (CNA) #4 | Described monthly and weekly weight documentation and procedures | |
| Registered Dietitian (RD) | Explained weight monitoring protocols, reweigh triggers, and documentation practices | |
| Certified Nursing Assistant (CNA) #5 | Described meal intake documentation responsibilities and challenges | |
| Registered Nurse (RN) #1 | Described oversight of meal intake documentation and staff responsibilities | |
| Assistant Administrator | Discussed awareness of weight monitoring issues and documentation practices | |
| Administrator | Described facility procedures for weight and meal intake monitoring and documentation |
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 3, 2023
Visit Reason
Covid-19 Survey with one Level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: May 9, 2022
Visit Reason
Complaint Survey with one Level 2 standard health citation for free from abuse and neglect, isolated scope, corrected by April 2022.
Findings
Complaint Survey with one Level 2 standard health citation for free from abuse and neglect, isolated scope, corrected by April 2022.
Deficiencies (1)
Free from abuse and neglect
Inspection Report
Complaint Investigation
Capacity: 60
Deficiencies: 1
Date: Jan 17, 2022
Visit Reason
Covid-19 Survey with one Level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Findings
Covid-19 Survey with one Level 2 standard health citation for reporting to national health safety network, widespread scope, not corrected at time of report.
Deficiencies (1)
Reporting - national health safety network
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Sep 1, 2021
Visit Reason
The inspection was conducted as a recertification survey to assess compliance with regulatory standards for nursing home operations.
Findings
The facility was found deficient in maintaining a safe, clean, and homelike environment, proper food storage and preparation, and proper disposal of garbage and refuse. Specific issues included soiled floors in resident rooms, improper cooling of food, inadequate dishwashing machine rinse pressure, unclean kitchen and kitchenettes, and unsanitary conditions around the trash compactor.
Deficiencies (3)
F 0584: The facility did not provide effective housekeeping and maintenance services. Floors in multiple resident rooms were soiled with dirt and brownish build-up.
F 0812: The facility did not store, prepare, distribute, and serve food in accordance with professional standards. TCS foods were not cooled properly, the dishwashing machine rinse pressure was below manufacturer specifications, and kitchen floors and equipment were unclean.
F 0814: The facility did not dispose of garbage and refuse properly. The trash compactor and surrounding area were not maintained in a sanitary condition.
Report Facts
Dishwashing machine rinse pressure: 17
Internal temperature of corned beef roasts: 48.6
Number of corned beef roasts: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Interviewed regarding floor cleaning deficiencies | |
| Administrator | Interviewed regarding audit and corrective actions for floor cleaning and food service deficiencies | |
| Director of Food Service | Interviewed regarding food cooling, dishwashing machine issues, and kitchen cleanliness |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 26, 2019
Visit Reason
The inspection was a recertification survey to assess compliance with regulatory requirements for Evergreen Commons Rehabilitation and Nursing Center.
Findings
The facility was found deficient in multiple areas including maintenance issues with leaking shower drains, failure to coordinate mental health assessments for residents, inadequate monitoring during gradual dose reductions of psychotropic medications, improper disposal of garbage, and failure to maintain infection control practices during wound care.
Deficiencies (5)
F 0584: The facility did not provide effective maintenance services; a shower floor drain in Greenbush 2 unit was leaking onto the ceiling of Greenbush 1 unit.
F 0644: The facility failed to refer residents with newly diagnosed mental illness for a level II PASRR review for two residents.
F 0758: The facility did not ensure monitoring of behaviors during a gradual dose reduction of psychotropic medication for one resident, resulting in a failed GDR and unjustified medication increase.
F 0814: The facility did not properly dispose of garbage; the trash compactor was leaking liquid waste and the door was left open.
F 0880: The facility failed to maintain infection control during dressing changes for two residents; staff did not change gloves appropriately and a resident's leg was placed directly on a heels-off cushion.
Report Facts
Residents reviewed for psychotropic medications: 5
Residents reviewed for PASRR: 2
Date of survey completion: Aug 26, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Regional Director of Physical Plant and Maintenance | Interviewed regarding leaking shower floor drain. | |
| Social Worker #1 | Interviewed about failure to conduct level I screens for mental illness. | |
| Resident Assistant (RA) #5 | Interviewed about awareness of resident behaviors during GDR. | |
| Licensed Practical Nurse (LPN) #6 | Interviewed about resident behaviors and documentation during GDR. | |
| Registered Nurse Manager (RNM) #7 | Interviewed about documentation requirements for GDR and medication justification. | |
| Assistant Director of Nursing (ADON) #5 | Interviewed about documentation of resident behaviors and medication justification. | |
| Nurse Practitioner (NP) #2 | Interviewed about GDR initiation and documentation of resident behaviors. | |
| Director of Food Service | Interviewed about trash compactor maintenance and staff education. | |
| Licensed Practical Nurse (LPN) #1 | Observed and interviewed regarding improper glove use during dressing change. | |
| Assistant Director of Nursing/Infection Control Nurse (ADON/ICN) #1 | Interviewed about infection control practices and glove use during dressing changes. | |
| Registered Nurse Manager (RNM) #2 | Interviewed about infection control practices during dressing changes. |
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