Evergreen Post Acute
EVERGREEN POST ACUTE in SMYRNA, DE — inspection on April 17, 2025.
Found 4 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 R130's clinical record revealed:
3/7/25 - R130 was admitted to the facility.
3/10/25 - A review of R130's care plan for ADL self-care deficit documented [R440] will be clean, dressed and well groomed daily to promote dignity and psychosocial wellbeing for ninety days. R440's interventions included assist with daily hygiene, grooming, dressing, oral are, and eating as needed.
3/13/25 - R130's admission MDS assessment documented the resident was severely cognitively impaired and required substantial maximum assistance for personal hygiene and grooming.
4/8/25 9:26 AM - An observation of R130's hands revealed encrusted dark debris underneath each fingernail on the right and left hands.
Additionally, R130's fingernails were long and needed to be trimmed.
4/11/25 10:48 AM - During a phone interview RP2 (Responsible Party) stated, I noticed that her nails are dirty and long, so I was planning on bringing in a nail clipper and a file to do her nails today.
4/11/25 11:01 AM - Another observation confirmed that R130 still had not been provided nail care. R130's nails on both hands still had dark encrusted debris underneath the resident's fingernails.
4/11/25 11:07 AM -
During an interview E16 (RN, UM) checked R130's fingernails on both hands. E16 confirmed R130 had not been provided nail care. E16 stated, Yes they do need to be cleaned and cut. E16 then stated, Well last week the CNA was trying to do [R130's] nails and she became combative so it couldn't get done.
4/11/25 11:20 AM - E2 (DON) confirmed R130 needed nail care and then stated, Ok this will be taken care of right away.
4/11/25 11:45 AM - E2 confirmed and stated, [R130] had been provided nail care.
46988
2.
Review of R73's clinical record revealed:
1/2/20 - R73 was admitted to the facility.
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 04/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977
Review of R130's clincial record revealed:
3/7/25 - R130 was admitted to the facility.
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 04/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977
The facility failed to provide R3 large portions.
Findings include:
Review of R3's clinical record revealed:
5/24/24 - R3 was admitted to the facility.
1/23/25 - A physician's order for R3 documented low concentrated sweets diet, regular texture, thin liquid consistency: give large portions for all three meals.
4/14/25 12:10 PM - An observation of R3's meal tray that contained one piece of chicken, mashed potatoes, string beans, fruit cup and drinks on tray.
The mashed potatoes and vegetables were one serving and not large portions.
4/14/25 12:26 PM - An interview with E40 (CNA) confirmed that R3 was on large portions and if R3 wants them she will ask staff for more. E40 confirmed that the mashed potatoes and green beans were not large portion.
4/14/25 12:29 PM - An interview with E41 (FSD) confirmed that large portions refers to the sides and double portions refers to the entrees.
4/15/25 12:15 PM - An observation of R3's meal tray that contained chicken broccoli casserole, side of rice, banana, and a fresh fruit cup.
The casserole and side of rice were regular portions.
4/15/25 12:19 PM - An interview with E39 (CNA) and E40 (CNA) confirmed that R3's portions were not large portions.
4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).
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 04/17/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Post Acute 3034 South Dupont Blvd Smyrna, DE 19977
7/30/24 - R112 was admitted to the facility.
8/27/24 3:12 PM - A physician's order documented that R112 was on contact isolation due to scabies for fourteen days.
11/9/24 - A physicians order was written for R112 consult to dermatology related to scabies.
11/13/24 - A specialist physician's (dermatologist) progress note documented that R112 was not contagious and to remove isolation precautions.
4/15/25 10:30 AM - An interview with C2 (NP) and C5 (NP) confirmed that R112 was on contact precautions from 8/27/24 to 11/13/24.
There was a ten week delay in consulting the dermatologist resulting in R112 being in isolation for 78 days.
47621
2. R644's clinical record revealed:
Cross refer