Inspection Reports for
Evergreen Health and Rehabilitation Center

The facility failed to follow care plans related to oxygen therapy for multiple residents, including incorrect oxygen flow rates and failure to clean oxygen concentrator filters as ordered. Observations and interviews confirmed these deficiencies, with dirty equipment and oxygen administered at incorrect rates.

Complaint Intake Numbers GA00236704 and GA00247590 were substantiated without citations. Complaint Intake Numbers GA00244713 and GA00237033 were unsubstantiated.

The facility was found not in substantial compliance with regulations, with deficiencies including failure to refer a resident for PASARR Level II screening, failure to follow care plans for oxygen therapy administration and equipment cleaning, and administering oxygen at incorrect flow rates for several residents. Some complaints were substantiated without citations, others were unsubstantiated.

The facility was found not in substantial compliance with life safety requirements, including deficiencies in hazardous area door smoke resistance, sprinkler system maintenance, corridor door openings, smoke barrier wall integrity, and smoking regulations enforcement. These deficiencies could potentially affect all residents.

The complaint investigation involved three complaint intake numbers (GA00235354, GA00235450, GA00235625). The allegation was that resident R#2 touched resident R#1 inappropriately. The incident occurred on 5/15/2023 but was not reported to the state agency until 5/16/2023 at 2:49 p.m. The facility delayed reporting the abuse allegation and initially miscommunicated the nature of the incident to the Administrator and state agency.

The facility failed to protect a resident's right to be free from physical abuse by another resident and failed to report the alleged abuse incident to the state agency within two hours as required. The investigation revealed delays in reporting and inadequate initial communication about the abuse allegation.

The facility was found not in substantial compliance due to deficiencies including failure to ensure confidentiality of resident medical records on one nursing unit and failure to obtain a physician's order for oxygen therapy and properly label/store oxygen delivery devices for one sampled resident.

The facility was found not in substantial compliance due to newly installed screen doors swinging against the direction of egress and corridor doors failing to close to create a smoke tight barrier, affecting all residents and staff in the north hall area.

The facility was found not in compliance with infection control regulations due to failure to ensure proper cleaning and disinfecting of the COVID-19/PUI Unit. Nursing staff were using disinfectant products prior to cleaning surfaces and were not knowledgeable of the disinfecting products' contact times.

The facility was found not in substantial compliance with emergency preparedness testing requirements, failing to conduct required full-scale and tabletop exercises. Additionally, deficiencies were found in fire alarm system maintenance, smoke detector sensitivity, and electrical wiring safety, placing residents at risk in emergencies.

Complaint number GA00195322 was substantiated with a deficiency related to failure to provide a proper written 30-day discharge notice for resident #1. The investigation included record reviews, interviews with family members, hospital social worker, Ombudsman, facility staff, and medical director.

The facility failed to provide a written 30-day discharge notice that included all required information for one resident out of three reviewed. Interviews and record reviews confirmed the notice was verbal and lacked required details such as the right to appeal and specific unmet needs.

The facility failed to provide a written 30-day discharge notice containing all required information for one resident out of three reviewed for transfer/discharge. The notice was given verbally but lacked documentation of specific needs, right to appeal, and legal counsel information. Family members and the Ombudsman were not properly informed in writing.

The facility was found not in substantial compliance with life safety requirements, including failure to provide smoke detectors for door release at cross corridor doors, inadequate emergency lighting, improper fire stopping in smoke barriers, unsafe electrical wiring and equipment, and lack of metal containers with self-closing lids in designated smoking areas.

The facility failed to ensure the emergency power generator was properly installed and maintained, including lack of a required remote annunciator and inadequate testing documentation. These deficiencies could place residents and staff at risk during an emergency.

The facility was found not in substantial compliance with fire safety requirements, including improper installation and monitoring of the fire alarm system, inadequate smoking area safety provisions, lack of emergency lighting in the medication preparation room, absence of a remote annunciator for the emergency generator, and failure to maintain proper records for emergency generator testing and maintenance.