Evergreen Estates Retirement Community

Poisonous materials, including mouthwash and disinfecting wipes, were found accessible in a resident's room despite the resident being unable to safely use them.

A new medical evaluation had not been completed following a change in the resident's medical condition.

Failure to implement procedures for medication storage and monitoring, specifically regarding inaccurate blood glucose readings recorded in the Medication Administration Record.

The home failed to follow prescriber orders because prescribed medications were not available in the home at the scheduled times.

The home failed to report resident medication refusals to the prescriber as required.

Prescription medications and syringes were found unlocked, unattended, and accessible on a resident's bedside nightstand.

A resident's medical evaluation did not include documented information regarding their special health or dietary needs.

The facility failed to address a resident's missing denture, which resulted in the resident choking on food and the facility failing to update the dietary order promptly.

Frozen bakery rolls and orange juice concentrate were stored directly on the floor in the walk-in freezer.

Multiple food items, including beef paste, pie, and cake, were found in refrigerators in opened or unsealed containers.

Staff reported that frozen food is sometimes left out on the counter to air thaw for extended periods of time.

The kitchen had stained floors with dirt and grime, black mold on the wall above the dishwashing station, and food items stored on the floor.

The quality management review failed to address several required elements, including incident reporting, complaint procedures, and staff training.

The home failed to complete an Act 13 form to the local Area Agency on Aging following a physical altercation between residents.

The home failed to submit incident reports to the Department regarding uncompleted prescribed blood sugar tests for two residents.

A resident was subjected to physical force when pushed by another resident, resulting in a closed compression fracture.

A large dark stain was present in the center of the carpet in a resident's bedroom.

The facility failed to post required signage regarding smoking regulations at the main entrance and the designated smoking area.

A strong odor of urine was noted in a resident's bedroom and the adjacent hallway.

Two full and uncovered trash cans were observed in the kitchen.

Annual medical evaluations were not completed for Residents #4, #8, and #9.

The medical evaluation for Resident #5 did not indicate the date the resident was evaluated.

The medical evaluation for Resident #3 was incomplete, lacking body positioning, health status, cognitive functioning, and the medical professional's name.