Inspection Reports for Evergreen Retirement Residence

The inspection was an unannounced required one-year annual inspection of the Evergreen Retirement Facility to assess compliance with licensing requirements.

The facility was found to be generally compliant with no immediate health and safety hazards observed. The kitchen, resident bedrooms, bathrooms, laundry, medication storage, and records were inspected and found to meet regulatory standards.

The visit was conducted as an unannounced complaint investigation regarding an allegation that facility staff did not safeguard a resident's confidential information.

The investigation found insufficient evidence to confirm or deny that facility staff left resident's confidential information accessible to unauthorized persons. The allegation was deemed unsubstantiated.

The complaint alleged that on 04/27/25, resident #1 observed resident #2 reading confidential paperwork belonging to resident #1 at the concierge desk area. The facility had no staff assigned to the lobby during the relevant hours, and the identity of the person who left the documents accessible was unknown. The allegation was unsubstantiated due to lack of evidence.

An unannounced complaint investigation visit was conducted to investigate allegations that the facility coffee maker was in disrepair and staff were not providing hot water to residents for hot tea or coffee.

The allegation was found to be unsubstantiated. Interviews with seven residents and three staff confirmed the coffee maker was broken but alternatives such as instant coffee and hot water were provided. The Licensing Program Analyst observed working coffee makers and hot water machines available for resident use.

The complaint was unsubstantiated based on resident and staff interviews and physical observations during the investigation.

An unannounced complaint investigation visit was conducted to investigate allegations that staff were threatening to evict a resident for verbally abusing another resident.

The investigation found that the resident was issued an eviction letter for violating house rules but the eviction was rescinded and the resident was not evicted. Based on gathered information, the allegation was deemed unsubstantiated.

The complaint alleged that staff were threatening to evict a resident for verbally abusing another resident. Interviews and document reviews showed the eviction letter was issued but later rescinded. The resident was not evicted at the time of the visit. The allegation was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-08-30 regarding staff training, timeliness of assistance, facility security, and adequacy of food service at Evergreen Retirement Facility.

The investigation found all allegations to be unsubstantiated. Staff were adequately trained to meet resident needs, assisted residents in a timely manner, ensured the facility was secure, and provided adequate food service. No immediate health and safety risks were observed.

The complaint investigation addressed multiple allegations including inadequate staff training, untimely assistance to residents, unsecured facility doors, and inadequate food service. All allegations were found to be unsubstantiated based on interviews, observations, and record reviews.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not ensure residents were spoken to in an appropriate manner.

The investigation included interviews with staff, residents, and the Administrator, and a review of records. The allegation that the Wellness Director made upsetting comments was denied by all parties and residents interviewed expressed no concerns. The allegation was deemed unsubstantiated.

The complaint alleged that the Wellness Director made upsetting comments about health treatments of a resident (R1). Interviews with the Administrator, Wellness Director, staff, and residents found no evidence to support the allegation. The complaint was unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by an allegation that staff did not seek medical attention for a resident in a timely manner.

The allegation was substantiated based on interviews and review of medical records showing staff had knowledge of the resident's decline and increased needs since 10/22/22. The deficiency posed an immediate health and safety risk. The licensee submitted a Plan of Correction which was cleared on 03/18/24.

The complaint was substantiated. The investigation included interviews with the facility administrator, staff, and residents, and review of medical records from the hospital and skilled nursing facility. The Plan of Correction was submitted and cleared.

The document contains an error message stating 'Index out of range of report list', indicating no valid inspection report data is available.

No findings or inspection content present due to error in report data retrieval.

The inspection was an unannounced required one-year annual inspection to evaluate compliance with licensing regulations at Evergreen Retirement Facility.

The facility was found to be in compliance with all applicable regulations with no deficiencies observed. The physical plant, resident and staff files, medication storage, and safety measures were all in proper order.

The visit was an unannounced complaint investigation conducted in response to allegations received on 04/05/2024 regarding inadequate food service, untimely response to call buttons, and staff stealing residents' belongings.

The investigation found insufficient evidence to substantiate any of the allegations. Food service was generally adequate with an alternative menu available, call buttons were functional and staff responded within 3 to 5 minutes, and no evidence supported the claim of stolen residents' belongings. No health and safety hazards were noted.

The complaint included three allegations: 1) Staff do not provide adequate food service to residents; 2) Staff do not answer residents' call buttons in a timely manner; 3) Staff stole residents' belongings. All allegations were found to be unsubstantiated based on interviews, observations, and record reviews.

The visit was an unannounced complaint investigation triggered by a complaint received on 2023-07-27 regarding allegations that a resident's personal items were not safeguarded.

The investigation found no pertinent information to support the allegation that the resident's personal items were not safeguarded. Interviews with staff and residents, as well as document reviews, indicated the allegation was unsubstantiated and no health or safety hazards were noted.

The complaint alleged that a resident's jewelry box was previously tampered with and was now missing. Staff explained that the resident's belongings were locked in their room after hospital transfer until family retrieved them. Interviews with seven residents confirmed staff statements, and the resident did not list a jewelry box on the personal inventory. The allegation was unsubstantiated.

The visit was an unannounced complaint investigation triggered by allegations that staff were not seeking appropriate medical services for residents and were forcing residents to accept emergency transport to the hospital.

Based on interviews with staff and residents, review of facility records, and incident logs, there was insufficient information to support the allegations. The complaint was determined to be unsubstantiated and no health or safety hazards were noted during the visit.

The complaint alleged that staff did not seek appropriate medical care and forced residents to accept emergency hospital transport. Investigations included interviews with staff and residents, review of medical and incident records, and a physical tour. Findings showed staff sought medical services as needed and residents were not forced to accept emergency transport. The complaint was unsubstantiated.

An unannounced complaint investigation visit was conducted in response to an allegation that staff did not prevent a resident from stealing another resident's personal belongings.

The investigation found insufficient information to support the allegation that resident R2 stole jewelry from resident R1. Interviews and document reviews indicated that residents are responsible for securing their own belongings and no health or safety hazards were noted.

The allegation was that staff failed to prevent resident R2 from stealing a wedding ring from resident R1. Interviews with residents and staff, as well as review of resident property records, did not substantiate the claim. The allegation was determined to be unsubstantiated.

The inspection was an unannounced complaint investigation visit conducted to investigate multiple allegations including staff neglect in seeking timely medical attention for a resident after a fall, severe dehydration, wandering due to lack of supervision, medication administration failures, theft of resident belongings, and inadequate food service.

The investigation substantiated that staff failed to seek timely medical attention for a resident who fell and sustained a head injury, posing an immediate health and safety risk. Other allegations including severe dehydration due to neglect, wandering away from the facility, failure to administer medications, theft of belongings, and inadequate food service were found to be unsubstantiated due to insufficient evidence.

The complaint was received on 2023-01-04 and investigated due to allegations including failure to seek timely medical attention after a resident's fall, severe dehydration, wandering, medication administration failures, theft, and inadequate food service. The fall and delayed medical attention allegation was substantiated, while the others were unsubstantiated.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2023-04-18 regarding staff assistance, bed bug issues, and verbal harassment of residents.

The investigation found insufficient evidence to substantiate any of the allegations. Observations, interviews, and document reviews indicated no bed bugs, no verbal harassment, and that the resident in question did not require assistance as alleged.

The complaint involved three allegations: 1) staff did not ensure appropriate assistance was provided to a resident, 2) the facility did not properly address bed bugs, and 3) staff verbally harassed a resident. All allegations were found to be unsubstantiated based on interviews, observations, and document reviews.

The visit was an unannounced complaint investigation triggered by an allegation that staff did not dispense medication as prescribed to residents.

The investigation found insufficient information to support the allegation that residents missed medication. Staff and resident interviews, as well as medication records, confirmed that residents managed their own medications and no discrepancies were observed. The allegation was unsubstantiated and no health or safety hazards were noted.

The complaint alleged that resident #1 had not received medication for two days and resident #2 was not receiving medications as per doctor's orders. The allegation was found to be unsubstantiated based on interviews, observations, and document review.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2024-02-21 regarding medication administration, staff training, timely assistance to residents, and staff smoking marijuana at the facility.

After interviews, observations, and document reviews, all allegations were found to be unsubstantiated due to insufficient evidence. Residents were receiving medications as prescribed, staff were properly trained, residents were assisted timely, and no evidence of staff smoking marijuana was found.

The complaint investigation addressed four allegations: residents not receiving medications as prescribed, untrained staff assisting with medication, residents not assisted timely due to lack of staff, and staff smoking marijuana at the facility. All allegations were determined to be unsubstantiated based on interviews, observations, and document reviews.

An unannounced complaint investigation was conducted in response to an allegation that staff do not serve residents food of good quality, including claims that food is cold, overcooked or undercooked, and lacks variety.

Based on observations, record review, and interviews with staff and residents, there was insufficient evidence to verify the allegation. Most residents and staff reported satisfaction with the food quality, temperature, and variety. The allegation was unsubstantiated and no health or safety hazards were noted.

The complaint alleged poor food quality including cold, overcooked or undercooked food and lack of variety. The allegation was found to be unsubstantiated after investigation.

The visit was an unannounced complaint investigation triggered by allegations of staff financially abusing residents and failing to safeguard residents' personal belongings.

After interviews with staff and residents, and review of relevant records, the allegations of financial abuse and failure to safeguard personal belongings were found to be unsubstantiated. No immediate health and safety hazards were noted during the visit.

The complaint involved allegations that staff took a resident's debit card and made unauthorized charges, and that a new debit card had been stolen from the facility. Investigations including interviews and record reviews found no evidence to support these allegations, resulting in an unsubstantiated determination.

The inspection was an unannounced complaint investigation visit triggered by allegations that staff does not ensure the facility is free of rodents and pests.

The investigation substantiated the allegation of rodents in the facility, with observations of rodent droppings and glue traps in multiple areas, and confirmed by staff interviews and pest management reports. However, the allegation regarding cockroaches was unsubstantiated as no cockroaches were observed during the visit and pest control services were in place.

The complaint investigation was substantiated for rodents with sufficient evidence from observation, interviews, and document review. The cockroach allegation was unsubstantiated due to lack of evidence and ongoing pest control measures.

The visit was conducted to perform additional interviews related to a complaint control number 28-AS-20230213105132.

Licensing Program Analyst interviewed residents to obtain further information pertaining to the complaint. An exit interview and copy of the report were provided.

Visit was complaint-related, conducted to gather more information through resident interviews. No substantiation status stated.

The visit was an unannounced complaint investigation conducted in response to allegations that a resident's toileting needs were not being met and that the facility was not meeting residents' hair care needs.

The investigation included interviews with staff, residents, and review of documents and observations. No evidence was found to substantiate the allegations; residents were assisted timely with toileting and hair care, and no residents were observed to be unclean or have matted hair. The allegations were determined to be unsubstantiated.

The complaint investigation was unsubstantiated based on interviews with staff and residents, document review, and observations. Allegations included a resident being covered in urine and feces and having matted hair, which were denied by staff and residents.

The visit was an unannounced complaint investigation conducted in response to an allegation that staff failed to meet a resident's grooming needs.

The investigation found no evidence to support the allegation. Staff interviews and record reviews indicated the resident was independent in grooming and the facility provided beauty salon services. The allegation was unsubstantiated.

The complaint alleged that staff failed to meet resident #1's grooming needs, specifically that the resident's hair was braided and new hair growth looked tangled. The allegation was investigated and found to be unsubstantiated.

The visit was an unannounced complaint investigation conducted in response to allegations that facility staff do not keep residents' rooms clean and free of trash and that staff are not meeting residents' care needs.

The investigation found that residents' rooms were clean and free of trash, and residents confirmed that cleaning was done as required. Staff interviews and record reviews confirmed that resident care needs were being met according to care plans and medication orders. Both allegations were unsubstantiated.

The complaint investigation was unsubstantiated based on inspection, observations, interviews with residents and staff, and record reviews. No evidence supported the allegations regarding cleanliness or care needs.

The inspection was an unannounced complaint investigation triggered by an allegation that a resident inhaled and ingested hazardous chemicals.

The investigation substantiated that resident #1 inhaled Lysol, posing an immediate health and safety risk. The resident had fallen twice during the visit and was assisted by paramedics. The Executive Director was informed and agreed to secure chemicals to prevent access by residents.

The complaint was substantiated based on interviews and investigation findings that resident #1 inhaled and ingested hazardous chemicals, specifically Lysol.

An unannounced complaint investigation visit was conducted to investigate an allegation that the facility was not safeguarding a resident's personal items, specifically that Resident #1's money was stolen in December 2022.

The investigation found no substantiated evidence of missing money or reports thereof. Interviews with the resident, Executive Director, and Wellness Director confirmed no reports or investigations of missing money. The allegation was deemed unsubstantiated.

The complaint alleged the facility was not safeguarding a resident's personal items, specifically missing money. The allegation was unsubstantiated based on interviews and record reviews showing no reports or investigations of missing money.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2020-12-15 regarding residents' dietary needs not being met and residents' rooms not being at a comfortable temperature.

The investigation found that the majority of residents and staff corroborated that dietary and diabetic needs were being met and that room temperatures were comfortable. Based on evidence and interviews, both allegations were found to be unsubstantiated.

The complaint investigation was unsubstantiated. Allegations included neglect/lack of supervision regarding dietary needs and physical plant issues regarding room temperature. Both allegations were found unsubstantiated after interviews, observations, and record reviews.

The visit was an unannounced complaint investigation conducted in response to allegations received on 2021-12-03 regarding staff not meeting residents' needs, inadequate food service, and lack of activities.

The investigation found no preponderance of evidence to substantiate the allegations. Staff and residents denied the claims, and observations and document reviews confirmed adequate staffing, knowledgeable food service, and provision of activities.

The complaint investigation was unsubstantiated. Allegations included staff shortages leading to inadequate care, inadequate food service due to lack of nutrition knowledge, and absence of activities. Interviews, observations, and document reviews did not corroborate these allegations.

Unannounced required 1-year visit focusing on COVID-19 Infection Control Practices and general facility compliance.

The inspection found multiple deficiencies including lack of soap, paper towels, and sanitizer in some resident rooms, improperly stored PRN medication, maintenance issues such as broken glass on fire extinguisher compartments, water damage, plumbing problems, and obstructions in passageways. Some issues were corrected during the visit.

The inspection was an unannounced complaint investigation visit triggered by allegations received on 2021-12-03 regarding staff not meeting residents' needs, inadequate food service, and lack of activities.

The investigation found no preponderance of evidence to substantiate the allegations. Staff interviews, resident interviews, and document reviews showed sufficient staffing, knowledgeable food service staff with dietitian oversight, and active resident participation in scheduled activities.

The complaint investigation was unsubstantiated. Allegations included staff shortages leading to neglect, inadequate food service, and no activities provided. Interviews and observations did not corroborate these claims, and the facility was found to be in compliance.

The visit was conducted as an unannounced complaint investigation regarding an allegation that the facility has insufficient staffing.

The investigation included interviews, observations, and record reviews, concluding there was insufficient evidence to prove the allegation of insufficient staffing. Resident and staff interviews indicated that residents' needs were met and staffing was sufficient. The allegation was determined to be unsubstantiated.

The complaint alleged insufficient staffing at the facility. The investigation was unannounced and included multiple visits. The allegation was found to be unsubstantiated based on observations, interviews, and record reviews.

The inspection was conducted as an unannounced complaint investigation visit regarding allegations that staff failed to provide adequate food service to residents at Evergreen Retirement Facility.

The investigation included interviews with staff, residents, and review of food menus and supplies. The findings indicated that although the allegation may have happened or is valid, there was not a preponderance of evidence to prove the alleged violation occurred, resulting in an unsubstantiated finding.

The complaint alleged that staff failed to provide adequate food service to residents, specifically that the food did not meet residents’ dietary needs. The allegation was found to be unsubstantiated after investigation.

The inspection was an unannounced complaint investigation visit triggered by a complaint received on 2020-03-05 regarding staffing adequacy and provision of activities at the facility.

The investigation found the allegations to be unsubstantiated based on interviews with residents, staff, and review of documents, confirming adequate staffing and provision of activities prior to the pandemic.

The complaint alleged inadequate staffing and lack of resident activities. The investigation concluded the allegations were unsubstantiated.

An unannounced complaint investigation visit was conducted due to allegations of insufficient staffing and failure to meet residents' needs at Evergreen Retirement Facility.

The allegation of insufficient staffing was substantiated due to staff resignations during the pandemic, but no deficiency was issued as the department was notified prior and residents did not report care concerns. The allegation that staff failed to meet residents' needs was unsubstantiated as residents confirmed they continued to receive necessary care despite some delays.

The complaint was substantiated regarding insufficient staffing caused by staff resignations during the pandemic. However, the allegation that residents' needs were not met was unsubstantiated based on resident interviews and observations.

Licensing Program Analyst Galarza conducted an unannounced Required 1-year visit focusing on COVID-19 Infection Control Practices at Evergreen Retirement Facility.

The inspection found multiple deficiencies including lack of required COVID-19 signage at the main entrance and throughout the facility, absence of hand sanitizer in most resident rooms and common areas, staff and residents not consistently wearing masks, and inaccuracies in medication administration records for two residents.

The inspection was conducted as an unannounced complaint investigation following a complaint received on 08/07/2020 alleging that the facility did not safeguard residents' personal property.

The investigation found that the facility did not safeguard residents' personal property, specifically a missing land line telephone and other valuables. The facility's theft and loss policy was not in compliance with Title 22, placing responsibility for lost or stolen property on residents unless negligence by staff is proven. The allegations were substantiated based on interviews and record review.

The complaint investigation was substantiated. The allegation was that the facility did not safeguard resident's personal property, including a missing land line telephone. Interviews with residents, staff, and the administrator, as well as record reviews, supported the substantiation.

The inspection was conducted in response to a complaint alleging inadequate staffing, poor communication with authorized representatives, and failure to provide proper notification of rate increases at Evergreen Retirement Facility.

The investigation found sufficient staffing levels and timely communication with authorized representatives. The facility provided proper notification of rate increases. The allegations were determined to be unsubstantiated due to lack of preponderance of evidence.

The complaint included allegations of inadequate staffing, failure to promptly or appropriately answer communications to authorized representatives, and failure to provide proper notification of rate increases. The investigation concluded these allegations were unsubstantiated.