Below 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 Post Acute during CMS and state inspections, most recent first.
Failure to obtain mental health services for a resident with major depression and suicidal ideation. Psychiatric consultant notes said further therapy could be helpful after the resident stopped seeing a therapist, but there was no documented follow-up to secure ongoing MH services. The care plan later addressed active SI with 988, no leaving the resident alone, and 1:1 monitoring, but did not include MH services; the SSW Director and Interim DNS were unaware of the consultant notes and expected others to follow up.
A resident with severe cognitive impairment and a history of falls did not consistently receive required supervision and assistance devices, such as fall mats, enabler bars, and a call light within reach. Despite being assessed as high fall risk and needing significant help with transfers, the resident experienced two unwitnessed falls, one resulting in injury. Staff were unclear about the resident's needs, and the care plan was not updated after incidents, leading to lapses in fall prevention measures.
A resident with opioid abuse was prescribed daily methadone, but an agency LPN misinterpreted the medication order, opened all prefilled bottles, and administered an extra dose after the resident had already received one at a clinic. Staff confusion over the order and unreadable labels contributed to the error, resulting in the resident receiving two doses in one day and the facility losing its ability to provide weekly methadone take-outs.
The facility failed to provide a person-centered activity program for three residents, leading to a decline in their psychosocial well-being. A resident with severe dementia was left in front of a TV without engagement, another resident with cognitive deficits spent most of the time in bed despite having activity preferences, and a third resident with dementia was not involved in activities despite expressed interests. The Activities Director admitted to not having programs for dementia residents and acknowledged the lack of tailored activities.
The facility failed to ensure meals served to residents in their rooms were at palatable temperatures. Multiple residents reported their breakfast was cold when served in their rooms. An observation showed that while scrambled eggs were initially hot, the delay in tray delivery resulted in cold eggs and toast. The Dietary Director and Administrator acknowledged the complaints.
The facility failed to properly label and store food and beverages in one of the unit refrigerators, as observed by staff. Items such as meatballs, pretzel bites, shredded meat, and various liquids were found unlabeled and undated, contrary to the facility's policy requiring proper labeling and dating. Staff confirmed the deficiency, acknowledging the expectation for proper labeling and storage to prevent spoilage and cross-contamination.
The facility failed to provide PT services as ordered for four residents, leading to a deficiency in rehabilitation services. A resident with a contusion and abnormal gait did not receive PT for 11 days due to the PT being on vacation without coverage. Another resident with Parkinson's disease missed three days of PT because the PT was out of town. A resident with a traumatic subdural hemorrhage only received PT once, and a resident with severe chest pain did not receive any PT due to the absence of a therapist and lack of a coverage plan.
A resident with dementia was physically assaulted by another resident with PTSD, resulting in injury. The incident, witnessed by staff, occurred near the nurse's station, where the aggressor struck the victim on the face, causing eye injury. Despite the facility's abuse policy, the altercation was not prevented, leaving the victim feeling scared and unsafe.
A resident with severe ulcers expressed a preference for morning and evening wound care to avoid missing activities and improve sleep. Despite the facility's ability to customize treatment times, the resident's request was not honored, leading to inconvenience and potential quality of life reduction.
The facility failed to provide baseline care plans to two residents within 48 hours of admission, as required. One resident with cognitive deficits and their family did not receive a care plan, while another resident's plan omitted critical information about their indwelling urinary catheter. The DNS acknowledged these oversights.
A resident with dementia and hearing loss experienced a deficiency in communication support due to the facility's failure to ensure hearing aids were charged and a dry erase board was available. Despite the care plan's directives, staff inconsistently managed the resident's hearing aids and did not consistently use visual communication aids, impacting the resident's ability to comprehend and engage in daily activities.
A resident with Parkinson's disease and muscle weakness, requiring total assistance with personal hygiene, was observed with significant chin hairs due to the facility's failure to provide necessary care. The resident relied on staff for shaving unwanted facial hair, which was not addressed despite the care plan's requirements. A CNA acknowledged the issue, and the DNS expected adherence to the care plan.
A resident admitted for wound care did not receive the prescribed daily application of silver sulfadiazine cream due to its unavailability. There was no documentation of wound care on the following day, and the resident later complained to a physician about not receiving care, ultimately leaving the facility AMA.
Two residents in a facility did not receive necessary restorative services to maintain or improve their range of motion and mobility due to the absence of an active RA program. The facility lacked dedicated RA staff, and the Director of Rehabilitation and the administrator confirmed that CNAs were not trained to carry out these specialized programs.
A resident with an indwelling urinary catheter did not receive appropriate care due to a lack of documentation and physician orders. Staff were unaware of the catheter's specifications and care requirements, leading to inadequate management. The resident's catheter bag was observed to be improperly managed, and staff admitted to not providing necessary care due to insufficient guidance.
A facility failed to ensure proper dialysis services and communication for a resident with end-stage renal disease. The resident did not receive a Dialysis Center Communication Form for multiple treatments, and nursing staff did not obtain necessary pre- and post-dialysis information. An LPN was unaware of the resident's dialysis schedule, and the last documented weight was outdated. The Director of Nursing confirmed the lack of adherence to the facility's dialysis policy.
The facility failed to provide trauma-informed care for two residents, one with PTSD and another with a history of traumatic events. Both residents lacked care plans addressing their trauma histories and potential triggers, despite being cognitively intact and able to communicate their needs. Staff acknowledged the oversight, admitting no care plans were developed to prevent re-traumatization.
A resident with hemiparesis and hemiplegia exhibited aggressive and depressive behaviors, but the facility failed to provide necessary behavioral health care. Despite staff reports of the resident's aggression and depressive symptoms, no comprehensive assessment or effective interventions were implemented. The resident's psychosocial well-being was not addressed in their care plan, and the Social Services Director was unaware of the resident's behaviors.
A resident with dysphagia and cognitive deficits was not provided with the requested double meal portions despite a family member's request and communication to the facility staff. The resident continued to receive regular portions, indicating a failure in communication and implementation of dietary preferences.
A facility failed to implement Enhanced Barrier Precautions (EBPs) for a resident with an indwelling catheter, as required by CDC guidelines and the facility's policy. Observations showed no PPE or signage outside the resident's room, and staff interviews confirmed the oversight. This placed residents at risk for infections and cross-contamination.
The facility failed to post accurate and complete staffing information, with the Direct Care Staff Daily Report (DCSDR) found incomplete for various shifts on multiple occasions. Discrepancies were also noted between DCSDRs posted in different locations. Interviews confirmed expectations for timely and accurate postings were not met.
A resident with major depressive disorder reported being spoken to in a demeaning manner by a CNA, who admitted to having a loud communication style that led to multiple resident complaints. The DNS and Administrator acknowledged the CNA's failure to treat residents with dignity, as required by the facility's Courtesy Policy.
Failure to Obtain Mental Health Services
Penalty
Summary
The facility failed to ensure necessary behavioral health care and services were provided for one resident with diagnoses including major depression and suicidal ideation. Psychiatric consultant notes documented that the resident had last spoken to a therapist and requested to discontinue services with that therapist; the consultant stated further therapy could be helpful and recommended nursing staff and social services assist the resident in finding ongoing therapy outside the facility. There was no documented evidence in the resident’s clinical record that the facility followed up to obtain mental health services after those notes. The resident’s care plan later included active suicidal ideations with interventions such as calling 988, not leaving the resident alone, and implementing one-to-one monitoring if the resident mentioned wanting to kill himself or herself, but it did not include mental health services. Staff interviews indicated the Social Services Director was not aware of the psychiatric consultant notes and stated it was not her responsibility to follow up on mental health notes, and the Interim DNS was also not aware of the notes and expected the RCM to follow up.
Failure to Provide Adequate Supervision and Assistance Devices to Prevent Resident Falls
Penalty
Summary
A deficiency was identified when a resident with a history of falls, severe cognitive impairment, and significant mobility limitations did not receive adequate supervision and assistance devices to prevent accidents. The resident, who had diagnoses including a left femur fracture, dementia, muscle weakness, and unsteadiness, was assessed as a high fall risk and required maximum assistance with transfers. Despite these needs, the resident experienced two unwitnessed falls after admission, one of which resulted in injury to the head and face. The care plan included interventions such as the use of a gait belt, fall mats, enabler bars, and keeping the call light within reach, but these were not consistently implemented or maintained. Observations and interviews revealed that the resident's call light was frequently not within reach, fall mats and enabler bars were not present as required, and the wheelchair was missing from the room. Staff interviews indicated confusion and inconsistency regarding the resident's care needs, with some staff believing the resident was independent despite documentation indicating a need for moderate to maximum assistance. The Kardex and care plan were not updated to reflect changes in the resident's condition or after the falls, and staff were not always aware of or following the current interventions listed in the care plan. Further, the care plan was not revised after the resident's fall that resulted in injury, and interventions for fall prevention were not added or adjusted. Staff confirmed that required safety devices had been removed without corresponding updates to the care plan, and there was a lack of communication and documentation regarding the resident's fall risk and required interventions. These failures led to the resident not receiving the necessary supervision and assistance devices to prevent accidents, as required by facility policy and the resident's assessed needs.
Improper Methadone Administration Due to Medication Order Misinterpretation
Penalty
Summary
A deficiency occurred when a resident with a diagnosis of opioid abuse was prescribed methadone, with physician orders specifying a daily dose of 20 ml. Facility policy required medications to be administered according to written orders, with clarification sought if there was any uncertainty. However, an agency LPN misinterpreted the methadone orders and opened all six prefilled bottles of the resident’s weekly supply, rendering the medication unusable and necessitating its destruction. As a result, the resident was sent to the methadone clinic to receive the scheduled dose and returned with a replacement supply. Later the same day, the same LPN administered a second dose of methadone to the resident, despite the resident stating they had already received their dose at the clinic. Documentation confirmed that the LPN signed out and administered the additional dose. The LPN reported confusion regarding the physician’s order and difficulty reading the medication labels, which contributed to the error. Other staff confirmed the sequence of events, including the destruction of the original supply and the administration of the extra dose. The incident led to the revocation of the facility’s certification for weekly methadone take-outs, requiring the resident to visit the clinic daily for medication administration. Interviews with staff and the resident confirmed the administration of the extra dose and the confusion surrounding the medication orders and labeling. The resident did not experience a change from baseline after receiving the second dose, as observed by a respiratory therapist who provided a breathing treatment later that day.
Failure to Provide Person-Centered Activity Program
Penalty
Summary
The facility failed to provide an ongoing person-centered activity program for three residents, leading to a decline in their psychosocial well-being and diminished quality of life. Resident 28, who was admitted with severe dementia and other conditions, was observed sitting in a wheelchair in front of a television for extended periods without engagement in activities. Despite having preferences for group activities, music, and outdoor time, the resident was not provided with sensory supplies or meaningful activities. The Activities Director admitted to not having programs for residents with dementia and acknowledged the lack of activities tailored to Resident 28's needs. Resident 46, admitted with cognitive and communication deficits, was found to spend most of the time in bed with the television on, despite expressing preferences for music, outdoor activities, and socialization. The resident's family member reported not being consulted about the resident's activity preferences, and the Activities Director confirmed that the resident was not offered opportunities to engage in preferred activities. The care plan interventions were not specific to the resident's interests, and the Activities Director was unsure how to achieve improvement in this area. Resident 254, diagnosed with dementia, was observed in a room without personal items or engagement in activities. The resident's representative stated that the resident enjoyed outdoor activities and music but was not involved in any activities. The Activities Director admitted that the resident's care plan included activities not based on expressed interests and that the resident's participation was limited to meals in the dining room. The facility's staff acknowledged the lack of activities offered to the residents and the expectation for a person-centered activities program.
Failure to Serve Meals at Palatable Temperatures
Penalty
Summary
The facility failed to ensure that meals served to residents in their rooms were at palatable temperatures, as observed in one of two carts reviewed for food quality. Multiple residents, including Resident 40, Resident 24, and Resident 15, reported that their breakfast was cold when served in their rooms. On specific dates, residents consistently complained about the cold temperature of their meals. An observation revealed that while the scrambled eggs were initially at 188 degrees Fahrenheit, the delivery of trays began much later, resulting in cold eggs and toast by the time the last tray was served. The Dietary Director and the Administrator acknowledged the complaints about cold food served in rooms, confirming the deficiency in maintaining meal temperatures.
Improper Food Labeling and Storage in Facility Refrigerator
Penalty
Summary
The facility failed to ensure that food and beverages were labeled and stored in a manner that minimized spoilage and cross-contamination, as observed in one of the two unit refrigerators reviewed for sanitary conditions. This deficiency was identified through observation, interview, and record review, revealing that numerous food and beverage items in the residents' refrigerator were not properly labeled or dated. Items such as meatballs, pretzel bites, shredded meat, smoked cheese dip, chocolate fudge, fruit cubes, and various pitchers of liquids were found unlabeled and undated. Additionally, an open bag of burritos and three previously opened bottles of soda pop were also not labeled with an open date. The facility's policy required refrigerated food items from outside sources to be stored in containers with the date received, the product name, and the resident's name and room number. Unlabeled and undated foods were to be discarded. However, during the inspection, Staff 3 (Administrator in Training) and Staff 12 (Dietary Director) confirmed that the food and beverage items were not properly labeled, dated, or discarded when expired. They acknowledged that they expected the residents' food and beverage items to be labeled and dated or discarded if not properly stored, indicating a lapse in adherence to the facility's policy and professional standards.
Failure to Provide Physical Therapy Services as Ordered
Penalty
Summary
The facility failed to provide physical therapy (PT) services as ordered for four residents, leading to a deficiency in rehabilitation services. Resident 154, admitted with a contusion and abnormal gait, was prescribed PT three times a week for eight weeks but did not receive any PT treatment until 11 days after the evaluation due to the PT being on vacation without coverage. Similarly, Resident 21, with Parkinson's disease and muscle weakness, did not receive PT for three days as scheduled because the PT was out of town, and no coverage was available. Resident 254, admitted with a traumatic subdural hemorrhage, was ordered to receive PT three times weekly but only received therapy once on the day of evaluation. Resident 303, with severe chest pain, was scheduled for PT four times per week but did not receive any therapy due to the absence of a physical therapist and lack of a coverage plan. The Director of Rehabilitation and the Administrator confirmed the lack of PT services due to insufficient staffing and coverage, which was against the facility's expectations and policies.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse, as evidenced by an incident involving two residents. Resident 10, who was admitted with diagnoses including obstructive pulmonary disease and dementia, was physically assaulted by Resident 27, who had end-stage renal disease and PTSD. Both residents were cognitively intact according to their respective MDS assessments. The incident occurred near the nurse's station, where Resident 27 struck Resident 10 on the left side of the face, resulting in a finger poking Resident 10 in the eye. This altercation was witnessed by multiple staff members, including an RN and two CNAs, who confirmed the physical aggression and the resulting injury to Resident 10. Staff interviews revealed that Resident 10 expressed feeling scared and unsafe following the incident. The facility's Abuse Policy and Procedure, dated August 2024, defines abuse as the willful infliction of injury or punishment resulting in physical harm or mental anguish. Despite this policy, the facility did not prevent the physical altercation between the residents, thereby failing to protect Resident 10 from abuse. The facility's administration, including the Administrator, DNS, and Regional Nurse Consultant, were aware of the incident, acknowledging the physical altercation that took place.
Failure to Honor Resident's Wound Care Timing Preference
Penalty
Summary
The facility failed to honor a resident's preference for the timing of wound care, which was scheduled twice daily. The resident, who was admitted with a stage four pressure ulcer and a non-pressure chronic ulcer with necrosis of the bone, expressed that the current wound care schedule was inconvenient. The resident preferred wound care to be conducted in the morning and evening to avoid missing scheduled activities and to ensure better sleep. Despite the resident's request, the schedule was not adjusted, and wound care continued to be administered at times that interfered with the resident's activities and rest. Interviews with staff revealed that the wound care schedule was coordinated around the timing of the resident's pain medication and the availability of nurses, rather than the resident's preferences. The facility's administrator and director of nursing services acknowledged that treatment times could be customized based on residents' preferences, yet the resident's request for a change in the wound care schedule was not honored. This oversight placed the resident at risk for impaired sleep and reduced quality of life.
Failure to Provide Baseline Care Plans and Include Catheter Care
Penalty
Summary
The facility failed to provide a baseline care plan to residents and their representatives within 48 hours of admission, as required by their policy. This deficiency was identified in two residents. The first resident, admitted in December 2024 with cognitive and communication deficits, did not receive a baseline care plan, nor was it provided to the involved family member. Both the resident and the family member expressed their desire to have a copy of the care plan, and the Director of Nursing Services (DNS) acknowledged the oversight. The second resident, admitted in January 2025 with complications related to an indwelling urinary catheter, had a baseline care plan initiated that failed to include information about the catheter. The Nursing Admission Assessment had noted the presence of the catheter, yet this critical information was omitted from the care plan. The DNS confirmed the omission, indicating a lapse in ensuring comprehensive care planning for the resident's specific medical needs.
Deficiency in Communication Support for Resident with Hearing Loss
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with dementia and hearing loss, leading to a deficiency in communication. The resident was admitted with a baseline care plan indicating the need for bilateral hearing aids and a dry erase board for effective communication. However, observations revealed that the resident's hearing aids were often not charged, rendering them ineffective, and a dry erase board was not consistently available in the resident's room. Staff members, including CNAs and a speech-language pathologist, noted the resident's inability to hear or comprehend verbal communication without the aids and the absence of a dry erase board, which was crucial for the resident's understanding. Interviews with staff and a resident representative highlighted ongoing issues with the management of the resident's hearing aids, including failure to charge them overnight and inconsistent use of visual communication aids. The resident's representative reported frequent problems with the hearing aids, and staff acknowledged the importance of the aids for the resident's comprehension. Despite the speech-language pathologist's efforts to inform staff about the resident's needs, the facility did not ensure the consistent use of the prescribed communication aids, resulting in a risk of diminished quality of life and potential decline in the resident's ability to perform activities of daily living.
Failure to Assist Resident with Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident with Parkinson's disease and muscle weakness, leading to a deficiency in personal hygiene care. The resident, who was admitted in March 2024, had moderate cognitive impairment and required total assistance with personal hygiene and grooming. Observations on February 10 and February 12, 2025, revealed the resident had significant chin hairs, which they were unable to manage due to limited arm mobility. The resident expressed reliance on staff for shaving unwanted facial hair. A Certified Nursing Assistant (CNA) acknowledged the presence of long chin hairs and stated that care information was obtained from the Kardex. The Director of Nursing Services (DNS) expected staff to follow the care plan, which included providing appropriate personal hygiene care, such as facial hair removal.
Failure to Provide Ordered Wound Care
Penalty
Summary
The facility failed to follow physician orders for daily wound care for a resident admitted for treatment of lower extremity venous stasis ulcers. The admission orders required the application of silver sulfadiazine cream to the resident's right leg once daily. However, on one occasion, the wound care was not provided because the cream was unavailable. There was also no documentation to confirm whether wound care was completed the following day. A physician progress note later revealed that the resident complained about not receiving wound care during their stay. The resident subsequently left the facility against medical advice.
Failure to Provide Restorative Services for Residents
Penalty
Summary
The facility failed to provide appropriate treatment and services to maintain and prevent a potential decrease in range of motion (ROM) or mobility for two residents reviewed for restorative services. Resident 5, admitted with diagnoses including non-traumatic brain hemorrhage, epilepsy, and Wernicke's encephalopathy, was supposed to receive restorative nursing (RA) services twice a week. However, the resident's ROM task logs indicated the last RA services were provided in November 2024, and observations in February 2025 showed the resident was not engaged in any ROM exercises. The Director of Rehabilitation confirmed that there was no active RA program since December 2024 due to the lack of dedicated RA staff, and the facility administrator acknowledged that CNAs did not carry out RA programs as they required specialized training. Similarly, Resident 28, with diagnoses including a brain stem stroke, severe dementia, Alzheimer's disease, and dysphagia, was to perform sit-to-stand exercises with assistance. However, the resident's mobility RA task logs showed the last RA services were provided in February 2024, and observations in February 2025 revealed the resident was not participating in restorative services. The Director of Rehabilitation and the facility administrator confirmed the absence of an active RA program due to staffing issues, resulting in the residents not receiving the necessary restorative services.
Failure in Catheter Care for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter. The resident, admitted in January 2025, had a diagnosis that included complications associated with an indwelling urinary catheter and dementia. Despite the presence of the catheter, there was no documentation in the resident's clinical record indicating the need for the catheter or any treatment and services related to it. Additionally, there were no physician orders detailing the catheter's specifications or care requirements. Observations and interviews revealed further deficiencies in care. On February 10, 2025, the resident was seen with the catheter tubing and bag visible under their wheelchair, and the resident was unable to provide information about the catheter. A resident representative expressed concerns about the lack of regular catheter care. Staff members, including a CNA and an LPN, admitted to not providing catheter care due to a lack of knowledge and absence of physician orders. The resident returned from a medical appointment with a catheter bag filled with dark yellow urine, indicating a lack of catheter management. The LPN Resident Care Manager was unaware of the resident's catheter until informed on February 11, 2025, and confirmed that catheter care should be completed every shift with appropriate orders in place.
Failure to Ensure Proper Dialysis Communication and Monitoring
Penalty
Summary
The facility failed to ensure proper dialysis services and communication protocols were in place for a resident requiring dialysis. The resident, who was admitted with end-stage renal disease and PTSD, was scheduled for dialysis treatments three times a week. However, from late December to mid-February, there was no evidence that nursing staff contacted the dialysis center to obtain necessary pre-dialysis and post-dialysis information, including the resident's weights. The last documented weight for the resident was recorded on February 3rd, and the last Dialysis Center Communication Form was dated December 24th. Observations and interviews revealed that the resident was not provided with a Dialysis Center Communication Form when leaving for dialysis appointments. Additionally, an agency LPN was not informed about the resident's dialysis schedule or the need to complete the communication form. The Director of Nursing Services confirmed the lack of completed forms and missing weight documentation, indicating a failure to adhere to the facility's dialysis policy and ensure proper monitoring and communication with the dialysis provider.
Failure to Provide Trauma-Informed Care
Penalty
Summary
The facility failed to provide trauma-informed care for two residents, leading to a deficiency in addressing their behavioral-emotional needs and potential for re-traumatization. Resident 27, who was admitted with PTSD and end-stage renal disease, was observed in her room without any evidence of a trauma assessment or care plan addressing her PTSD triggers. Despite being cognitively intact and able to communicate her needs, Resident 27 reported that no one at the facility discussed her PTSD or potential triggers. Staff interviews confirmed that no care plan was developed for her trauma history, and staff were unaware of her specific triggers. Similarly, Resident 46, admitted with hemiparesis and hemiplegia, had a documented history of traumatic events but lacked a care plan addressing these traumas. Although the resident expressed the importance of family involvement in care discussions, there was no evidence that family members were interviewed about the resident's trauma history or potential triggers. Staff acknowledged the oversight, admitting that despite the resident's positive trauma screen, no care plan was implemented to prevent re-traumatization.
Failure to Address Behavioral Health Needs
Penalty
Summary
The facility failed to provide necessary behavioral health care and services for a resident who was admitted with diagnoses including hemiparesis and hemiplegia. Upon admission, the resident was noted to be cognitively intact but reported feeling little interest or pleasure in activities and feeling down, depressed, or hopeless. Despite these indicators, the resident's psychosocial well-being was not adequately addressed in their care plan, and no comprehensive assessment was completed to identify potential precipitating factors for the resident's behavior. Throughout the resident's stay, progress notes indicated that the resident exhibited aggressive, combative, and uncooperative behaviors, including verbal and physical aggression towards staff. Multiple staff members reported these behaviors to the nursing staff, but no effective interventions were implemented. The Social Services Director was unaware of the resident's aggressive behaviors and had not developed a care plan to address these issues. Additionally, a referral to a mental health agency was made following the resident's depressive comments, but the status of this referral was unknown. Observations revealed that the resident spent most of their time in bed, with little engagement in activities, and was constantly supervised to prevent falls. The resident expressed dissatisfaction with their care and a lack of communication regarding their mood and care preferences. The Director of Nursing Services acknowledged the need for a care plan to address the resident's mood and behaviors, but no such plan was in place at the time of the survey.
Failure to Accommodate Resident Dietary Preferences
Penalty
Summary
The facility failed to accommodate the dietary preferences of a resident who was admitted with diagnoses including dysphagia and cognitive and communication deficits. The resident was on a regular diet with a minced and moist texture, and it was noted that weight gain was desirable. Despite a request from the resident's family member to increase meal portion sizes due to the resident's constant hunger, the facility continued to provide regular portions. This request was communicated to the Social Services Director and subsequently to the Director of Nursing Services (DNS), but the change was not implemented. Observations and interviews revealed that the resident's meal ticket did not reflect the request for double portions, and the kitchen staff was unaware of any such request. The DNS had requested the kitchen to provide double portions, but this was not executed, indicating a breakdown in communication and implementation of dietary preferences. This deficiency placed the resident at risk of not receiving preferred food, as the facility did not follow through on the request to adjust meal portions.
Failure to Implement Enhanced Barrier Precautions for Resident with Catheter
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBPs) for a resident with an indwelling catheter, which is a requirement to prevent the spread of multidrug-resistant organisms (MDROs). The Centers for Disease Control and Prevention (CDC) guidelines and the facility's own Transmission Based Precautions Policy mandate the use of gowns and gloves during high-contact care activities for residents with indwelling catheters. However, observations over two days revealed that there was no isolation cart with personal protective equipment (PPE) outside the resident's room, nor was there any signage indicating the need for EBPs. Staff interviews confirmed the oversight, as a Certified Nursing Assistant (CNA) and the Assistant Director of Nursing acknowledged that the resident should have been on EBPs due to the presence of a catheter. The CNA assigned to the resident was unaware of the need for EBPs and had not been following any infection control precautions. This lack of adherence to infection control protocols placed residents at risk for infections, communicable diseases, and cross-contamination.
Inaccurate and Incomplete Staffing Information Posting
Penalty
Summary
The facility failed to post accurate and complete staffing information, as required, which placed residents and the public at risk for incomplete and inaccurate staffing information. On multiple occasions, the Direct Care Staff Daily Report (DCSDR) was found to be incomplete for various shifts. Specifically, on February 10th, the DCSDR for the morning shift was incomplete, and on February 11th, the DCSDR was incomplete for the morning, evening, and night shifts. Additionally, discrepancies were noted on February 12th, where two different DCSDRs posted in separate locations within the facility did not match. Interviews with the Staffing Coordinator and the Administrator confirmed that the DCSDRs were expected to be complete and accurate by specific times for each shift and were to be posted in designated areas, which was not adhered to as observed.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to ensure that residents were treated with dignity, as evidenced by the interactions between Staff 7, a CNA, and Resident 105. Resident 105, who was admitted to the facility with a diagnosis of major depressive disorder, reported that Staff 7 spoke to them in a demeaning manner, akin to talking to a child. This included comments about the resident's use of a urinal and incidents of bedwetting. The resident expressed dissatisfaction with being yelled at and treated disrespectfully, stating that they had informed other CNAs about the issue, but no improvements were made. Resident 105 also mentioned that Staff 7 communicated similarly with other residents. Staff 7 admitted that their voice sometimes escalated and became loud, which was a common complaint among residents, leading to some requesting that Staff 7 not enter their rooms. Staff 2, the DNS, confirmed that there had been multiple complaints about Staff 7's communication style, which often made residents uncomfortable. Staff 1, the Administrator, acknowledged that Staff 7 did not adhere to the facility's expectations of treating residents with kindness and respect, as outlined in the facility's Courtesy Policy. This failure to maintain a dignified and respectful environment for Resident 105 and potentially other residents constituted a deficiency in the facility's care standards.
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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 Portland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rose City Nursing And Rehabilitation | 1.5 mi | ★★★★★ | 1 | 0 |
| Glisan Post Acute | 1.7 mi | ★★★★★ | 11 | 0 |
| Gateway Care And Retirement | 1.9 mi | ★★★★★ | 0 | 0 |
| Porthaven Post Acute | 2 mi | ★★★★★ | 9 | 0 |
| Menlo Park Post Acute | 2.1 mi | ★★★★★ | 15 | 0 |
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