Inspection Report
Follow-Up
Census: 89
Capacity: 125
Deficiencies: 2
Mar 25, 2025
Visit Reason
The inspection visit was a follow-up to verify the implementation of a previously submitted plan of correction related to an incident involving a resident ingesting poisonous materials.
Findings
The facility was found to have fully implemented the submitted plan of correction, including removal of hazardous items from the resident's room, conducting room audits, and preparing a new medical evaluation for the resident after a change in medical condition.
Deficiencies (2)
| Description |
|---|
| Poisonous materials were not kept locked and inaccessible to residents, as a full unopened bottle of Scope mouthwash and other hazardous items were found in a resident's room despite the resident no longer being capable of safely using poisons. |
| A new medical evaluation was not completed after the resident's medical condition changed following the ingestion incident. |
Report Facts
License Capacity: 125
Residents Served: 89
Secured Dementia Care Unit Capacity: 13
Residents Served in Dementia Care Unit: 11
Current Hospice Residents: 6
Residents Age 60 or Older: 84
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 45
Residents with Physical Disability: 6
Total Daily Staff: 134
Waking Staff: 101
Inspection Report
Complaint Investigation
Census: 95
Capacity: 125
Deficiencies: 5
Jan 28, 2025
Visit Reason
The inspection was conducted as a complaint and interim review to assess compliance with regulatory requirements.
Findings
Multiple deficiencies were identified related to medication storage and administration, documentation of medication refusals, following prescriber's orders, and resident assessments. The facility submitted plans of correction which were determined to be fully implemented by the follow-up date.
Complaint Details
The inspection was complaint-driven and interim in nature, with the submitted plan of correction fully implemented as of 01/28/2025.
Deficiencies (5)
| Description |
|---|
| Medications and syringes were found unlocked, unattended, and accessible in a resident's room contrary to regulations requiring locked storage. |
| Failure to properly document and report blood glucose readings and discrepancies between glucometer readings and Medication Administration Records. |
| Refusals of prescribed medications were not documented or reported to the prescriber as required. |
| Medications were not administered as prescribed due to unavailability in the home, including repeated violations. |
| Resident's initial assessment did not include necessary information regarding the use and safety of a bedside mobility device (enabler bar). |
Report Facts
License Capacity: 125
Residents Served: 95
Secured Dementia Care Unit Capacity: 15
Secured Dementia Care Unit Residents Served: 14
Hospice Current Residents: 4
Residents Age 60 or Older: 93
Residents with Mobility Need: 27
Residents Diagnosed with Mental Illness: 1
Residents Diagnosed with Intellectual Disability: 1
Residents with Physical Disability: 5
Inspection Report
Complaint Investigation
Census: 91
Capacity: 125
Deficiencies: 5
May 21, 2024
Visit Reason
The inspection was conducted as a complaint investigation and incident review at Evergreen Estates Retirement Community on 05/21/2024.
Findings
The inspection identified multiple deficiencies including neglect related to a resident choking incident due to missing dentures and delayed diet order, incomplete medical evaluations missing dietary needs, failure to meet residents' special dietary needs with proper physician orders, improper self-administration of medications by a resident assessed as incapable, and failure to follow prescriber's medication orders for two residents.
Complaint Details
The visit was complaint-related as indicated by the reason for inspection and the investigation of a choking incident involving Resident 1.
Deficiencies (5)
| Description |
|---|
| Resident 1's upper denture went missing and the home did not assist in securing health care, resulting in a choking incident; delayed obtaining a new diet order until the department's investigation. |
| Resident 2's medical evaluation did not include special health or dietary needs. |
| Resident 1 was placed on a pureed diet per family request without a physician's order until later. |
| Resident 2 self-administers medications but was assessed as incapable to do so by a qualified practitioner. |
| Resident 1 and Resident 2 were not administered prescribed medications on specified dates. |
Report Facts
License Capacity: 125
Residents Served: 91
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 11
Hospice Current Residents: 10
Residents Diagnosed with Mental Illness: 3
Residents Diagnosed with Intellectual Disability: 1
Residents with Mobility Need: 34
Residents with Physical Disability: 3
Inspection Report
Complaint Investigation
Census: 89
Capacity: 125
Deficiencies: 4
Feb 6, 2024
Visit Reason
The inspection was conducted as a complaint investigation with an unannounced partial inspection on 02/06/2024.
Findings
The inspection found multiple violations related to food storage and kitchen cleanliness, including stains and mold in the kitchen, food stored on the floor, unsealed food containers, and improper thawing of food. A plan of correction was submitted and fully implemented by 03/29/2024.
Complaint Details
The inspection was triggered by a complaint and conducted as a partial unannounced visit on 02/06/2024. The submitted plan of correction was fully implemented.
Deficiencies (4)
| Description |
|---|
| Kitchen had multiple stains on the floor with dirt and grime, mold on the wall above the dishwashing station, and food items improperly stored under shelving units. |
| Box of frozen bakery rolls and frozen orange juice concentrate stored on the floor in the walk-in freezer. |
| Opened and unsealed 12 ounce can of beef paste and other open food items in refrigerators. |
| Frozen food was sometimes left out on the counter to air thaw for extended periods instead of approved thawing methods. |
Report Facts
License Capacity: 125
Residents Served: 89
Memory Care Capacity: 13
Memory Care Residents Served: 11
Current Hospice Residents: 7
Residents 60 Years or Older: 84
Residents Diagnosed with Mental Illness: 1
Residents with Mobility Need: 35
Resident Support Staff: 124
Waking Staff: 93
Inspection Report
Follow-Up
Census: 89
Capacity: 125
Deficiencies: 24
Nov 7, 2023
Visit Reason
The inspection was conducted as a follow-up to verify the implementation of a previously submitted plan of correction, as well as for renewal, complaint, and incident reasons.
Findings
The facility was found to have multiple deficiencies including failure to report suspected resident abuse properly, incomplete incident reports, inadequate quality management plan content, resident abuse incidents, insufficient CPR/first aid trained staff, incomplete staff training records, unsafe resident personal equipment, unsanitary conditions, obstructed egress routes, combustible materials accessible to residents, overdue furnace inspection and cleaning, incomplete fire drill records, smoking policy violations, incomplete menu postings, unsecured medications, expired medications, medication labeling and administration errors, and incomplete resident support plans. All deficiencies had plans of correction accepted and were implemented by December 2023.
Deficiencies (24)
| Description |
|---|
| Failure to complete Act 13 form for suspected resident abuse. |
| Incident reports not submitted for missed prescribed blood sugar tests. |
| Quality management plan did not address required elements including incident reporting and complaint procedures. |
| Resident abuse incident resulting in injury and hospitalization. |
| Insufficient number of staff trained in CPR and first aid on multiple dates. |
| Incomplete staff training records for fire safety and emergency preparedness. |
| Resident enabler bars not securely attached, posing entrapment risk. |
| Overwhelming smell of incontinence and incontinence stains in secured dementia care unit. |
| Trash dumpster lids left open, allowing potential insect and rodent infestation. |
| Torn carpet in resident bedroom posing tripping hazard. |
| Exit doors and egress routes blocked by furniture and trash cans. |
| Combustible materials accessible to residents in resident bedroom. |
| Furnace inspection overdue since May 2022. |
| Furnace cleaning overdue. |
| Fire drill records incomplete, missing resident counts and other required details. |
| Smoking observed outside community room in prohibited area. |
| Menus not posted for current and following weeks in November. |
| Prescription medications and syringes found unlocked and unattended in resident rooms. |
| Expired PRN medication found in medication cart. |
| Medication label did not reflect changed dosage order. |
| Resident medication checks did not match documentation on Medication Administration Record (MAR). |
| Controlled substance balance incorrectly documented in controlled substance log. |
| Failure to follow prescriber's orders for medication administration. |
| Resident support plans did not document need for leg brace and enabler bar. |
Report Facts
License Capacity: 125
Residents Served: 89
Residents in Secured Dementia Care Unit: 13
Resident Support Staff: 0
Total Daily Staff: 118
Waking Staff: 89
Residents Age 60 or Older: 83
Residents with Mobility Need: 29
Inspection Report
Complaint Investigation
Census: 87
Capacity: 125
Deficiencies: 12
Aug 17, 2023
Visit Reason
The inspection was conducted as a complaint investigation to review compliance with regulations and verify the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including lack of proper smoking area signage, sanitary condition issues such as urine odor in a resident's room, uncovered trash receptacles in the kitchen, use of plastic utensils in the memory care unit, inadequate smoking area maintenance, expired and improperly stored medications, unlabeled OTC medications, medication count discrepancies, failure to report significant resident condition changes, and missing posted directions for key-locking devices in the secure dementia care unit. All deficiencies had plans of correction accepted and were implemented by 09/25/2023.
Complaint Details
The inspection was complaint-related as indicated by the reason 'Complaint' and was conducted unannounced on 08/17/2023.
Deficiencies (12)
| Description |
|---|
| No sign at the main entrance stating 'Smoking is Permitted in Designated Smoking Areas Only' and no signs stating 'Smoking Permitted' at the designated smoking area on the patio. |
| Strong odor of urine in Resident 1's bedroom and adjacent hallway. |
| Two full and uncovered rectangular trash cans in the kitchen. |
| Large dark stain in the carpet of Resident 2's bedroom. |
| Plastic utensils and Styrofoam cups regularly used in the P Hall. |
| Single smoking tower present with ashes on patio and wall where no receptacle was available. |
| Expired prescription medication found in the P Hall medication cart. |
| Resident 4 had medication tablets removed from original blister and taped into another blister instead of being destroyed. |
| OTC medication bottles in P Hall and West Hall medication carts were not labeled with resident names. |
| Discrepancies in medication count sheets for Resident 5 who no longer resides in the home. |
| Resident 6 had feces on the floor indicating a significant change in condition not previously assessed. |
| Directions for operating the home's locking mechanism not conspicuously posted near exit door closest to room P 111 in the Secure Dementia Care Unit. |
Report Facts
Residents Served: 87
License Capacity: 125
Residents Served in Secured Dementia Care Unit: 12
Capacity of Secured Dementia Care Unit: 13
Current Hospice Residents: 6
Residents Age 60 or Older: 82
Residents with Mobility Need: 41
Residents with Physical Disability: 3
Total Daily Staff: 128
Waking Staff: 96
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Kim Jackson | LPN Director of Resident Care | Provided remedial training related to medication storage, resident change of status reporting, and medication procedures. |
Inspection Report
Complaint Investigation
Census: 78
Capacity: 125
Deficiencies: 11
Dec 12, 2022
Visit Reason
The inspection was a partial, unannounced visit conducted due to a complaint and interim review on 12/12/2022.
Findings
Multiple deficiencies were identified related to incomplete or missing medical evaluations, improper medication storage and administration, failure to report medication refusals timely, incomplete preadmission screening, and inadequate resident support plans including fall prevention. Plans of correction were accepted and implemented by late January 2023.
Complaint Details
The inspection was complaint-related and interim in nature, triggered by concerns leading to a partial unannounced visit on 12/12/2022.
Deficiencies (11)
| Description |
|---|
| Medical evaluation for Resident #5 did not indicate the date the resident was evaluated. |
| Medical evaluation for Resident #3 was incomplete, missing body positioning/movement, health status, cognitive functioning, and medical professional's name. |
| Resident #4, #8, and #9 had missing or incomplete annual medical evaluations. |
| Medication Administration Records (MAR) for Residents #3, #4, and #10 showed blood glucose readings without corresponding glucometer readings. |
| Resident #10 refused medication doses which were not reported to the prescriber within 24 hours. |
| Resident #10 was prescribed a medication that was not administered due to unavailability in the home. |
| Resident #2’s preadmission screening form did not include a determination that the resident's needs could be met by the home. |
| Resident #4’s most recent additional assessment was incomplete or missing. |
| Resident #5 had repeated falls with injuries but the support plan did not address fall prevention or additional needs. |
| Support plans for Residents #5, #6, #7, and #9 were not signed by the assessor or resident as required. |
| Resident #1’s written cognitive preadmission screening for the Secure Dementia Care Unit was completed after admission. |
Report Facts
License Capacity: 125
Residents Served: 78
Secured Dementia Care Unit Capacity: 13
Secured Dementia Care Unit Residents Served: 8
Hospice Current Residents: 5
Residents Age 60 or Older: 74
Residents with Mobility Need: 28
Residents with Physical Disability: 1
Documented Falls for Resident #5: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Resident Care | Involved in reviewing medical evaluations, medication error remediation, and reporting medication errors and refusals at Quality Assurance meetings. | |
| Resident Care Coordinator | Involved in reviewing medical evaluations, medication error remediation, and reporting medication refusals. | |
| Administrator | Responsible for reviewing DME's, preadmission screening forms, support plans, and placing reminder signs; also disciplined staff and oversaw corrective actions. | |
| Med Tech | Disciplined and remediated for errors in blood glucose readings and medication refusals. | |
| Y Ramos | Former LPN | Support plans submitted by this individual were noted; terminated for cause. |
Inspection Report
Census: 81
Capacity: 125
Deficiencies: 0
Jun 9, 2022
Visit Reason
The inspection was conducted as a partial, unannounced visit due to an incident at the facility.
Findings
No regulatory citations or deficiencies were identified during the inspection.
Report Facts
Resident Census: 81
Total Licensed Capacity: 125
Memory Lane Capacity: 13
Memory Lane Residents Served: 10
Current Hospice Residents: 7
Residents Age 60 or Older: 78
Residents with Mental Illness: 1
Residents with Intellectual Disability: 0
Residents with Mobility Need: 18
Residents with Physical Disability: 1
Total Daily Staff: 99
Waking Staff: 74
Inspection Report
Renewal
Deficiencies: 0
May 19, 2022
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Renewal
Deficiencies: 0
Sep 14, 2021
Visit Reason
The inspection was conducted as a licensing inspection by the Pennsylvania Department of Human Services, Bureau of Human Service Licensing.
Findings
No regulatory citations were identified as a result of this inspection.
Inspection Report
Follow-Up
Census: 62
Capacity: 125
Deficiencies: 2
Aug 20, 2021
Visit Reason
The inspection visit on 08/20/2021 was a follow-up to verify the implementation of a previously submitted plan of correction for the Evergreen Estates Retirement Community.
Findings
The submitted plan of correction was determined to be fully implemented, with continued compliance required. The report details deficiencies related to annual medical evaluations and additional assessments for residents, which have been addressed by the Director of Nursing through a tickler file system to maintain compliance.
Deficiencies (2)
| Description |
|---|
| The most recent medical evaluations for Resident 1 and Resident 2 were not completed annually as required. |
| The most recent additional assessments for Resident 1 and Resident 2 were not completed annually as required. |
Report Facts
License Capacity: 125
Residents Served: 62
Secured Dementia Care Unit Capacity: 13
Residents Served in Dementia Unit: 7
Hospice Residents: 1
Resident Mobility Need: 7
Total Daily Staff: 69
Waking Staff: 52
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Responsible for reviewing residents' annual medical evaluations and assessments, updating the tickler file, and ensuring ongoing compliance |
Notice
Capacity: 125
Deficiencies: 0
Feb 5, 2021
Visit Reason
The document serves as a renewal notification and issuance of a regular license for Evergreen Estates Retirement Community to operate as a Personal Care Home, pursuant to a renewal application submitted on November 20, 2020.
Findings
The Department has approved the renewal application and issued a regular license. It advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Maximum capacity: 125
Secure Dementia Care Unit capacity: 13
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary, Office of Long-term Living | Signed the renewal notification letter. |
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