Inspection Reports for Evergreen Post Acute LLC
3034 South Dupont Boulevard, Smyrna, DE, 19977
Back to Facility ProfileInspection Report Summary
The most recent inspection on September 8, 2025, found no deficiencies during an unannounced complaint investigation. Earlier inspections showed a pattern of deficiencies primarily related to resident rights, care planning, medication administration, infection control, and privacy, with some issues resulting in harm and hospitalization. A substantiated complaint in January 2025 cited failures to report and investigate an allegation of abuse appropriately, but no enforcement actions or fines were listed in the available reports. Most complaint investigations were unsubstantiated, and follow-up surveys in mid-2024 found the facility in substantial compliance with no deficiencies. The inspection history indicates some improvement over time, with recent surveys showing fewer or no deficiencies compared to prior reports.
Deficiencies (last 3 years)
Deficiencies (over 3 years)
14.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Delaware average
Delaware average: 8.8 deficiencies/yearDeficiencies per year
20
15
10
5
0
Census
Latest occupancy rate
133 residents
Based on a September 2025 inspection.
Census over time
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Sep 8, 2025
Visit Reason
An unannounced Complaint Survey was conducted at the facility from September 2, 2025, through September 8, 2025.
Findings
No deficient practice was identified during the survey.
Complaint Details
The complaint investigation was unannounced and no deficient practice was identified, indicating no substantiated deficiencies.
Report Facts
Survey sample residents: 15
Inspection Report
Annual Inspection
Census: 135
Deficiencies: 17
Apr 17, 2025
Visit Reason
An unannounced Annual, Complaint and Emergency Preparedness Survey was conducted at Evergreen Post Acute LLC from April 8, 2025 through April 17, 2025. The survey included observations, interviews, and review of clinical records and other facility documents.
Findings
The survey identified multiple deficiencies related to resident rights, care planning, infection control, medication administration, privacy, safety, and other regulatory requirements. Some deficiencies were cited with severity levels ranging from Level B to Level G, including a past noncompliance for medication errors. The facility was required to implement corrective actions and audits to ensure compliance.
Severity Breakdown
Level B: 1
Level D: 13
Level E: 1
Level G: 1
Deficiencies (17)
| Description | Severity |
|---|---|
| Facility failed to ensure resident R14 was treated with respect and dignity related to knocking and waiting for response before entering room. | Level D |
| Facility failed to ensure resident R641's representative was included in advance directive acknowledgment for resident with cognitive impairment. | Level D |
| Facility failed to notify resident R188 in advance of changes to their bill and failed to provide timely refund for days not stayed. | Level D |
| Facility failed to protect personal privacy of residents R37, R69, R72, and R133 by not securing computer screens with protected health information. | Level D |
| Facility failed to provide a clean and homelike environment in resident rooms with chipped paint, exposed metal, missing tiles, and black marks. | Level D |
| Facility failed to ensure resident R112 was free from involuntary seclusion. | Level D |
| Facility failed to complete comprehensive assessment after significant change for resident R136. | Level D |
| Facility failed to ensure resident R644 was free of medication errors; medication error resulted in harm and hospitalization. | Level G |
| Facility failed to ensure medication carts were properly labeled with open dates. | Level B |
| Facility failed to provide adequate supervision and assistance devices to prevent accidents for resident R35 with fall risk. | Level D |
| Facility failed to provide therapeutic diet as prescribed for resident R3. | Level D |
| Facility failed to provide care plans consistent with resident rights and needs for multiple residents including R40, R50, R91, R119, R120, R130, R440. | Level E |
| Facility failed to provide adequate oral care for dependent residents including R73, R114, R130. | Level D |
| Facility failed to provide assistive communication devices for resident R132 with communication deficit. | Level D |
| Facility failed to provide adequate food safety and sanitation in kitchen and food service areas. | Level D |
| Facility failed to implement infection prevention and control program including failure to monitor antibiotic usage and follow isolation precautions. | Level D |
| Facility failed to provide pneumococcal and influenza immunizations and education to residents. | Level D |
Report Facts
Residents present: 135
Residents sampled: 43
Deficiency completion dates: 6
Fall risk score: 35
Medication error date: Sep 13, 2024
Medication error fine amount: 0
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E45 | Certified Nursing Assistant (CNA) | Named in findings related to knocking on resident R14's door without waiting for response |
| E44 | Central Supply | Named in findings related to knocking on resident R14's door without waiting for response |
| E2 | Director of Nursing (DON) | Named in multiple findings including privacy, care planning, infection control |
| E1 | Nursing Home Administrator (NHA) | Named in multiple findings reviews and interviews |
| E5 | Social Worker (SW) | Named in findings related to care planning and discharge planning |
| E7 | Certified Nursing Assistant (CNA) | Named in findings related to room repairs and resident care |
| E8 | Maintenance Director | Named in findings related to environmental repairs and work orders |
| E46 | Registered Nurse (RN) | Named in findings related to behavioral assessments |
| E16 | Registered Nurse (RN) | Named in findings related to resident care and privacy |
| E18 | Licensed Practical Nurse (LPN) | Named in medication cart inspection findings |
| E26 | Certified Nursing Assistant (CNA) | Named in infection control observations |
| E40 | Certified Nursing Assistant (CNA) | Named in therapeutic diet findings |
| E41 | Food Service Director | Named in food service and sanitation findings |
| E33 | Guest Services | Named in communication board and language barrier findings |
| E49 | Licensed Practical Nurse (LPN) | Named in communication board and language barrier findings |
| E12 | Licensed Practical Nurse (LPN) | Named in infection control and antibiotic stewardship findings |
| E27 | Staff Licensed Practical Nurse (LPN) | Named in medication error investigation |
| E10 | Admissions Director | Named in transfer notification findings |
| E11 | RNAC | Named in hospice care findings |
| E34 | Licensed Practical Nurse (LPN) | Named in language barrier findings |
| E37 | Certified Nursing Assistant (CNA) | Named in oral care findings |
| E36 | Certified Nursing Assistant (CNA) | Named in oral care findings |
| E38 | Certified Nursing Assistant (CNA) | Named in isolation precautions findings |
| E2 | Director of Nursing (DON) | Named in multiple findings including oral care and infection control |
| E18 | Licensed Practical Nurse (LPN) | Named in medication cart inspection findings |
Inspection Report
Complaint Investigation
Census: 144
Deficiencies: 2
Jan 14, 2025
Visit Reason
An unannounced complaint survey was conducted at the facility from January 10, 2025, through January 14, 2025, based on allegations of abuse, neglect, exploitation, or mistreatment.
Findings
The facility failed to report and investigate an allegation of abuse as required by regulations. The investigation found no evidence that the facility reported the allegation to the state agency, and staff did not follow policies related to abuse investigation and reporting.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate an allegation of abuse in a timely and appropriate manner according to state and federal regulations.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to report alleged violations of abuse, neglect, exploitation, or mistreatment immediately and to other required agencies within specified timeframes. | SS=D |
| Failure to investigate and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress. | SS=D |
Report Facts
Facility census: 144
Sample size: 8
Deficiencies cited: 2
BIMS score: 8
BIMS score range: 0
BIMS score range: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E1 | Nursing Home Administrator (NHA) | Named in relation to findings about failure to report and investigate abuse allegations |
| E2 | Director of Nursing (DON) | Named in relation to findings about failure to report and investigate abuse allegations |
| E3 | Assistant Director of Nursing (ADON) | Interviewed regarding knowledge of abuse allegation statements |
| E4 | Social Worker (SW) | Interviewed regarding statements related to abuse allegations |
| E6 | Licensed Practice Nurse (LPN) | Interviewed regarding staff behavior and statements about abuse allegations |
| E7 | Certified Nursing Assistant (CNA) | Reported staff being mean to resident R1 |
| E8 | Supervisor | Interviewed about statements and documentation related to abuse allegations |
| F1 | Staff member reported to have been mean to resident R1 and involved in abuse allegation statements |
Inspection Report
Follow-Up
Census: 136
Deficiencies: 0
Aug 15, 2024
Visit Reason
An unannounced Follow-Up Survey to the Annual and Complaint Survey ending May 30, 2024, was conducted at this facility from August 14, 2024 through August 15, 2024.
Findings
The facility was found to be in substantial compliance with 42 CFR Part 483, Subpart B, Requirements for Long Term Care Facilities as of July 24, 2024. No deficiencies were identified at the time of the survey.
Report Facts
Survey sample size: 17
Inspection Report
Complaint Investigation
Census: 140
Deficiencies: 0
Jun 18, 2024
Visit Reason
An unannounced Complaint Survey was conducted at the facility on June 18, 2024.
Findings
No deficient practice was identified during the survey.
Complaint Details
The survey was complaint-related and no deficient practice was identified, indicating no substantiated deficiencies.
Report Facts
Survey sample residents: 2
Inspection Report
Annual Inspection
Census: 133
Deficiencies: 15
May 30, 2024
Visit Reason
An unannounced Annual and Complaint Survey was conducted at this facility from May 9, 2024, through May 30, 2024, to assess compliance with regulatory requirements and investigate complaints.
Findings
The survey identified multiple deficiencies related to resident rights, reasonable accommodations, advance directives, accuracy of assessments, comprehensive care plans, medication administration, infection control, and other regulatory requirements. The facility failed to ensure privacy, proper care planning, accurate assessments, and adequate staff education in several areas.
Complaint Details
The survey included complaint investigation as it was an Annual and Complaint Survey. Specific complaints involved privacy violations, failure to accommodate resident preferences, missing personal items, and inadequate care planning and assessments. The complaint findings were substantiated as evidenced by multiple deficiencies cited.
Severity Breakdown
F 550: 1
F 558: 1
F 578: 1
F 641: 1
F 644: 1
F 656: 1
F 658: 1
F 686: 1
F 690: 1
F 756: 1
F 757: 1
F 773: 1
F 812: 1
F 842: 1
F 880: 1
Deficiencies (15)
| Description | Severity |
|---|---|
| Facility failed to promote resident's dignity by keeping urinary collection bag in a privacy bag. | F 550 |
| Facility failed to accommodate resident preferences for showers. | F 558 |
| Facility failed to offer opportunity to formulate advance directives to some residents. | F 578 |
| Facility failed to ensure accuracy of assessments for multiple residents. | F 641 |
| Facility failed to coordinate PASARR assessments and screenings. | F 644 |
| Facility failed to develop and implement comprehensive care plans for residents. | F 656 |
| Facility failed to ensure medication administration met professional standards. | F 658 |
| Facility failed to provide care and services to prevent pressure ulcers. | F 686 |
| Facility failed to ensure bladder and bowel incontinence care and assessments were implemented. | F 690 |
| Facility failed to ensure drug regimen review was completed monthly by a licensed pharmacist. | F 756 |
| Facility failed to ensure drug regimen was free from unnecessary drugs. | F 757 |
| Facility failed to ensure lab results were promptly reported to medical provider. | F 773 |
| Facility failed to ensure food safety requirements were met including proper storage and sanitation. | F 812 |
| Facility failed to maintain resident records confidentially and accurately. | F 842 |
| Facility failed to establish and maintain an infection prevention and control program. | F 880 |
Report Facts
Facility census: 133
Investigative sample: 30
Deficiency completion dates: 7
Medication orders reviewed: 4
Residents reviewed for care plans: 5
Residents reviewed for assessments: 30
Residents reviewed for PASARR: 6
Residents reviewed for bladder and bowel care: 5
Residents reviewed for pressure ulcers: 2
Residents reviewed for drug regimen: 4
Residents reviewed for infection control: General infection control program deficiencies noted
Residents reviewed for food safety: Food safety deficiencies noted during kitchen inspection
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E36 | Certified Nurse's Aide (CNA) | Interviewed regarding privacy bag for urinary collection |
| E2 | Director of Nursing (DON) | Reviewed findings with surveyor |
| E4 | Consultant | Reviewed findings with surveyor |
| E21 | Corporate Clinical Nurse | Reviewed findings with surveyor |
| E19 | Registered Nurse (RN) | Interviewed regarding resident preferences and care |
| E65 | Resident | Interviewed regarding shower preferences |
| E7 | Social Work (SW) | Interviewed regarding behavioral documentation |
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding advance directives and care plans |
| E80 | Resident | Interviewed regarding grievance and missing personal items |
| E15 | RN Nursing Supervisor | Entered medication orders |
| E18 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration |
| E39 | Licensed Practical Nurse (LPN) | Interviewed regarding continence care |
| E43 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E40 | Wound Nurse Practitioner (NP) | Interviewed regarding wound care |
| E42 | Wound RN | Interviewed regarding wound care |
| E24 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E58 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E60 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E113 | Nurse Practitioner (NP) | Interviewed regarding wound care and complaints |
| E10 | Pharmacist Consultant | Interviewed regarding medication regimen review |
| E38 | Unit Manager (UM) | Interviewed regarding medication monitoring |
| E37 | Registered Nurse Assessment Coordinator (RNAC) | Interviewed regarding assessments |
| E44 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E113 | Nurse Practitioner (NP) | Interviewed regarding infection control complaint |
| E21 | Corporate Clinical Nurse | Interviewed regarding lab results and care |
| E48 | Registered Nurse/Unit Manager (RN/UM) | Interviewed regarding continence care |
| E52 | Nurse | Interviewed regarding insulin administration |
| E9 | Nurse Practitioner (NP) | Interviewed regarding wound care and insulin administration |
| E113 | Nurse Practitioner (NP) | Interviewed regarding infection control and complaint |
| E7 | Social Work (SW) | Interviewed regarding PASARR and care plans |
| E65 | Resident | Interviewed regarding shower preference |
| E80 | Resident | Interviewed regarding grievance |
| E14 | Social Work Assistant | Interviewed regarding grievance |
| E113 | Nurse Practitioner (NP) | Interviewed regarding infection control complaint |
| E18 | Licensed Practical Nurse (LPN) | Interviewed regarding wound care |
| E40 | Wound Nurse Practitioner (NP) | Interviewed regarding wound care |
| E42 | Wound RN | Interviewed regarding wound care |
| E21 | Corporate Clinical Nurse | Interviewed regarding bladder and bowel care |
| E35 | Licensed Practical Nurse Supervisor (LPN Sup) | Interviewed regarding bladder and bowel care |
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding neurologist consult and care |
| E6 | Medical Doctor (MD) | Interviewed regarding wound care and medication |
| E22 | Registered Nurse (RN) | Interviewed regarding lab results |
| E39 | Licensed Practical Nurse (LPN) | Interviewed regarding continence care |
| E59 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E60 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E21 | Corporate Clinical Nurse | Interviewed regarding continence care |
| E18 | Licensed Practical Nurse (LPN) | Interviewed regarding wound care |
| E40 | Wound Nurse Practitioner (NP) | Interviewed regarding wound care |
| E42 | Wound RN | Interviewed regarding wound care |
| E21 | Corporate Clinical Nurse | Interviewed regarding bladder and bowel care |
| E35 | Licensed Practical Nurse Supervisor (LPN Sup) | Interviewed regarding bladder and bowel care |
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding neurologist consult and care |
| E6 | Medical Doctor (MD) | Interviewed regarding wound care and medication |
| E22 | Registered Nurse (RN) | Interviewed regarding lab results |
| E39 | Licensed Practical Nurse (LPN) | Interviewed regarding continence care |
| E59 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E60 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E21 | Corporate Clinical Nurse | Interviewed regarding continence care |
| E18 | Licensed Practical Nurse (LPN) | Interviewed regarding wound care |
| E40 | Wound Nurse Practitioner (NP) | Interviewed regarding wound care |
| E42 | Wound RN | Interviewed regarding wound care |
| E21 | Corporate Clinical Nurse | Interviewed regarding bladder and bowel care |
| E35 | Licensed Practical Nurse Supervisor (LPN Sup) | Interviewed regarding bladder and bowel care |
| E1 | Nursing Home Administrator (NHA) | Interviewed regarding neurologist consult and care |
| E6 | Medical Doctor (MD) | Interviewed regarding wound care and medication |
| E22 | Registered Nurse (RN) | Interviewed regarding lab results |
| E39 | Licensed Practical Nurse (LPN) | Interviewed regarding continence care |
| E59 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E60 | Certified Nursing Assistant (CNA) | Interviewed regarding continence care |
| E21 | Corporate Clinical Nurse | Interviewed regarding continence care |
Inspection Report
Complaint Investigation
Census: 133
Deficiencies: 0
Oct 24, 2023
Visit Reason
An unannounced complaint survey was conducted at the facility from October 24, 2023 through October 25, 2023.
Findings
As a result of observations, record review, and interview, no deficiencies were identified during the survey.
Complaint Details
The complaint survey was unannounced and no deficiencies were identified, indicating no substantiated issues.
Report Facts
Survey sample size: 3
Inspection Report
Annual Inspection
Census: 124
Deficiencies: 10
Apr 11, 2023
Visit Reason
An unannounced Annual and Complaint Survey was conducted at the facility from April 3, 2023 through April 11, 2023 to assess compliance with federal and state regulations.
Findings
The survey identified multiple deficiencies related to safe environment, notice requirements before transfer/discharge, ADL care, quality of care, dialysis, nurse aide performance reviews, medication error rates, dental services, resident records, and COVID-19 immunization. Plans of correction were provided for each deficiency.
Severity Breakdown
SS=D: 10
Deficiencies (10)
| Description | Severity |
|---|---|
| Facility failed to provide a clean and homelike environment; black matter and brown substance observed in shower stall. | SS=D |
| Facility failed to ensure notice requirements before transfer/discharge were met; Ombudsman was not notified for hospital transfers. | SS=D |
| Facility failed to provide oral hygiene and grooming of facial hair for a resident requiring extensive assistance. | SS=D |
| Facility failed to initiate timely treatment for a resident's skin condition (pinky toe). | SS=D |
| Facility failed to monitor dialysis catheter for a resident receiving dialysis. | SS=D |
| Facility failed to ensure nurse aide performance evaluations were conducted every 12 months for six employees. | SS=D |
| Facility failed to ensure medication error rate was below 5%; medication pass observations identified 3 errors out of 26 opportunities (11.5%). | SS=D |
| Facility failed to ensure residents received routine and emergency dental services; a resident did not have dental appointment scheduled. | SS=D |
| Facility failed to maintain resident records accurately and confidentially; failed to properly identify medication indication and track dental services. | SS=D |
| Facility failed to provide required COVID-19 immunization education, documentation, and consent forms for residents and staff. | SS=D |
Report Facts
Facility census: 124
Investigative sample: 37
Medication error rate: 11.5
Medication error threshold: 5
Number of nurse aides with late evaluations: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| E18 | Housekeeping | Interviewed regarding cleaning schedule and shower room deficiencies |
| E7 | Social Services Director (SSD) | Interviewed regarding hospital transfer notification deficiencies |
| E23 | Certified Nursing Assistant (CNA) | Interviewed regarding oral care deficiencies for resident R98 |
| E20 | Registered Nurse (RN) | Observed medication pass and assessed medication error related to resident R116 |
| E24 | Licensed Practical Nurse (LPN) | Interviewed regarding oral care and dental services for resident R98 |
| E13 | Human Resources | Interviewed regarding late nurse aide performance evaluations |
| E14 | Wound Care Nurse Practitioner (WCNP) | Interviewed regarding skin treatment deficiencies for resident R128 |
| E15 | Licensed Practical Nurse (LPN) | Interviewed regarding skin treatments for resident R128 |
| E16 | Licensed Practical Nurse (LPN) | Interviewed regarding dialysis catheter care and skin treatments |
| E17 | Licensed Practical Nurse (LPN) Unit Manager | Interviewed regarding dialysis catheter care |
| RP1 | Responsible Party | Interviewed regarding dental services for resident R98 |
| E19 | Licensed Practical Nurse (LPN) | Interviewed regarding medication administration and resident care |
| E1 | Nursing Home Administrator (NHA) | Participated in exit conferences and reviewed findings |
| E2 | Director of Nursing (DON) | Participated in exit conferences and reviewed findings |
| E3 | Regional Nurse | Participated in exit conferences and reviewed findings |
| E8 | Nurse Aide | Performance evaluation overdue |
| E9 | Nurse Aide | Performance evaluation overdue |
| E10 | Nurse Aide | Performance evaluation overdue |
| E11 | Nurse Aide | Performance evaluation overdue |
| E12 | Nurse Aide | Performance evaluation overdue |
| E21 | Nurse Aide | Performance evaluation overdue |
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