Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Care Center during CMS and state inspections, most recent first.
Failure to Report Fall With Head Injury Requiring Hospital Transfer: A cognitively intact resident with multiple mobility-related diagnoses had an unwitnessed fall while self-transferring from the commode to the bed, struck his head, and had bleeding to the forehead before being sent to the acute hospital for further evaluation. The DON stated the event was not reported to state agencies because the resident was alert and the injury was viewed as minor, although staff stated the facility process was to report falls with injury, including head injuries and hospital transfers, to the state agency.
A resident with multiple comorbidities, including ESRD, heart failure, and abnormal breathing, was discharged home without the physician-ordered medical equipment, including continuous oxygen, wheelchair, and shower chair. Although discharge documentation stated that medical equipment and oxygen supplies were delivered and explained, the SSD and family reported that no equipment was provided and that the oxygen concentrator was not available at the time of discharge. RN, SSD, DON, and ADM interviews confirmed that the facility’s discharge process requires ensuring all ordered equipment is in place before discharge and that this did not occur for this resident, resulting in an unsafe discharge contrary to facility policy.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents. The environment did not meet required safety standards, resulting in insufficient oversight.
Three residents experienced missed or delayed medical appointments due to inadequate transportation arrangements, lack of accommodation for transportation preferences, and poor communication between staff, residents, and responsible parties. Issues included late arrivals, inappropriate vehicles, and extended wait times after appointments, with incomplete documentation and unclear staff responsibilities contributing to the deficiencies.
A resident with a history of trauma was not provided with trauma-informed care upon admission to the facility. Despite disclosing her traumatic past and expressing fear of being around unfamiliar men, the facility did not implement effective interventions to avoid triggers. The resident was placed in a room near male residents, causing distress and anxiety. Staff were unaware of her traumatic history due to a lack of training, and her requests for room changes were not addressed, leading to feelings of isolation and fear.
The facility failed to employ a full-time DON from December 2024 to March 2025. A nursing consultant performed some DON duties part-time, but no full-time DON was designated. This absence potentially risked inadequate care planning and supervision, affecting residents' health and safety.
The facility failed to ensure privacy for two residents during health discussions, as the social services director's office was too small and residents' rooms did not provide adequate privacy. Both residents reported concerns about discussing personal health information due to the presence of roommates and staff. The facility's policy emphasized confidentiality, but the lack of a suitable private area led to potential breaches of privacy.
A facility failed to create a trauma-informed care plan for a resident with a history of trauma, despite identifying her trauma upon admission. The resident, who was cognitively intact and had multiple diagnoses, experienced triggers that caused her to relive past traumas. Staff interviews revealed a lack of awareness of the resident's trauma history and the importance of identifying triggers, contrary to the facility's policies on comprehensive care plans and trauma-informed care.
Two residents were denied the opportunity to reheat food brought by family after 7:00 p.m. due to the lack of a functioning microwave and the absence of dietary staff. Both residents, who were cognitively intact, expressed anger over this restriction, which did not respect their autonomy. The facility's policy allowed food from outside but did not accommodate reheating after dietary staff hours, impacting residents' rights to self-determination.
A resident with cognitive intactness and multiple medical conditions was abused by a CNA who hit them with a closed fist during personal care. The resident became aggressive, leading to the CNA's inappropriate response. Staff interviews confirmed the incident, which violated the facility's abuse prevention policies.
The facility failed to maintain food safety standards, as observed in three key areas: improper sanitizer concentration used by a kitchen staff member, failure to record food temperatures before serving, and storing kitchenware while still wet. These actions could potentially expose residents to foodborne illnesses due to bacterial growth.
Two residents were not provided privacy during medical procedures by an LVN, who checked vital signs and administered medications in public areas. Despite facility policies requiring privacy, these actions were conducted in view of others, compromising the residents' dignity and respect. Both residents had no cognitive deficits, highlighting the importance of adhering to privacy protocols.
The facility failed to complete dialysis communication forms for two residents undergoing hemodialysis, as observed through interviews and record reviews. One resident, admitted with end-stage kidney disease and a fractured femur, lacked documentation of post-dialysis assessments on multiple dates. Another resident had incomplete forms for several dates in May. Staff interviews revealed that charge nurses and medical records staff were responsible for ensuring form completion, which was not done, risking delayed detection of complications.
A resident was administered heparin for venous thromboembolism prophylaxis without a comprehensive care plan in place. Despite the resident's significant medical conditions, facility staff, including an LVN, the MDS Nurse, and the DON, confirmed the absence of a care plan to monitor the anticoagulant use. This oversight was contrary to the facility's policy requiring timely development of care plans.
A resident with Type 2 Diabetes Mellitus did not have their fasting blood sugar levels monitored as per physician's orders, which required daily checks. The DON confirmed the absence of records for these checks, and the LVN was unaware of the resident's diabetes diagnosis and monitoring order. The MDSN noted that prompts for blood sugar checks were missing in the MAR, and the Medical Records Staff acknowledged the need for more careful review of orders.
A resident's prescribed Lactulose medication for constipation was unavailable for administration due to a failure in reordering. An LVN discovered the unavailability during a medication pass, and the DON confirmed that nurses are responsible for ensuring timely medication orders. The facility's policy mandates timely delivery to prevent administration delays.
A resident with a history of cerebral infarction and dysphagia was not provided with the prescribed finger food diet, receiving whole pieces of chicken and other non-finger foods instead. The CNA did not verify the meal against the tray ticket, assuming it was already checked by the nurse. This oversight was confirmed by the RNA and MDSN, and the DSM acknowledged the error, highlighting a failure in the facility's process to ensure dietary orders are followed.
A resident reported and was observed to have fecal stains on the toilet in their bathroom, indicating a failure in maintaining a sanitary environment. The DON and IP confirmed the issue as an infection control problem, with potential risks of pathogen transmission. The facility's policies on cleanliness were not adhered to, as evidenced by the unclean bathroom.
The facility did not meet the required square footage per resident in 12 out of 19 rooms, as observed during a survey. Despite this, residents had adequate privacy, storage, and accessibility. The facility has requested a waiver continuance, claiming no adverse effects on resident health and safety.
Failure to Report Fall With Head Injury Requiring Hospital Transfer
Penalty
Summary
The facility failed to report an incident of bodily injury that required hospitalization for one resident after an alleged fall on 5/13/26. The resident had diagnoses including blindness to the left eye, myocardial infarction, heart failure, peripheral vascular disease, difficulty walking, need for assistance with personal care, and absence of the right toes. The resident’s MDS dated 4/21/26 showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. According to the EMR and the Change in Condition Evaluation, the resident was found lying on the floor in his room after attempting to self-transfer from the commode to the bed, reported hitting his head, and had bleeding from the left side of the head. The physician was notified and ordered transfer to the acute hospital for further evaluation. During interviews, staff stated the resident had an unwitnessed fall with a head injury and was transferred to the hospital, but the DON stated the incident was not reported to state agencies because the resident was alert and the bleeding was minor, and the facility considered it a minor injury under its clinical judgment. Multiple staff members stated the facility process was to report falls with injury, including head injuries and falls requiring hospital transfer, to state agencies. A resident who witnessed the event stated the resident lost balance while self-transferring, struck his head on the commode, then hit the foot of the bed and fell to the floor. The facility policy required allegations of abuse/neglect/exploitation and injuries of unknown source to be reported immediately, with serious bodily injury reported no later than 2 hours after discovery or suspicion, and sufficient investigative information reported within 5 working days.
Unsafe Discharge Without Required Medical Equipment and Oxygen
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe and orderly discharge for a cognitively intact resident who required specific medical equipment and services upon leaving the facility. The resident was admitted with multiple diagnoses including DM, bacterial infections, ESRD, hypertension, heart failure, and abnormalities of breathing. The resident’s MDS showed a BIMS score of 15, indicating intact cognition. Physician discharge orders dated 2/19/26 specified that the resident was to be discharged home with post-discharge needs including home health nursing, home health PT and OT, a wheelchair, a shower chair, and oxygen. An existing order from 12/5/25 required continuous oxygen at 4 L/min via nasal cannula related to abnormalities of breathing. Despite these orders, the resident was discharged without the ordered medical equipment. The SSD confirmed that the resident was discharged with physician orders for home health, PT, OT, shower chair, walker, and oxygen concentrator, but no medical equipment was provided to the resident upon or prior to discharge. The discharge summary documentation stated that medical equipment was delivered at bedside and that all oxygen supply was handed over to home health, with explanations given on how to use the oxygen supply, but this conflicted with interviews and other record review indicating that the equipment was not actually provided. The SSD also stated that home health was contacted on the day of discharge and that the home health agency had notified her that the oxygen concentrator would not be available upon discharge, and that the resident’s medical equipment and oxygen concentrator were not delivered to the new residence prior to discharge. Interviews with facility staff further described the failure in the discharge process. RN 1 stated that the facility’s process for discharge was to ensure residents had all medications, education, and medical equipment needed for a safe discharge, and that the resident should not have been discharged without the physician-ordered medical equipment and oxygen concentrator. The SSD stated that the resident had been issued a notice of non-payment and had informed her of plans to rent a room from a friend, but acknowledged that the discharge was not safe and that the resident was not educated on the need for medical equipment or the potential consequences of not having it. The DON and the ADM both stated that facility process required ensuring all needed medical equipment was in place prior to discharge and acknowledged that the resident’s discharge without the ordered equipment was unsafe and not consistent with facility policy and procedure on transfer and discharge, which requires orientation and planning to ensure a safe and orderly transfer or discharge.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to prevent potential incidents. No additional details regarding the specific hazards, the individuals involved, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Ensure Timely and Appropriate Transportation for Medical Appointments
Penalty
Summary
The facility failed to adequately assist residents in arranging and coordinating transportation to and from medical appointments, resulting in missed or delayed appointments for three residents. One resident, who had a history of end stage renal disease and diabetes, experienced repeated issues with a specific transportation company, leading to missed appointments and the need to reschedule. The resident's preference for a different transportation provider was not accommodated, and when concerns were raised with the Social Services Designee (SSD), the resident was advised to contact their insurance rather than receiving direct assistance from the facility. Documentation showed that the resident was cognitively intact and had clearly communicated her transportation preferences and frustrations. Another resident, with a history of hemiplegia, cerebral edema, and mental health disorders, missed appointments due to transportation problems, including a vehicle with a flat tire and a van that could not accommodate his specialized wheelchair. The resident's responsible party reported poor communication from the facility regarding missed and rescheduled appointments, and there was no documentation of these communications in the resident's chart. The SSD confirmed that transportation issues had occurred and that communication with responsible parties was not consistently documented. A third resident, who was cognitively intact and had diagnoses including Alzheimer's disease and congestive heart failure, was left waiting for hours after a medical appointment because the scheduled transportation did not arrive. The resident ultimately had to arrange alternative transportation, resulting in significant distress. Facility staff interviews and record reviews revealed that the process for monitoring residents' departures and returns from appointments was inconsistent, with incomplete logs and unclear responsibilities among staff. The Director of Nursing and Administrator acknowledged gaps in communication, documentation, and staff training related to transportation arrangements and resident safety during off-site appointments.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care for a resident who had a history of trauma due to past sexual and physical abuse. Upon admission, the resident disclosed her traumatic history and expressed fear of being around unfamiliar men. Despite this, the facility did not recognize the severity of her trauma and did not implement effective interventions to avoid triggers. The resident was placed in a room across from a male resident, which caused her significant distress, including sleeplessness and anxiety, as she feared male residents might enter her room at night. The resident's care plan did not include trauma-informed care, and staff were not aware of her traumatic history or the environmental triggers affecting her. Interviews with facility staff, including CNAs and LVNs, revealed a lack of training and awareness regarding trauma-informed care. The resident's requests to be moved to a different room were not addressed, and she felt isolated and unsupported by the facility staff, who reportedly dismissed her concerns. The facility's policy on trauma-informed care was not followed, as evidenced by the absence of a care plan addressing the resident's trauma and triggers. The resident's high score on the trauma evaluation was not acted upon, and her primary care physician was not notified. The lack of a trauma-informed care plan and staff training contributed to the resident's re-traumatization and feelings of isolation, depression, and fear.
Failure to Employ Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate and employ a full-time Director of Nursing (DON) from December 2024 to March 2025. During this period, the facility did not have a DON assigned, as confirmed by interviews with the Administrator and Assistant Administrator. They stated that a DON was supposed to start working full-time but did not due to unforeseen circumstances. Instead, a nursing consultant completed some DON duties 1-2 times per week, but this was not sufficient to meet the full-time requirement. Registered Nurses were assigned as supervisors for the day but did not perform any DON duties. The clinical resource also confirmed that there was no DON employed at the facility, and she assisted with DON duties only 1-3 days a week, without being the interim DON or working full-time hours. The facility's policy and procedure indicated the intent to comply with RN staffing requirements, including designating a full-time DON. The job description for the DON outlined responsibilities such as planning, organizing, and directing the Nursing Service Department in accordance with standards and regulations. The absence of a full-time DON had the potential to result in inadequate care planning and supervision, placing residents' health and safety at risk.
Lack of Privacy for Resident Health Discussions
Penalty
Summary
The facility failed to protect and promote the rights of residents' privacy for two of nine sampled residents when it did not provide a private area for them to discuss their personal health information. Resident 1, who was admitted with diagnoses including Major Depressive Disorder, Morbid Obesity, Anxiety, insomnia, and alcohol abuse, expressed concerns about the lack of privacy during personal conversations and medical visits. Resident 1 reported that discussions with the social services director (SSD) were not private due to the presence of a roommate and staff entering and exiting the room. Additionally, the SSD's office was too small to accommodate private conversations. Resident 2, who was admitted with diagnoses of Morbid Obesity, Anxiety, and other stimulant abuse, also reported a lack of privacy for private conversations unless roommates were removed from the room. Resident 2 felt that the privacy curtain in her room was insufficient to keep her health information private from staff and other residents. The SSD confirmed that the office space provided was inadequate for private discussions and that she had been directed to conduct private health conversations in residents' rooms, which did not ensure privacy when other roommates or staff were present. The facility's policy and procedure on confidentiality of personal and medical records emphasized the right to secure and confidential records and stated that confidential information should not be discussed in public or semi-public areas. Despite this policy, the facility did not provide a suitable private area for residents to discuss their personal health information, leading to a potential breach of confidentiality and privacy for Residents 1 and 2.
Failure to Implement Trauma-Informed Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for trauma-informed care for a resident who had a history of trauma. Upon admission, the admitting nurse and social services director identified the resident's history of trauma but did not create a care plan to recognize trauma and triggers that impacted the resident's care. This oversight resulted in the resident experiencing triggers that caused her to relive past traumas during her stay at the facility. The resident was admitted with diagnoses including Major Depressive Disorder, Morbid Obesity, Anxiety, Insomnia, and Alcohol Abuse. Despite being cognitively intact, as indicated by a perfect score on the Brief Interview for Mental Status, the resident's care plan did not address her past trauma or associated triggers. Interviews with facility staff, including a CNA, LVN, and SSD, revealed that they were unaware of the resident's trauma history and the importance of identifying triggers to provide appropriate care. The facility's policies and procedures for comprehensive care plans and trauma-informed care emphasize the need for individualized interventions and collaboration with residents and their families to minimize triggers and avoid re-traumatization. However, these procedures were not followed in the case of the resident, as no care plan was created to address her trauma and triggers, even after a high score on the trauma evaluation. This lack of a care plan was acknowledged by various staff members, including the administrator and clinical resource, who recognized the importance of establishing a plan of care to prevent further trauma and triggers.
Facility Fails to Support Residents' Rights to Reheat Food
Penalty
Summary
The facility failed to uphold the rights of two residents by not allowing them to reheat food brought in by their families after 7:00 p.m. This was due to the absence of a functioning microwave for resident use and the facility's policy that only dietary staff, who were not available after 7:00 p.m., could reheat food. Both residents were cognitively intact and expressed anger and frustration over this restriction, which they felt did not respect their individuality and autonomy. Resident 1, who was admitted with diagnoses including Major Depressive Disorder, Morbid Obesity, Anxiety, and Bipolar Disorder, reported that the facility staff informed him they were not supposed to assist with reheating his food. Similarly, Resident 2, who had type 2 diabetes mellitus and anemia, was told that the microwave used for reheating resident food was broken and that staff were not allowed to assist in reheating food. Instead, Resident 2 was offered facility snacks, which did not meet his preference for consuming his own food. The facility's policy allowed food brought by family or visitors but required it to be handled safely and stored properly. However, the policy did not accommodate the residents' right to reheat their food after the dietary staff had left for the day. The assistant administrator and other staff confirmed that there was no microwave available for resident use and that the facility's process was to have dietary staff reheat food, which was not possible after 7:00 p.m. This led to a situation where residents' rights to self-determination and a homelike environment were not fully supported.
Resident Abuse by CNA
Penalty
Summary
The facility failed to protect a resident from abuse when a certified nursing assistant (CNA) was observed hitting the resident with a closed fist. The incident involved a resident who was admitted with diagnoses including hemiplegia, epilepsy, morbid obesity, muscle weakness, and major depressive disorder. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status score of 14 out of 15. During an episode of personal hygiene care, the resident became aggressive, kicking and scratching the CNA, who then retaliated by hitting the resident on the right thigh. Interviews with staff and the resident confirmed the occurrence of the incident. The resident recalled being hit twice on the right hip by the CNA, which caused pain and mental trauma. Another CNA present during the incident corroborated the resident's account, stating that the resident was resisting care and that the CNA hit the resident multiple times. The facility's policy and procedure on abuse, neglect, and exploitation clearly prohibit such actions, defining abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. The facility's staff, including a Licensed Vocational Nurse and another CNA, acknowledged that the incident constituted abuse and was not in line with the facility's process for handling aggressive behaviors. The facility's policy emphasizes the importance of recognizing and managing resident behaviors appropriately, which includes stepping away and allowing the resident to calm down. Despite regular training on abuse prevention, the CNA involved in the incident failed to adhere to these guidelines, resulting in the abuse of the resident.
Food Safety and Sanitation Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in several instances. One kitchen staff member, identified as CK 2, was observed using a surface sanitizer with zero parts-per-million (ppm) concentration when wiping a food preparation table. This was contrary to the expected range of 50-100 ppm for chlorine solutions or 150-200 ppm for quaternary ammonium compounds, as per the facility's policy and professional standards. The Registered Dietician and Dietary Services Manager both acknowledged that such a low concentration was unacceptable and could lead to bacterial growth, potentially causing illness among residents. Another deficiency was noted when CK 1 did not take the temperature of food items after heating them in the microwave before serving them to a resident. The facility's policy requires that all hot and cold food temperatures be recorded before service to ensure safety. CK 1 admitted to not recording the temperature of the vegetarian patties, which should have been heated to 165 degrees Fahrenheit. The Dietary Services Manager confirmed that failing to check food temperatures is a safety and quality issue that could result in residents becoming ill. Additionally, the facility was found to be improperly storing kitchenware. Plates, plate holders, lids, and cooking pans were observed to be stacked and stored while still wet, which is against the facility's policy and FDA guidelines that mandate air drying to prevent microorganism growth. The Registered Dietician and Dietary Services Manager both stated that dishware should be completely dry before storage to avoid bacterial growth, which could lead to foodborne illnesses among residents.
Failure to Provide Privacy During Medical Procedures
Penalty
Summary
The facility failed to ensure the dignity and privacy of two residents during the administration of medications and the checking of vital signs. For Resident 146, the Licensed Vocational Nurse (LVN) 3 conducted these activities in a public hallway, where other residents and staff were present, thus not providing the necessary privacy. Resident 146, who had no cognitive deficits as indicated by a BIMS score of 14 out of 15, was exposed to a lack of privacy despite the facility's policy requiring such measures. Similarly, Resident 243 was not afforded privacy during the same procedures. LVN 3 checked vital signs and administered medication while the resident was in bed with the privacy curtain open, exposing the resident to others passing by. Resident 243 also had no cognitive deficits, with a BIMS score of 15 out of 15. The facility's policies clearly state the importance of providing privacy during such procedures, yet these guidelines were not followed, resulting in a breach of the residents' rights to dignity and respect.
Incomplete Dialysis Communication Forms for Residents
Penalty
Summary
The facility failed to ensure that dialysis communication forms were completed for two residents, Resident 142 and Resident 25, who were undergoing hemodialysis. This deficiency was identified through observations, interviews, and record reviews. Resident 142, who had been admitted with end-stage kidney disease and a fractured femur, was observed in her room and reported attending dialysis three times a week. However, there was no documentation of completed post-dialysis assessments of her access sites on multiple dates. Similarly, Resident 25, also diagnosed with end-stage renal disease, had incomplete dialysis communication forms for several dates in May 2024. Interviews with facility staff, including CNAs, LVNs, and the Director of Nursing, revealed that the responsibility for ensuring the completion of these forms lay with the charge nurse and medical records staff. The LVNs and medical records staff acknowledged the absence of completed forms and the importance of these documents in tracking new orders and updates from the dialysis center. The facility's policy on hemodialysis emphasized the need for timely communication and documentation, which was not adhered to in these cases, placing the residents at risk for delayed detection and management of complications from their dialysis access sites.
Failure to Implement Care Plan for Anticoagulant Use
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident who was administered heparin as a prophylactic measure for venous thromboembolism. Despite the resident's admission with significant medical conditions, including a fracture of the right femur and end-stage renal disease, no care plan was initiated to address the use of anticoagulant medication. This oversight was identified during a review of the resident's clinical records, where it was noted that the heparin order was placed, but no corresponding care plan was documented. Interviews with facility staff, including an LVN, the MDS Nurse, and the DON, confirmed the absence of a care plan for the resident's anticoagulant use. Each staff member acknowledged the importance of a care plan in directing nursing care and monitoring for potential side effects of the medication. The facility's policy on care plans emphasized the need for a comprehensive, person-centered plan to be developed within a specified timeframe, which was not adhered to in this case.
Failure to Monitor Blood Sugar Levels in Diabetic Resident
Penalty
Summary
The facility failed to provide quality care and treatment in accordance with professional standards for a resident with Type 2 Diabetes Mellitus. The resident's fasting blood sugar levels were not monitored as per the physician's orders, which required daily checks at 6:00 a.m. This oversight was identified during an observation and interview with the resident, who confirmed that his blood sugar levels had not been checked. The Director of Nursing (DON) acknowledged the absence of records for blood sugar monitoring since the order was placed, attributing it to a mistake by the nursing staff who failed to follow the physician's orders. Further investigation revealed that the Licensed Vocational Nurse (LVN) responsible for the night shift was unaware of the resident's diabetes diagnosis and the order to check blood sugar levels. The Minimum Data Set Nurse (MDSN) also confirmed that the prompts for blood sugar checks were not appearing in the Medication Administration Record (MAR). The Medical Records Staff and the DON admitted that the orders should have been reviewed more carefully, emphasizing the importance of daily review of MD orders to prevent potential mistakes and harm. The facility's policy on diabetes management required monitoring and reporting of blood sugar levels, which was not adhered to in this case.
Failure to Administer Prescribed Medication Due to Unavailability
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the administration of medication to meet the needs of a resident. Specifically, a resident's Lactulose medication, prescribed for constipation, was not available for administration on a particular day. During a medication pass observation, an LVN noted that the medication was unavailable and confirmed that the outgoing nurse did not mention the unavailability of the medication or whether the pharmacy had been notified. The resident had a history of constipation and muscle weakness, and the medication was part of their routine treatment. The Director of Nursing (DON) stated that licensed nurses were responsible for ordering medications in advance to ensure availability. The facility's policy required timely delivery of medications to prevent delays in administration. However, the medication was not reordered in time, leading to the missed dose.
Failure to Provide Correct Food Texture for Resident
Penalty
Summary
The facility failed to provide the appropriate food texture for a resident who required large portions of finger foods due to their inability to use utensils. During an observation, it was noted that the resident was served whole pieces of chicken breast, steamed rice, cut-up broccoli, and fruit cobbler, which did not align with the ordered finger food diet. The Certified Nursing Assistant (CNA) responsible for serving the meal did not verify the food consistency against the meal tray ticket, assuming the licensed nurse had already checked it. This oversight was confirmed by the Rehabilitative Nurse Assistant (RNA) and the Minimum Data Set Nurse (MDSN), who both acknowledged that the food served was not suitable for finger food consumption. The resident in question had a medical history of cerebral infarction, hemiplegia, hemiparesis, and dysphagia, which necessitated the finger food diet to accommodate their difficulty in using utensils. The Registered Dietitian (RD) and the Director of Nursing (DON) both emphasized the importance of adhering to the prescribed diet to prevent weight loss, as the resident was unable to feed themselves effectively with the incorrect food texture. The Dietary Services Manager (DSM) confirmed that the resident did not receive the correct diet consistency, highlighting a breakdown in the facility's process for ensuring dietary orders are followed, as outlined in their policy and procedure for Food and Nutrition Services.
Infection Control Deficiency Due to Unclean Bathroom
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for a resident, identified as Resident 34, when brown-colored fecal stains and remnants were found on the toilet and toilet seat in the resident's bathroom. This issue was identified during an interview and observation on May 13, 2024, where Resident 34 expressed discomfort using the bathroom due to its uncleanliness. The resident was cognitively intact, as indicated by a Brief Interview for Mental Status (BIMS) score of 15, suggesting full cognitive awareness of the situation. The Director of Nursing (DON) and the Infection Preventionist (IP) both confirmed the presence of fecal matter on the toilet and acknowledged it as an infection control issue. The facility's policies on infection prevention and control, safe and homelike environment, and routine cleaning and disinfection were reviewed, indicating that environmental cleaning and disinfection should be performed according to facility policy to prevent the transmission of communicable diseases. However, the presence of fecal matter on the toilet seat and bowl demonstrated a failure to adhere to these policies, posing a risk of cross-contamination and transmission of pathogens such as Clostridium difficile and Hepatitis C.
Facility Fails to Meet Minimum Square Footage Requirements
Penalty
Summary
The facility failed to provide and maintain the minimum required square footage per resident in 12 out of 19 rooms during a survey conducted from May 13 to May 17, 2024. Specifically, rooms 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 19 did not meet the regulatory requirements of 80 square feet per resident in multiple occupancy rooms and 100 square feet for single occupancy rooms. Despite this deficiency, the report notes that residents had a reasonable amount of privacy, adequate closets and storage spaces, available bedside stands, sufficient room for nursing care, and accessibility for wheelchairs and toilet facilities. The facility has requested a continuance of a waiver, asserting that the waiver will not adversely affect the health and safety of the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Fresno
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pacific Gardens Nursing And Rehabilitation Center | 0.2 mi | ★★★★★ | 30 | 0 |
| Orchard Post Acute | 0.6 mi | ★★★★★ | 2 | 0 |
| Twilight Haven | 1 mi | — | 0 | 0 |
| Stonehaven Senior Living | 1 mi | — | 0 | 0 |
| Sierra Vista Healthcare | 1.9 mi | ★★★★★ | 18 | 0 |
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