Pinnacle Rehabilitation & Health Center

F-F657 example 1

1. Review of Resident R130's clinical record revealed:

3/7/25 - Resident R130 was admitted to the facility.

3/10/25 - A review of Resident R130's care plan for ADL self-care deficit documented [Resident R440] will be clean, dressed and well groomed daily to promote dignity and psychosocial wellbeing for ninety days. Resident R440's interventions included assist with daily hygiene, grooming, dressing, oral are, and eating as needed.

3/13/25 - Resident 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 Resident R130's hands revealed encrusted dark debris underneath each fingernail

on the right and left hands. Additionally, Resident 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 Resident R130 still had not been provided nail care. Resident 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 Resident R130's fingernails on both hands. E16 confirmed Resident 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 [Resident R130's] nails and she became combative so it couldn't get done.

4/11/25 11:20 AM - E2 (DON) confirmed Resident 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, [Resident R130] had been provided nail care.

46988

2. Review of Resident R73's clinical record revealed:

1/2/20 - Resident R73 was admitted to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 1/4/20 - A care plan documented that Resident R73 required assitance with all ADL's with the following interventions: assist with daily hygiene, grooming, oral care, and eating as needed; encourage to participate in self care; Level of Harm - Minimal harm or praise all efforts; report any changes or decline to provider. potential for actual harm 2/25/25 - A quaterly MDS documented Resident R73 required set up or clean up assistance of one staff member for Residents Affected - Few oral hygiene. Additionally the MDS documented R73had a BIMS score of 15 meaning he was cognitively intact.

4/8/25 8:21 AM - An interview with Resident R73 revealed the need for assistance with ADL's and he feels that staff is not attentive to his needs.

4/10/25 9:37 AM - An interview with Resident R73 confirmed that he brushes his teeth after staff set up breakfast. Also, Resident R73 confirmed he had not been set up at this time to bursh his teeth.

4/10/25 11:26 AM - An observation of Resident R73 had not brushed his teeth and Resident R73's toothbrush was sitting in cup

in bathroom dry.

4/10/25 11:34 AM - An interview with E45 (CNA) confirmed that she did not assist Resident R73 with oral care this morning. Additionally E45 confirmed documenting the oral care was completed in EMR.

The facility failed to assist Resident R73 with ADL's.

51358

3. Review of Resident R114 clinical record revealed:

10/1/24 - Resident R114's was admitted to the facility.

2/20/25 - A quarterly MDS documented that Resident R114 was dependent on staff for personal hygiene.

2/26/25 - Resident R114's care plan included that the resident required assist of one person for ADL care. Resident R144's care plan did not include refusal of nail care.

4/8/25 8:17 AM - An observation revealed that Resident R114 had black debris underneath all his fingernails.

4/8/25 1:15 PM - An observation revealed that Resident R114 had black debris underneath all his fingernails.

4/9/25 8:50 AM - An observation revealed that Resident R114 had black debris underneath all his fingernails.

4/10/25 9:00 AM - During an interview E36 (CNA) stated when she gives a bath she washes residents entire body, provides nail care, and the resident bath days are two times a week unless there are special instructions on task list.

4/10/25 9:05 AM - During an interview, E37 (CNA) confirmed Resident R114 received a bath on 4/5/25 and 4/9/25

during the 7:00 AM to 3:00 PM shift. E37 also acknowledged the nail care was her responsibility and stated

she would complete it at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 4/10/25 9:07 AM - During a confirming interview E12 (LPN) confirmed black debris underneath all his nails .

Level of Harm - Minimal harm or 4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON). potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or 46988 potential for actual harm Based on interview and record review it was determined that for two (Resident R112 and Resident R644) out of forty three Residents Affected - Few residents reviewed in the investigative sample, the facility failed to ensure received treatment and care in accordance with professional standards of practice and physician orders. Findings include:

1. Review of Resident R112's clinical record revealed:

Cross refer

F-F677 example 1

2. Review of Resident R130's clincial record revealed:

3/7/25 - Resident R130 was admitted to the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 3/10/25 - A review of Resident R130's care plan for ADL self-care deficit documented [Resident R440's] will be clean, dressed and well-groomed daily to promote dignity and psychosocial wellbeing for ninety days. Resident R440's interventions Level of Harm - Minimal harm or included assist with daily hygiene, grooming, dressing, oral care, and eating as needed. potential for actual harm 3/13/25 - Resident R130's admission MDS assessment documented the resident was severely cognitively impaired Residents Affected - Some and required substantial maximum assistance for personal hygiene and grooming.

4/8/25 9:26 AM and 4/11/25 11:07 AM - Observations confirmed that Resident R130's nails on both hands were long, with dark encrusted debris underneath each nail. E16 (RN UM) confirmed that Resident R130 needed nail care.

4/11/25 11:07 AM - E16 (RN UM) stated Well last week the CNA was trying to do [Resident R130's] nail care and she ecame combative so it couldn't get done. E16 also confirmed Resident R130's ADL care plan had not been revised to reflect refusal of nail care. E16 stated, No she has not been care planned for refusing nail care.

40260

3. Review of Resident R119's clinical record revealed:

5/13/24 - Resident R119 was admitted to the facility.

5/20/24 - An admission MDS was completed.

5/22/24 - The admission Resident Care Conference Attendance Sheet for Resident R119's post admission care plan meeting lacked evidence of attendance or input from a physician, a registered nurse, a CNA, or dietary staff.

4/17/25 8:34 AM - In an email communication, the surveyor notified E1 (NHA) and E2 (DON) that there was

a lack of evidence of input by all IDT members at the initial care plan meeting. E1 responded that the facility will ensure participation from these parties immediately and ongoing in all care plan meetings, including the initial meetings.

4. Review of Resident R120's clinical record revealed:

5/14/24 - Resident R120 was admitted to the facility.

5/20/24 - An admission MDS was completed.

5/20/24 - The admission Resident Care Conference Attendance Sheet for Resident R120's post admission care plan meeting lacked evidence of attendance or input from a physician, a registered nurse, a CNA, or dietary staff.

4/17/25 8:34 AM - In an email communication, the surveyor notified E1 (NHA) and E2 (DON) that there was

a lack of evidence of input by all IDT members at the initial care plan meeting. E1 responded that the facility will ensure participation from these parties immediately and ongoing in all care plan meetings, including the initial meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 46988

Level of Harm - Minimal harm or 5. Review of Resident R91's clinical record revealed: potential for actual harm 2/27/25 - Resident R91 was admitted to the facility. Residents Affected - Some 3/5/25 - An admission MDS was completed for Resident R91.

3/7/25 10:00 AM - The admission Resident Care Conference Attendance Sheet for Resident R91's post admission care plan meeting lacked evidence of attendance or input from a physician, a CNA, or dietary staff.

4/14/25 11:57 AM - An interview with E5 (SW) confirmed that all members of the interdisciplinary team were not present or provided input on 3/7/25 for Resident R91's care plan meeting. E5 confirmed input from the physician, CNA, and dietary was not provided.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Level of Harm - Minimal harm or 39058 potential for actual harm Based on interview, observation and record reviews it was determined that for one (Resident R132) out of one Residents Affected - Few resident reviewed for communication the facility failed to provide assistive devices to support communication for Resident R132 who was fluent only in Spanish.

3/8/25 - Resident R132 was admitted to facility for rehabilitation.

3/8/25 - The care plan documented that Resident R132's participation in activities was limited due to a language barrier, as the resident was fluent only in Spanish. Resident R132 had difficulty communicating, as evidenced by a limited understanding and use of English. The care plan goal was to facilitate communication through alternative methods, such as a communication board, to express needs and wants. Interventions included teaching Resident R132 how to use a communication book/board or electronic device and utilizing a Spanish interpreter as needed.

3/10/25 - A baseline care plan documented Spanish as the primary language for Resident R132.

3/10/25 - A physician's order for speech therapy evaluation and treatment 1-3x per week for 41 days for dysphagia therapy and group therapy as indicated.

3/17/25 - An admission MDS documented that Resident R132 has the ability to understand others and be understood by others adequately.

4/8/25 10:01 AM - An observation of Resident R132 interacting with E49 (LPN) revealed Resident R132 can speak very little and broken English using hand gestures to communicate her needs.

4/8/25 10:05 AM - During an interview with E49 (LPN) when asked how staff communicates with Resident R132, E49 stated that staff sometimes use a translation app on their personal cell phones to attempt communication with Resident R132 or call the resident's representative, (F7), to assist with translation when needed. E49 was unaware of whether the facility had a language line available for staff to use when communicating with residents who do not speak English.

4/9/25 3:15 PM - An observation of Resident R132's room with no communication board and an activities calendar printed in English hung on her wall.

4/9/25 3:28 PM: During an interview, E33 (Guest Services) stated that a daily bulletin is delivered to the bedside each morning listing available food options and daily activities. E33 also showed the surveyor a binder kept in the bedside table drawer that lists food choices residents can select from. The binder provided to Resident R132 was in English.

4/11/25 10:11 AM - During an interview, C9 (Speech Therapist Contractor) reported that a phone interpreter service was used to conduct the assessments. The printed swallow study instructions provided to the patient were in Spanish, and a communication board (pictures, spanish and english) was also given to assist with understanding. C9 noted that she collaborated with dietary services for Resident R132's.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0676 4/11/25 10:56 AM - During an interview, C10 (contractor Rehab Director) revealed that therapy uses the language line to communicate with Resident R132 and that a communication board had previously been provided for Level of Harm - Minimal harm or Resident R132 to keep in her room. potential for actual harm 4/11/25 - During an observation immediately following the above interview, no communication board was Residents Affected - Few found in Resident R132's room. Therapy staff provided the surveyor with a communication board at that time and it was placed on the residents bedside table.

4/16/25 - During an interview E1 (NHA) stated that language line information with phone number and instructions on use are posted at Resident R132's bedside as well as each nurse station and medication carts. E1 further stated that the facility also has a Spanish speaking employee that will help to interpret everyday conversations/daily living conversations when needed.

4/16/25 12:16 PM - An observation of Resident R132 in the hallway, smiling and engaging with the surveyor and staff. E34 (LPN) spoke to Resident R132 in English, asking if she had any current needs and if she would like to wait in the lobby for her lunch delivery from outside the facility. E34 repeated the questions multiple times. Resident R132 appeared confused, lifted her hands, and shrugged her shoulders, indicating she did not understand what was being asked.

4/16/25 12:49 PM - During an interview with Resident R132 with the use of an interpreter line, Resident R132 confirmed that

she does not like the food provided by the facility and further stated that she is not able to read the daily bulletin that lists food options and activities for the day as she is not able to read written language at all. Additionally, Resident R132 confirmed that Nursing and CNA staff do not use the language line when trying to communicate with her. Resident R132 further expressed feeling lonely, hopeless and frustrated as she does not understand what staff is saying and staff does not understand her.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or 47114 potential for actual harm Based on observation, interview, and record review it was determined that for four (Resident R130, Resident R73 and Resident R114) out Residents Affected - Few of fourteen residents reviewed for ADL (Activities of Daily Living) the facility failed to provide ADL care for dependent residents. Findings include:

Cross Refer,

F-F760

9/12/24 - Resident R644 admitted to the facility with diagnoses including but not limited to, heart failure and chronic obstructive pulmonary disease.

10/2/24 - C2 (contractor NP) entered order in Resident R644's EMR stating, DC (discontinue) PICC (peripherally inserted central catheter) RUE (right upper extremity) .

10/3/24 - Resident R644's Resident Care Conference Attendance Record documented that E23 (RN) and F3 (Resident R644's daughter) participated in this discharge planning conference. The paperwork stated, PICC will be pulled by nursing .

10/5/24 - Resident R644 was discharged home on hospice services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 4/11/25 2:08 PM - During a telephone interview, F3 (Resident R644's daughter) stated, .When my mom [Resident R644] arrived home after discharge from Evergreen, her PICC line was still in. It was supposed to be taken out at Level of Harm - Minimal harm or Evergreen prior to discharge. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm 39058

Residents Affected - Few Based on observation, record review and interview, it was determined that for one (Resident R35) out of 11 resiedents reviewed for accidents the facility failed to implement a care planned fall intervention. Findings include:

Review of Resident R35's clinical record revealed:

6/27/24 - Resident R35 was admitted to the facility.

6/27/24 - An admission MDS documented the resident required extensive to total assistance with most ADLs, including transfers and mobility. The resident was dependent for bed mobility, toileting, and dressing.

9/25/24 - Resident R35 was readmitted to the facility from the hospital with diagnoses including a right broken leg from

a fall at the facility.

A care plan revised on 10/2/24 included a new intervention for fall mats to be placed at the bedside when Resident R35 is in bed.

10/3/24 - A fall risk assessment scored Resident R35 at 17, indicating a high risk.

On the following dates, no fall mats were observed at the bedside while Resident R35 was in bed:

4/8/25 at 7:46 AM

4/11/25 at 2:27 PM

4/15/25 at 10:25 AM

On 4/15/25 from approximately 10:55 AM to 11:00 AM, during an interview and observation with E15 (CNA) and E16 (CNA) it was confirmed there were no fall mats at the bedside or in the room.

4/15/25 11:10 AM - An interview with E16 (Unit Manager) and E2 (Director of Nursing) it was revealed that

the intervention for fall mats was listed on the task list. E2 confirmed that fall mats should have been placed at the bedside while Resident R35 was in bed and stated the issue would be addressed immediately.

On 4/16/25 at 8:23 AM, during a final observation, Resident R35 was in bed with fall mats appropriately in place.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Potential for locked, compartments for controlled drugs. minimal harm 32810 Residents Affected - Some Based on observation and interview it was determined that for three out of three medication carts observed

the facility failed to ensure that opened medications were labeled with an open date. Findings include:

1. 4/8/25 6:25 AM - An observation and inspection of the Sierra Unit B cart revealed four liquid medications that were opened and undated. The finding was immediately confirmed by E18 (LPN).

2. 4/8/25 6:33 AM - An observation and inspection of the Sierra Unit A cart revealed two liquid medications that were opened and undated. The finding was immediately confirmed by E18 (LPN).

3. 4/8/25 6:53 AM - An observation and inspection of the Seaside Unit A cart revealed four liquid medications that were opened and undated. The finding was immediately confirmed by E19 (LPN).

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0808 Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law. Level of Harm - Minimal harm or potential for actual harm 46988

Residents Affected - Few Based on observation and interview, it was determined that for one (Resident R3) out of ten residents sampled for dining, the facility failed to provide the therapeutic diet that was prescribed by the physician. The facility failed to provide Resident R3 large portions. Findings include:

Review of Resident R3's clinical record revealed:

5/24/24 - Resident R3 was admitted to the facility.

1/23/25 - A physician's order for Resident 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 Resident 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 Resident R3 was on large portions and if Resident 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 Resident 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 Resident R3's portions were not large portions.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 32810

Residents Affected - Some Based on observation and interview it was determined that the facility failed to ensure food was stored, prepared, and served in manner that prevents food borne illness to the residents. Findings include:

1. 4/8/25 8:20 AM - Observation and inspection of the Sierra Unit nourishment refridgerator revealed that it contained a sandwich, container of pickles and a container of sliced tomatoes that were undated and unlabeled. The finding was immediately confirmed by E20 (LPN) unit manager.

2. 4/8/25 11:28 AM - During a dining observation in the main dining room, E21 (DA) was observed wearing gloves and holding a paper meal ticket in the right hand. At 11:33 AM, E21 left the dining room and entered

the kitchen to communicate with kitchen staff. E21 then returned to the dining room at the food service counter still holding the same meal ticket paper in right hand, touched her nose, adjusted her face mask with

the left hand then reached into the bag of bread with the same left hand to prepare a sandwich. The surveyor intervened, and E21 put down the meal ticket, and discarded both gloves and donned a new pair of gloves with out performing any hand hygiene. E21 immediately confirmed the findings and discarded the slice of bread.

3. 4/10/25 11:36 AM - 11:48 AM - During a follow up visit to inspect the facility kitchen the following was observed:

- Eight plates removed from plating area contained food debris.

- Two dessert cups removed from dish rack contained food debris.

- Meat stored on the top most shelf in the refrigerator thawing over vegetables.

- Visible dust on the fan in the dish area. E22 (FSD) immediately confirmed the findings.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621 potential for actual harm Based on record review and interview, it was determined that for two (Resident R14 and Resident R639) out of twelve residents Residents Affected - Some reviewed for infection control, the facility failed to initiate and maintain appropriate precautions per CDC guidelines. Additionally the facility failed to follow standard precautions. Findings include:

CDC's Infection Control Appendix A: Type and duration of Precautions Recommended for Selected Infections and Conditions .Multidrug-resistant organisms, infection or colonization (e.g., MRSA, VRE, VISA/VRSA, ESBLs, resistant S.pneumoniae) Contact + Standard . February 7, 2025

Facility's Infection Prevention and control Program Policy: .Policy Explanation and Compliance Guidelines: . 5. Isolation Protocol (Transmission-Based Precautions): a. A resident with an infection or communicable disease shall be placed on transmission-based precautions as recommended by current CDC guidelines. Rev 1/2025

Facility's Enhanced Barrier Precaution Policy: It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDRO). Enhanced Barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at risk of MDRO acquisition (e.g. residents with wounds or indwelling medical devices).

1.Review of Resident R14's clinical record revealed:

12/13/20 - Resident R14 was admitted to the facility with diagnoses including but not limited to, multiple sclerosis, seizures and S/P colostomy.

10/5/23 - 10:23 AM - C3 (consultant medical director) documented in Resident R14's progress note, .History of present illness: Patient is a [AGE] year old male with past medical history significant for HTN (hypertension) . colostomy .

4/1/24 - New EBP guidelines from CMS were effective in long term care facilities.

11/22/24 - C2 (consultant NP) initiated an order in Resident R14's EMR, Enhanced Barrier precautions related to history of ESBL urine, colostomy. Every shift for monitoring.

The facility failed to initiate EBP for Resident R14 until eight months (from 4/1/24 to 11/22/24) after the new guidelines were mandated.

4/16/25 - 12:01 PM - During an interview, E2 (DON) confirmed that Resident R14 has had a colostomy since he has been in the facility.

2. Review of Resident R639's clinical record revealed:

6/21/24 - Resident R639 was admitted to the facility with diagnoses including but not limited to, chronic obstructive pulmonary disease.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 10/3/24 - 5:37 PM - C4 (hospital MD) documented in Resident R639's discharge summary, Principal diagnosis: MRSA pneumonia . due to positive MRSA swab . discharge medications: .linezolid 600 mg (milligram) tablet- take 1 Level of Harm - Minimal harm or tablet by mouth 2 times a day for 20 days . potential for actual harm 10/3/24 - C2 (NP) entered order in Resident R639's EMR stating, linezolid tablet 600 mg - give 1 tablet by mouth every Residents Affected - Some 12 hours for infection of lungs for 20 days.

4/16/25 - 10:35 AM - A review of Resident R639's EMR revealed that there was not a contact precautions order in effect while Resident R639 was being treated for MRSA pneumonia with linezolid (antibiotic to treat MRSA pneumonia).

The facility failed to initiate contact precautions for Resident R639 while he was being treated for MRSA pneumonia from 10/3/24 to 10/24/24.

47114

4/8/25 6:16 AM - A random observation revealed a clear plastic trash bag with dirty briefs and gloves was sitting on the floor in front of room [ROOM NUMBER] which had signage on the door that indicated EBP (Enhanced Barrier Precautions).

4/8/25 6:20 AM - E26 (CNA) was observed leaving room [ROOM NUMBER] wearing disposable gloves. E26 picked up the trashbag and proceeded to walk across the hallway to room [ROOM NUMBER] another room with EBP signage on the door, placed the trash bag on the floor and entered the room wearing the contaminated gloves on both hands.

4/8/25 6:41 AM - During an interview E2 (DON) observed the trash bag was sitting on the floor in the doorway of room [ROOM NUMBER]. E2 stated, No this should not be it should go directly to the biohazard room. E2 picked the trash bag up off the floor, E26 opened the door to leave room [ROOM NUMBER] wearing gloves, E2 stopped E26 in the hallway and educated the CNA on wearing gloves, hand washing and that trash should not go from room to room and is to be taken to the biohazard room for disposal. The trash was disposed off by E2.

4/8/25 8:31 AM - An additional observation of room [ROOM NUMBER] with EBP signage revealed a clear plastic bag with dirty linen and a bag with briefs and other trash were sitting on the floor inside of room [ROOM NUMBER]. E16 (RN, UM) entered room [ROOM NUMBER] and picked the bags up off the floor. E16 confirmed and stated, Yes I know the trash bags being left on the floor is an infection control concern. E16 proceeded to take the bags to the biohazard room for disposal.

4/17/25 1:45 PM -Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 Implement a program that monitors antibiotic use.

Level of Harm - Minimal harm or 47621 potential for actual harm Based on record review and interview, it was determined that for two (Resident R18 & Resident R33) out of five residents Residents Affected - Few reviewed for antibiotic usage, the facility failed to monitor antibiotic usage. Findings include:

Facility's Antibiotic Stewardship program Policy: It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of

this program is to optimize the treatment of infections while reducing adverse events associated with antibiotic use . Rev. 12/2024

1. Review of Resident R18's clinical record revealed:

9/9/21 - Resident R18 was admitted to the facility.

12/10/24 - C5 (consultant NP) entered an order in Resident R18's EMR stating, Metronidazole (antibiotic) oral tablet 500 mg- give 1 tablet by mouth two times a day for cellulitis of penis for 5 days.

12/12/24 - C3 (consultant MD) documented in Resident R18's re-admission history and physical note, .admitted to [hospital] for penis necrosis, and underwent debridement of penis on 12/7/24 .Physical exam: Skin- see wound care note .Plan: Penis Necrosis: . continue on metronidazole 500 mg 1 tab every 12 hours for 5 days and cefpodoxime 200 mg 2 tabs 2 times a day for 5 days .

12/13/24 - C3 (consultant MD) entered order in Resident R18's EMR, Cefpodoxime proxetil (antibiotic) oral tablet 200 mg- give 2 tablets by mouth two times a day for cellulitis of penis X 5 days.

4/14/25 12:31 PM - A review of the facility's infection control line listing for December 2024 revealed that Resident R18's cefpodoxime and metronidazole antibiotic courses were not listed on the document. A review of Resident R18's hospitalization discharge summary dated 12/10/24 revealed Resident R18 was being treated with cefpodoxime post-operatively after having a necrotic mass removed from his penis.

The facility failed to implement their protocol to monitor antibiotic usage with regard to Resident R18's cefpodoxime and metronidazole.

2. Review of Resident R33's clinical record revealed:

12/25/24 - Resident R33 was admitted to the facility.

12/25/24 - C2 (consultant NP) initiated an order in Resident R33's EMR stating, Vancomycin HCl (antibiotic) 25 mg/ml solution- give 125 mg by mouth two times a day for c-diff for 5 days.

2/8/25 - C5 (consultant NP) initiated an order in Resident R33's EMR stating, Bactrim DS (antibiotic) oral tablet 800-160 mg- give 1 tablet by mouth two times a day for UTI (urinary tract infection).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0881 4/14/25 12:31 PM - A review of the facility's December 2024 infection control line listing revealed that Resident R33's vancomycin antibiotic course and C-difficile infection was not documented. A review of the facility's February Level of Harm - Minimal harm or 2025 infection control line listing revealed that Resident R33's Bactrim antibiotic course and UTI infection were not potential for actual harm documented.

Residents Affected - Few The facility failed to implement their protocol to monitor antibiotic usage with regard to Resident R33's vancomycin and Bactrim.

4/16/25 1:55 PM - During an interview, E12 (LPN/IP) stated that the monthly infection control line listing was

the method that the facility used to track infections and antibiotic usage in the facility.

4/17/25 1:45 PM -Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47621 potential for actual harm Based on record review and interview, it was determined that for two (Resident R33 and Resident R96) out of twelve residents Residents Affected - Few reviewed for pneumococcal vaccines, the facility failed to accurately assess the residents' pneumococcal vaccine status. Findings include:

Facility's Pneumococcal Vaccine (Series) Policy: It is our policy to offer our residents immunization against pneumococcal disease in accordance with current CDC guidelines and recommendations . Policy Explanation and Compliance Guidelines: 1. Each resident will be assessed for pneumococcal immunization upon admission .6. A pneumococcal vaccination is recommended for all adults [AGE] years and older and based on the following recommendations: . b. For adults [AGE] years or older who have only received a PPSV23: Give 1 dose PVC15 or PCV20. 1. The PCV15 or PCV20 dose should be administered at least one year after the most recent PPSV23 vaccination . Rev 1/2025

1. Review of Resident R33's clinical record revealed:

12/25/24 - Resident R33, aged [AGE] years, was admitted to the facility.

12/25/24 - Resident R33 signed Attachment D Pneumococcal Pneumonia and Influenza Vaccinations/Tuberculosis Testing form from the admission packet and consented to receive the pneumococcal pneumonia vaccine.

12/29/24 - Resident R33's admission MDS assessment documented Resident R33 as having a BIMS score of 14, which reflected normal cognition.

1/15/25 - Resident R33 was administered the PCV20 vaccine by the facility.

4/10/25 3:45 PM - A review of the DelVax (vaccine registry) website revealed Resident R33 had been administered PPV23 on 9/5/13 and PCV20 vaccine on 8/19/24, just five months prior.

4/14/25 10:49 AM - During an interview, E12 (staff LPN/ Infection Preventionist) confirmed that she had access to the DelVax website. E12 stated, .[nurse] used to put the vaccines in Delvax but she does not work here anymore. Now we do it sometimes. When the resident comes in, we ask them about their vaccines. We look on the hospital records and the historic records. If they are not up-to-date, we offer it to them .We only give the pneumococcal 20 vaccine here now .

2. Review of Resident R96's clinical record revealed:

10/1/24 - Resident R96 was admitted to the facility.

10/7/24 - Resident R96's admission MDS assessment documented a BIMS score of 9, which was reflective of moderate cognitive impairment.

4/11/25 10:35 AM - A review of Resident R96's face sheet revealed that F5 (Resident R96's daughter) was Resident R96's Power of Attorney (POA). The EMR contained documentation of Attachment D Pneumococcal Pneumonia and Influenza Vaccinations/Tuberculosis testing form that was signed by Resident R96. This document was not dated and granted consent for Resident R96 to be vaccinated with the pneumovax and influenza vaccines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 27 085020 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0883 4/11/25 11:04 AM - During an interview, E5 (SW Director) stated, For new admissions, we try to do the BIMS section of the MDS right away. If they come in during the evening, we try to do it the next day. A BIMS score Level of Harm - Minimal harm or for a person with cognitive impairment is 6 or 7. If they have a score of 10 -11, then it is a judgment decision. potential for actual harm We don't really have a cutoff score for when residents cannot make decisions. It is more of a judgment thing. There really is not any formal training for the BIMS test. It is a piece of paper that we follow. Residents Affected - Few

The facility failed to involve Resident R96's known POA in obtaining consents for vaccinations.

4/17/25 1:45 PM - Findings were reviewed with E1 (NHA) and E2 (DON).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 27 085020

F-F880

7/30/24 - Resident R112 was admitted to the facility.

8/27/24 3:12 PM - A physician's order documented that Resident R112 was on contact isolation due to scabies for fourteen days.

11/9/24 - A physicians order was written for Resident R112 consult to dermatology related to scabies.

11/13/24 - A specialist physician's (dermatologist) progress note documented that Resident 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 Resident 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 Resident R112 being in isolation for 78 days.

47621

2. Resident R644's clinical record revealed:

Cross refer