Evergreen Retirement

Eviction Procedures: 87224 (d) - The licensee shall set forth in the notice to quit the reasons relied upon for the eviction with specific facts to permit determination of the date, place, witnesses, and circumstances concerning those reasons. Based on interviews and record review, facility did not comply with providing R1 with an lawful eviction notice with specific reasons/dates, which poses/posed an immediate health, safety to persons in care

(c) If the resident's physician has stated in writing that the resident is unable to determine his/her own need for ... medication ... (2) Once ordered by the physician the medication is given according to the physician's directions. This requirement is not met by: Based on interviews and record review, facility did not comply with physician orders regarding R1's medication, which poses/posed an immediate health, safety to persons in care

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 Based on interviews and observations, the licensee did not comply with the section cited above. R1's room was not clean and full of clutter which poses/possessed a potential health, safety or personal rights risk to residents in care.

Reappraisals- In Part: (a) Pre-admission appraisal shall be updated as necessary…to note significant changes & keep appraisal accurate. Significant changes include: (3) Any illness or change in health care needs of the resident. This requirement was not met as evidenced by: Based on LPA’s review of R1’s medical records which document since 10/22/22 staff had knowledge of R1’s cognitive/physical decline & increased needs for service. This deficiency posed an immediate health and safety risk to the resident in care.

Acceptance and Retention Limitations- No resident shall be accepted or retained if any of the following apply: Dementia, unless the requirements of Section 87705, Care of Persons with Dementia, are met.This requirement was not met as evidenced by: a review of R1’s records indicate that R1 began to express behaviors and symptoms of dementia. Staff was aware of this decline, but failed to accurately assess R1 in order to meet their needs. This posed an immediate health and safety risk to the resident in care.

Reappraisals- The pre-admission appraisal shall be updated, in writing as frequently as necessary to note significant changes and to keep the appraisal accurate. The reappraisals shall document changes in the resident's physical, medical, mental, and social condition. Significant changes shall include but not be limited to: Any illness, injury, trauma, or change in the health care needs of the resident. This requirement was not met as evidence by: a review of R1’s medical records indicate that since October 22, 2022, facility staff had knowledge of R1’s cognitive and physical condition progressing

Incidental and Medical Dental Care- The licensee shall immediately telephone 9-1-1 if an injury or other circumstance has resulted in an imminent threat to a resident’s health including, but not limited to, an apparent life-threatening medical crisis This requirement was not met as evidenced by, R1 experienced a fall, suffered a head injury, and was found on a pool blood in the morning of 12/07/22. R1 was not sent to the hospital until the afternoon of that date. This poses an immediate health and safety risk to the resident in care.

87303(a) The facility shall be clean, safe, sanitary... 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: Based on inspection, and observation the Licensee did not ensure that the facility is safe and sanitary for wellbeing of residents and others. LPA observed rodent droppings in food storage/office, kitchen and reception desk. This poses a potential health, safety risk and personal rights violation to residents in care.

80076(a)(17) Food Service. Kitchens, food preparation, and storage areas shall be kept clean... free of rodents, and other vermin. This requirement is not met as evidenced by: Based on inspection, and observation the Licensee did not ensure that the kitchen was free from rodents. LPA observed rodent droppings in storage room/office on metal shelf, containers, boxes, food tin cans, food bags and underneath kitchen sink. This poses a potential health, safety risk and personal rights violation to residents in care.

Storage Space: (a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement was not met evidenced by, during today's visit, it was revealed that resident # 1(R1) inhaled Lysol. This is immediate health and safety risk to residents in care.

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.

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.

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.

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.

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.

Based on medication record review, the licensee did not comply with the section cited above. Six (6) medication records were reviewed. Two (2) residents [R1 & R2] MAR records were not accurate. Medications were listed on Medication Administration Record (MAR), but staff stated the medications have not been re-ordered because medications should be discharged. Physician discharge orders were not observed.[(observation) (interview) (record review)], [count] out of [total count] [(objects) (persons)] [identifiers] which poses an immediate health, safety or personal rights risk to persons in care.

Based on physical plant observations the licensee did not comply with the section cited above. The facility main entrance does not have required COVID-19 signs posted at the entrance. Signs are not posted throughout the facility in common areas, hallways, and public restrooms to promote handwashing, cough/sneeze etiquette, and physical distancing. During resident room checks 11 out of 12 resident rooms, staff break room, and 3rd floor common area did not have hand sanitizer available for residents and/or staff. Housekeeping staff (S1) was passing through the main lobby area with a supply cart and was observed not wearing a mask. In addition, the majority of the residents walking or lounging in common areas were not wearing masks. This poses a potential health, safety or personal rights risk to persons in care.

87218(a)(3) Theft and Loss: The licensee shall ensure an adequate theft and loss program as specified in Health and Safety Code Section 1569.153. The facility contract of admission... shall not require or suggest a lesser standard of responsibility for the personal property of residents than the law requires. This requirement was not met as evidenced by... Based upon interviews and record review, the licensee did not ensure that the facility's Theft and Loss policy aligns with Title 22 requirements. This poses a potential risk for the personal rights of persons in care.