Inspection Reports for Evergreen Residence

The inspection was conducted as a complaint investigation survey triggered by complaint #NV00073209 alleging failure to maintain complete and accurate resident records including missing ADL logs and medication administration records.

The complaint was unsubstantiated due to lack of sufficient evidence; however, a separate deficiency was identified related to unsecured medications found in the dining area. The facility failed to ensure medications were secured for all four residents, with an unlocked medication cabinet observed during the visit.

Complaint #NV00073209 alleged failure to maintain complete and accurate resident records resulting in missing ADL logs and medication administration records; the complaint was unsubstantiated due to lack of sufficient evidence.

This inspection was an annual State Licensure survey conducted by the Division of Public and Behavioral Health to assess compliance with NAC 449 for Residential Facilities for Groups.

The facility received a grade of B with several regulatory deficiencies identified, including maintenance issues with the facility premises, lack of person-centered service plans for all residents, incomplete medication administration reviews, missing administrator initials on medication profile reviews, incomplete tuberculosis testing documentation, and failure to maintain resident records in compliance with preferred name, pronoun, gender identity, and sexual orientation policies.

This inspection was conducted as a result of a complaint investigation survey triggered by two complaints alleging issues with facility temperature control and caregiver abuse.

No regulatory deficiencies were identified during the investigation. Both complaints regarding the facility's swamp cooler and caregiver abuse allegations were not substantiated due to lack of evidence. Observations, interviews, and document reviews were conducted with no further action necessary.

Two complaints were investigated: Complaint #NV00071646 alleging the facility's swamp cooler was not on and temperatures reached 87 degrees Fahrenheit, and Complaint #NV00071750 alleging caregiver abuse including hitting and yelling at residents. Both complaints were not substantiated due to lack of evidence.

The inspection was conducted as a complaint investigation survey following an allegation that the facility admitted a resident with an inappropriate level of care.

No regulatory deficiencies were identified during the investigation. The allegation could not be substantiated due to lack of sufficient evidence after reviewing resident records, conducting interviews, and observing the facility.

One complaint (#NV00070353) was investigated regarding admission of a resident with an inappropriate level of care; the complaint was not substantiated.

This inspection was conducted as an annual State Licensure survey of the Evergreen Residence facility to assess compliance with NAC 449 regulations for Residential Facility for Groups.

The facility received a grade of A; however, a regulatory deficiency was identified related to medication storage. Medications for all residents were found unsecured in common areas, violating storage requirements.

This inspection was a grading re-survey State Licensure Survey conducted to assess compliance with Nevada Administrative Code Chapter 449 for a Residential Facility for Groups.

The facility received a grade of A. A regulatory deficiency was identified related to personnel files and TB screening. Additionally, a sanitation deficiency was found due to trash debris not being contained in the backyard, posing a potential safety hazard to residents.

The inspection was conducted as a result of a State Licensure annual grading survey combined with a complaint investigation at the facility on 09/22/22.

The facility received a grade of C with multiple deficiencies identified including failure to ensure timely tuberculosis screening for employees, improper medication storage, failure to maintain a safe environment with staff not wearing masks, and incomplete or untimely resident documentation such as ADL assessments and Ultimate User Agreements. Two complaints were investigated, one substantiated regarding unsecured medication and medication self-administration.

Two complaints were investigated: Complaint #NV00066587 was not substantiated regarding misappropriation of property. Complaint #NV00065950 was substantiated regarding unsecured medication and medication self-administration.

This inspection was conducted as a State Licensure annual survey of the Evergreen Residence facility to assess compliance with Nevada Administrative Code Chapter 449 for Residential Facility for Groups.

The facility received a grade of A but had several regulatory deficiencies including improper storage of toxic substances with food, failure to document monthly smoke detector testing, and failure to obtain an exemption request for a resident receiving wound care.

This inspection was a State Licensure COVID-19 Focused Infection Control Survey conducted due to four positive COVID-19 asymptomatic residents and three positive staff in the facility.

The investigation included review of visitor screening, staff education and monitoring, emergency staffing plan, infection control practices, PPE inventory, and observation of staff PPE use. No regulatory deficiencies were identified.

This survey was conducted as a State Licensure COVID-19 Infection Control and Prevention Plan review with the facility Administrator.

The facility has a written infection control plan in accordance with CDC guidance, including visitor screening, staffing plans, PPE access and training, respirator program, and COVID-19 response protocols. No regulatory deficiencies were identified and no further action is necessary.

This inspection was conducted as an annual State Licensure survey of the Evergreen Residence facility on 3/31/2017 by the Division of Public and Behavioral Health.

The facility received a grade of A. One regulatory deficiency was identified related to cleanliness in the kitchen area, specifically failure to maintain cleanliness between the counter space/cabinets and the oven, with grease-like substance, food particles, and small brown or black substances resembling mouse droppings observed.

The inspection was conducted as a result of a complaint investigation initiated on 2016-05-18 and completed on 2016-05-19 regarding allegations of employee to resident abuse.

The investigation substantiated the complaint that an employee abused Resident #4 by inappropriate behavior, including tickling the resident's genitals. The facility terminated the employee involved. The resident denied abuse during assessment. The facility's policy on resident rights and employee training records were reviewed.

Complaint #NV00045659 was substantiated. The allegation of employee to resident abuse was substantiated based on observation and interviews. The employee involved was terminated following the incident.

The inspection was conducted as a result of a complaint investigation initiated on 2016-05-18 and completed on 2016-05-19 regarding alleged employee to resident abuse.

The investigation substantiated the complaint of employee to resident abuse involving Employee #4 and Resident #4. The facility terminated Employee #4 on 2016-04-30, not for guilt but to satisfy the guardian's request. Resident #4 denied any inappropriate touching and was found alert and oriented. The facility provided evidence of employee training on elder abuse prevention.

Complaint #NV00045659 was substantiated. The allegation of employee to resident abuse was substantiated.

This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for Evergreen Residence, a residential facility for elderly or disabled persons.

The facility received a grade of A but had several deficiencies including failure to ensure timely elder abuse prevention training for one employee, delayed fingerprinting for two employees, missing medication for one resident, and incomplete tuberculosis screening documentation for two residents.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 3/17/16 to assess compliance with state regulations for a residential facility for elderly or disabled persons.

The facility received a grade of A but had several deficiencies including failure to ensure elder abuse training was completed before care provision, failure to initiate fingerprints within required timeframes for some employees, failure to have medication on site as ordered, and failure to meet tuberculosis screening requirements for some residents.

The inspection was conducted as a complaint investigation based on an allegation regarding the use of restraints in the facility.

The complaint regarding use of restraints was not substantiated. However, deficiencies unrelated to the complaint were identified, including failure to obtain a bedfast waiver for a resident and failure to maintain a current written plan of care for a resident receiving hospice care.

Complaint #NV00043522 alleging use of restraints was investigated and found not substantiated.

The inspection was conducted as a complaint investigation triggered by Complaint #NV00043522 alleging use of restraints at the facility.

The complaint allegation of use of restraints was not substantiated. However, deficiencies unrelated to the complaint were identified, including the facility retaining a bedfast resident without a required waiver and failure to maintain a current written plan of care for that resident receiving hospice care.

Complaint #NV00043522 alleging use of restraints was investigated and found to be unsubstantiated.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted on 05/06/15 to assess compliance with regulatory requirements for a residential facility for elderly and disabled persons.

The facility was found to have deficiencies related to personnel files, medication storage, and resident files concerning tuberculosis testing. The facility received a grade of A, but some employees did not meet pre-employment physical examination requirements, medication storage protocols were not fully followed, and tuberculosis testing documentation was incomplete for some residents.

This inspection was conducted as an annual State Licensure survey to assess compliance with regulatory requirements for Evergreen Residence, a residential facility for elderly and disabled persons.

The facility received a grade of A but had several deficiencies including failure to ensure timely pre-employment physical examinations for one employee, failure to keep medications in locked containers, and failure to maintain required tuberculosis testing documentation for two residents.

This document is the result of an annual State Licensure survey conducted at the facility on 5/29/2014 to assess compliance with state regulations.

The facility received a grade of A with no regulatory deficiencies identified. Seven resident files and three employee files were reviewed during the survey.

This inspection was conducted as a result of a complaint investigation at Evergreen Residence on 06/17/2013, focusing on compliance with tuberculosis testing, use of restraints, and admission policies.

The facility was found deficient in maintaining personnel files with required health certificates, improper use of mechanical restraints on a resident, and failure to retain a resident requiring confinement in locked quarters. The facility received a grade of A despite these deficiencies.

The complaint investigation substantiated deficiencies related to tuberculosis testing compliance, improper use of restraints, and admission policy violations regarding confinement in locked quarters.

This Statement of Deficiencies was generated as a result of a complaint investigation conducted in the facility on 6/17/13 by the authority of NRS 449.0307, Powers of the Health Division.

The facility was found deficient in several areas including failure to ensure tuberculosis testing compliance for one employee, use of mechanical restraints on a resident, and admitting and retaining a resident requiring confinement in locked quarters without appropriate care. The facility received a grade of A.

The complaint investigation revealed issues with employee tuberculosis testing compliance, improper use of mechanical restraints on a resident, and admission and retention of a resident requiring confinement in locked quarters without appropriate care.

The inspection was conducted as an annual State Licensure survey of Evergreen Residence on 06/11/2012.

No regulatory deficiencies were identified during the survey. The facility received a grade of A.

This document is the result of an annual State Licensure survey conducted at the facility on 5/10/11 to assess compliance with state regulations.

The facility received a grade of A with no regulatory deficiencies identified. No further action was necessary.

This document is the result of an annual State Licensure survey conducted at Evergreen Residence on 5/17/2010 to assess compliance with state regulations for a residential facility for elderly and disabled persons.

The facility received a grade of A overall, but deficiencies were identified related to tuberculosis testing compliance. Specifically, 2 of 7 residents were missing the required second step TB test, affecting all residents.

This document is a Statement of Deficiencies generated as a result of an annual State Licensure survey conducted at Evergreen Residence on 5/28/2009.

The facility received a grade of A but had several deficiencies including missing FBI background checks for 3 of 4 employees, lack of window and door screens to prevent insect entry, failure to document a resident's injury and physician notification, and inaccurate ultimate user agreements for medication administration for 6 of 8 residents.