EVERGREEN RETIREMENT

Official classification

Type B

Official code

87466

Regulation authority

CCR

What the official deficiency says

87466: Observation of the Resident The licensee shall ensure that residents are regularly observed for changes in physical, mental, emotional and social functioning and that appropriate assistance is provided when such observation reveals unmet needs. When changes such as unusual weight gains or losses or deterioration of mental ability or a physical health condition are observed, the licensee shall ensure that such changes are documented and brought to the attention of the resident's physician and the resident's responsible person, if any.This requirement is not met as evidenced by: Based on the interviews conducted and record reviews, Licensee did not document that R1 obtained medical professional assistance for behavior observed which poses a potential health, safety or personal rights risk to residents in care.

Official plan of correction

The administrator agreed to certify in writing that upon observing changes in condition or behaviors in the residents, will provide assistance with obtaining proper medical care and submit a letter to the department by POC date.

Deadline recorded: Jul 13, 2026. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87468.1(a)(2)

Regulation authority

CCR

What the official deficiency says

(a) Residents in all residential care facilities for the elderly shall have all of the following personal rights: (2) To be accorded safe, healthful and comfortable accommodations, furnishings and equipment. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, some resident rooms did not have soap, paper towles or sanitizer. which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/16/2022 Plan of Correction Licensee will provide paper towles, soap and sanitizer in every room, provide in service on infection control, send signed roster of staff that attended in service and self certify when completed and send proof to LPA by POC date,

Official classification

Type A

Official code

87465(h)(2)

Regulation authority

CCR

What the official deficiency says

(h) The following requirements shall apply to medications which are centrally stored: (2) Centrally stored medicines shall be kept in a safe and locked place that is not accessible to persons other than employees responsible for the supervision of the centrally stored medication. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, PRN medication for one resident was not centrally stored which poses an immediate health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2022 Plan of Correction Staff will removed the PRN medication from resident room and provide proof to LPA by POC date. ***Corrected during visit and no further action is required.****

Official classification

Type B

Official code

87303(a)

Regulation authority

CCR

What the official deficiency says

The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation LPA and Sales Director Tahni Harp observed broken glass on fire extinguisher compartment and electrical doors in disrepair. Also Window in room 308 does not stay open on its own and wall in front of that window is in disrepair. Wall by tub in room 210 has water damage from possible leak which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2022 Plan of Correction Licensse will replace broken glass on fire extinguisher compartment and repair/replace the electrical doors, repair bathroom window in room 308 and paint wall by window in room 308 behind towel rack, Repair wall with water damage in room 210 and provide proof of repair to LPA by POC date. ***Glass on Fire extinguisher compartment was replaced during visit***

Official classification

Type B

Official code

87303(e)(6)

Regulation authority

CCR

What the official deficiency says

(e) Water supplies and plumbing fixtures shall be maintained as follows: (6) Toilet, handwashing and bathing facilities shall be maintained in operating condition. Additional equipment shall be provided in facilities accommodating physically handicapped and/or nonambulatory residents, based on the residents' needs. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation shower facet in room 208 needs replacement or repair. Sink in room 308 does not drain properly which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/30/2022 Plan of Correction Licensee will repair/replace facet in room 208 and repair sink drain in room 308 and send LPA proof by POC Date.

Official classification

Type B

Official code

87307(d)(6)

Regulation authority

CCR

What the official deficiency says

(6) All outdoor and indoor passageways and stairways shall be kept free of obstruction. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, LPA and Sales Director Tahni Harp obseerved 2 water tanks, a loose door and plastic sheeting obstructing passageway which poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/09/2022 Plan of Correction Licensse will remove the items obstructing passageways and send photos as evidence to LPA by POC date. ****obstructions were removed during visit and no further action is required****