Evergreen Estates Retirement Community.

“A resident's medical condition changed following an overdose incident and admission to the Emergency Room, but a new medical evaluation was not completed in response to this change.”

“Poisonous materials were not kept locked and inaccessible to residents. A resident who had ingested facial cleanser and was no longer capable of safely using poisons was found to have an unopened bottle of Scope mouthwash, Clorox disinfecting wipes, and Johnson's wash and shampoo in their room.”

“Prescription medications (anti-fungal powder and cream) were found unlocked, unattended, and accessible on a bedside nightstand in a resident's room. The resident cannot self-administer medications per their Assessment and Support Plan.”

“Blood glucose readings recorded on Medication Administration Records did not match glucometer readings taken at different times. Multiple residents had missing blood glucose readings on specified dates and times, indicating inadequate medication monitoring procedures.”

“Residents refused scheduled doses of prescribed medications on multiple occasions, and the home did not report these refusals to the prescriber within 24 hours as required.”

“Multiple residents did not receive prescribed medications as ordered because the medications were not available in the home. This is a repeated violation of the requirement to follow prescriber's orders.”

“A resident's Assessment and Support Plan did not adequately document the use of a bedside mobility device (enabler bar), including the specific need, intended use, risks, the resident's ability to use it safely, identification of the specific device, FDA guideline compliance, or the resident's supervision and mobility needs.”

“Resident 1's upper denture went missing approximately 2 months prior, and the home did not assist the resident to secure healthcare to address this concern. The resident subsequently choked on a piece of chicken nugget during lunch, requiring staff to repeatedly tap on the resident's back to dislodge the food. The home did not attempt to obtain a new diet order until the Department was on-site investigating the incident.”

“Resident 2's current medical evaluation does not include special health or dietary needs of the resident as required within the medical evaluation documentation.”

“The home placed Resident 1 on a pureed diet per family request without obtaining a physician's order for the pureed diet until after the placement occurred.”

“Resident 2 self-administers medications but has been assessed by a physician, physician's assistant, or certified registered nurse practitioner as incapable of self-administering medications, creating a contradiction in the resident's care.”

“Staff indicated that the kitchen sometimes leaves frozen food out on the counter to air thaw for extended periods of time, which is not an approved thawing method.”

“Kitchen had multiple stains on floors with dirt and grime under fixtures and appliances. Black mold was observed on the wall above the dishwashing station. Multiple food items including raw eggs and fruit were stored under shelving units in the walk-in refrigerator, and a large puddle of what appeared to be salad dressing or sauce was found under dry storage shelving units.”

“A box of frozen bakery rolls and a box of frozen orange juice concentrate were stored on the floor in the walk-in freezer.”

“A 12 ounce can of beef paste in the walk-in refrigerator was opened and unsealed. Additionally, a plate of pie, an open tin of premade angel food cake, and a large open box of banana cake in the standing refrigerator unit by dry food storage were found open and unsealed.”

“Sanitary conditions were not maintained; an overwhelming smell was noted during inspection.”

“The home failed to submit incident reports to the Department for two instances where prescribed blood sugar tests were not completed for residents.”

“The home failed to complete an Act 13 form and submit it to the local Area Agency on Aging following a physical altercation between two residents that resulted in injury to one resident.”

“The home's quality management plan reviews did not address reportable incident and condition reporting procedures, complaint procedures, staff person training, licensing violations and plans of correction, and resident or family councils.”

“A resident pushed another resident, causing them to fall to the ground and sustain a closed compression fracture, requiring emergency room treatment.”

“The home had insufficient staff certified in first aid and CPR present at all times. On multiple dates, the home only had one person working with current CPR and first aid training when regulations required at least one staff person for every 50 residents. This is a repeated violation.”

“Training records for direct care staff members do not include fire safety and emergency preparedness training that was conducted.”

“Four residents' enabler bars were not securely attached to the bed frame, posing an entrapment risk.”