Inspection Reports for Evergreen Health & Rehabilitation Center

The facility was found deficient in multiple areas including failure to conduct quarterly care conferences, failure to administer prescribed lidocaine patches, failure to provide tube feeding and hydration per physician orders, failure to obtain ordered laboratory tests, failure to provide assistive eating devices, and failure to maintain food safety standards in the kitchen.

The complaint documented that the resident fell out of bed at 5 AM, but the facility staff did not evaluate the resident promptly and delayed calling EMS until late afternoon. The resident was admitted to the hospital with a fractured neck and brain hematoma. Family members repeatedly requested hospital transfer, which was delayed by several hours despite visible injuries and pain.

The facility failed to promptly evaluate and transfer a resident who fell out of bed, resulting in delayed hospital transfer despite the resident having a fractured neck and subdural hematoma. Staff did not perform an adequate assessment or timely notify the physician, and the resident was only transferred after family insistence several hours later.

The complaint investigation revealed allegations that resident R802 sustained an untreated foot injury in the facility, and resident R801 was not provided timely incontinence care, being left wet and soiled for approximately 11 hours.

The facility failed to timely evaluate and treat a moderately comminuted avulsion fracture of resident R802's right heel, resulting in increased pain and impaired rehabilitation participation. Additionally, the facility failed to provide timely incontinence care for resident R801, who was left wet and soiled for approximately 11 hours.

The complaint investigation included intake #MI00150187 regarding psychotropic medication consent and intake #MI00150047 regarding pest control and bed bug infestation. The psychotropic medication consent was not obtained from the resident's Durable Power of Attorney for Healthcare (DPOA-H). The pest control complaint involved bed bugs found on resident R305 and inadequate staff procedures.

The facility failed to obtain consent from the legally authorized representative for psychotropic medications for one resident and failed to follow pest control procedures for another resident, resulting in bed bug infestations. The facility took corrective actions including staff education and policy implementation.

The complaint investigation involved allegations that on 10/15/24, resident R804 pushed resident R803 out of their wheelchair, and on 12/5/24, resident R806 was found covered in dried feces with staff allegedly indicating care was not needed as the resident was dying. The facility failed to report the neglect allegation timely to the Administrator and State Agency. Interviews with staff and review of records showed inconsistent documentation and lack of proper reporting.

The facility failed to protect a resident from physical abuse by another resident, resulting in one resident being pushed out of their wheelchair. Additionally, the facility failed to timely report allegations of neglect involving a resident left covered in dried feces. Interviews and record reviews revealed multiple incidents of resident altercations and inadequate reporting and documentation by staff.

The facility was found deficient in multiple areas including failure to promote residents' dignity, honor choice of attending physician, provide appropriate notice for room changes, ensure unrestricted visitation, execute advance directives, prepare safe discharges, implement baseline care plans for tube feeding, accurately document medication administration, provide wound care, follow up on physician consults, assess residents promptly after falls, maintain infection control protocols, and maintain kitchen sanitation and equipment.

The complaint alleged that on 5/27/24, resident R901 was transferred improperly by a Certified Nursing Assistant (CNA), resulting in the resident being dropped to the floor and sustaining knee pain. Multiple staff interviews and investigation concluded the resident was not dropped but twisted her leg during transfer. The resident's daughter was involved and expressed concerns about staff communication and response. The facility re-educated staff and conducted audits to prevent recurrence.

The facility failed to ensure safe transfer per plan of care and facility policy for one resident (R901), who complained of knee pain after transfer. Investigation found no evidence the resident was dropped, but the resident twisted her leg during transfer. The facility identified a Past Non-Compliance and implemented corrective actions including staff re-education and audits.

The survey was triggered by multiple complaints reported to the State Agency alleging the facility was not clean.

The facility failed to maintain a clean, comfortable, safe, and homelike environment, evidenced by soiled floors, walls, trash and debris throughout the facility, broken furniture and tiles, unsecured sharps and chemicals, visible pest harborage, and an unlocked medication cart. These deficiencies posed potential harm to multiple residents.

The complaint investigations pertain to multiple concerns including failure to administer pain medication as prescribed, failure to timely identify and communicate changes in condition, inadequate wound care, lack of supervision during medical appointments for a cognitively impaired resident, failure to obtain weights as per policy, failure to complete ordered lab tests, and failure to provide ordered rehabilitation services.

The facility failed to administer pain medication as ordered, timely identify and communicate changes in condition, provide adequate wound care and monitoring, ensure supervision for a cognitively impaired resident during appointments, obtain weights as per policy, complete ordered laboratory tests, and provide rehabilitation therapy as ordered. Multiple residents were affected with issues ranging from medication errors, untreated wounds, missed therapy sessions, and inadequate supervision.

The complaint alleged that R804 was left unattended in pain and bleeding without staff response until family intervention and 911 was called. For R801, the complaint alleged unsafe wheelchair positioning with a slippery pillow, unlocked wheelchair brakes, and call light out of reach, leading to a fall and injury.

The facility failed to adequately assess and treat R804's pain, resulting in unrelieved pain and delayed hospital transfer. Additionally, the facility failed to ensure safe wheelchair positioning and call light access for R801, leading to a fall and head injury. Interviews and record reviews confirmed these deficiencies with minimal harm to residents.

The complaint involved allegations that the facility improperly petitioned for guardianship despite the resident having a valid Durable Power of Attorney, failed to document narcotic medication administration accurately, and did not provide the correct therapeutic diet to a resident.

The facility failed to timely obtain and acknowledge a resident's choice for health care decision making prior to petitioning for third party guardianship, resulting in distress and potential denial of rights. Additionally, narcotic medications were not documented accurately per professional standards, and food was not provided in the prescribed texture for a resident, increasing risk of choking.

Multiple complaints were filed with the State Agency regarding issues such as inadequate discharge planning, inconsistent provision of ADLs, failure to perform neuro checks after falls, delayed wound treatment, improper wheelchair transport, delayed lab result review, missed dialysis appointments, and failure to treat urinary tract infections.

The facility was found deficient in multiple areas including failure to ensure a homelike dining experience, medication administration errors, inadequate discharge planning, inconsistent provision of activities of daily living such as bathing and grooming, failure to perform timely wound assessments and treatments, lack of neuro checks after a resident fall, delayed laboratory testing and follow-up, improper wheelchair transport and accident investigations, failure to timely treat urinary tract infections, inadequate hydration assessment and monitoring, inconsistent communication with dialysis centers, incomplete staff competency evaluations, improper medication storage and labeling, unsanitary kitchen conditions with improper food storage and handling, delayed meal service, and failure to follow infection control precautions.

Multiple complaints were filed with the State Agency regarding issues such as inadequate discharge preparation, inconsistent provision of ADLs, failure to perform neuro checks after a fall, pressure ulcer care deficiencies, delayed lab result review, dialysis communication failures, staff competency concerns, medication storage issues, delayed lab diagnostics, hydration monitoring failures, delayed meal service, kitchen sanitation problems, and infection control breaches.

The facility was found deficient in multiple areas including failure to ensure a homelike dining experience, medication administration errors, inadequate discharge planning, inconsistent provision of activities of daily living such as bathing and mobility assistance, failure to perform neuro checks after a resident fall, inadequate pressure ulcer care, delayed lab result review and treatment, improper dialysis communication, incomplete staff competency evaluations, unsafe medication storage and labeling, delayed laboratory diagnostics, untimely hydration assessment and monitoring, delayed meal service, unsanitary kitchen conditions, and improper infection control practices.

The complaint investigations included allegations of improper change of code status against resident wishes, failure to notify guardians of changes in condition, inadequate wound care leading to maggot infestation, delayed hospital transfer after stroke symptoms, significant unmonitored weight loss resulting in hospitalization, poor communication with dialysis centers, and inappropriate use of psychotropic medications without proper justification or non-pharmacological interventions.

The facility was found deficient in multiple areas including failure to consider resident input on code status, failure to notify legal guardians of changes in condition, inadequate wound care leading to maggot infestation, delayed hospital transfer after stroke symptoms, significant unmonitored weight loss, poor coordination with dialysis centers, and improper use of psychotropic medications without adequate justification or non-pharmacological interventions.