Evergreen Post Acute
EVERGREEN POST ACUTE in SMYRNA, DE — inspection on January 14, 2025.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of R1's clinical record revealed:
1/2/25 - R1 was admitted to the facility with diagnosis of Alzheimer's disease.
1/3/24 - A Brief Interview for Mental Status (BIMS) was completed for R1 and showed a score of 8 out of 15 indicating that the resident was moderately cognitively impaired.
1/13/25 11:43 AM -
During an interview E6 (LPN) stated that on 1/5/25, F1 reported that a staff was inappropriate to R1. E6 stated that E8 (Supervisor) did not request that they write a statement.
1/13/25 11:57 AM -
During an interview E7 (CNA) stated that on 1/5/25, F1 reported to her that a staff member was being mean to R1. E7 further stated that R1 had stated the staff was being rude. E7 reported this to E8 (Supervisor) and stated that E8 did not interview them or have them write a statement.
1/13/25 12:56 PM -
During an interview E8 stated that on 1/5/25, F1 reported to her that a staff member had said something to R1 that was not nice. E8 had F1 write a statement and then placed the statement under the door of E4 (SW) since it was the weekend. E8 stated that she checked the facility schedule on the alleged date/time of the incident and did not find an employee who matched the description.
1/13/25 1:16 PM -
During an interview, E4 stated that they saw the statement in her office on 1/6/25 and gave it to E3 (ADON).
1/14/25 12:09 PM -
During an interview E1 (NHA) stated they did not know about the statement written by F1, it was not brought forward as a formal matter and that R1 was discharged the next day.
1/13/25 2:07 PM -
During an interview, E1 (NHA) did not know about a statement made from F1 regarding R1's accusation of abuse and that an investigation should have been completed.
There was no evidence that the facility investigated R1's allegation of abuse to the state agency
1/14/25 12:55 PM - Findings were reviewed during the exit conference with E1 and E2 (DON).
085020
Review of R1's clinical record revealed:
1/2/25 - R1 was admitted to the facility with a diagnosis including Alzheimer's disease.
1/3/24 - A Brief Interview for Mental Status (BIMS) was completed for R1 and showed a score of 8 out of 15 indicating that the resident was moderately cognitively impaired.
1/13/25 11:57 AM -
During an interview, E7 (CNA) stated that on 1/5/25 F1 reported to her that a staff member was being mean to R1. E7 further stated that R1 had stated that the staff was being rude.
1/13/25 12:56 PM -
During an interview, E8 (Supervisor) stated that on 1/5/25 F1 reported to her that a staff member had said something to R1 that was not nice. E8 had F1 write a statement and then placed the statement under the door of E4 (SW), since it was the weekend.
1/13/25 1:16 PM -
During an interview, E4 stated that they saw the statement in her office on 1/6/25 and gave it to E3 (ADON).
1/13/25 1:56 PM -
During an interview, E3 (ADON) did not know about a statement made from F1 regarding R1's accusation of abuse.
1/13/25 2:07 PM -
During an interview, E1 (NHA) did not know about a statement made from F1 regarding R1's accusation of abuse.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
085020
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 085020 B.
Wing 01/14/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977