EVERGREEN POST ACUTE

SMYRNA, DE · 151 beds · For profit - Limited Liability company

5 Trust Score
Grade: F CRITICAL Risk → Stable

Red Flags

  • 5 citation(s) where residents suffered actual harm
  • $94,156 in fines
  • RN hours significantly below state average

Green Flags

No positive signals identified yet.

Quick Facts

★★★☆☆
CMS Overall
★★☆☆☆
Health Inspection
23
1.7x state avg
Deficiencies
$94,156
Fines (3-yr)
★★★☆☆
Staffing

Violation Timeline

April 16, 2025

20 deficiencyies
F0578 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

F0582 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

F0603 Potential Harm Scope/Severity: D

Freedom from Abuse, Neglect, and Exploitation Deficiencies

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Protect each resident from separation (from other residents, his/her room, or confinement to his/her room).

F0623 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

F0637 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Assess the resident when there is a significant change in condition

F0660 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Plan the resident's discharge to meet the resident's goals and needs.

F0760 Actual Harm Scope/Severity: G

Pharmacy Service Deficiencies

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Ensure that residents are free from significant medication errors.

F0550 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

F0583 Potential Harm Scope/Severity: D

Resident Rights Deficiencies

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Keep residents' personal and medical records private and confidential.

F0584 Potential Harm Scope/Severity: E

Resident Rights Deficiencies

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Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

F0641 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Ensure each resident receives an accurate assessment.

F0676 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0677 Potential Harm Scope/Severity: D

Quality of Life and Care Deficiencies

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

F0761 No Harm Scope/Severity: B

Pharmacy Service Deficiencies

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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 locked, compartments for controlled drugs.

F0808 Potential Harm Scope/Severity: D

Nutrition and Dietary Deficiencies

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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.

F0812 Potential Harm Scope/Severity: E

Nutrition and Dietary Deficiencies

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Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

F0881 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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Implement a program that monitors antibiotic use.

F0883 Potential Harm Scope/Severity: D

Infection Control Deficiencies

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

F0656 Potential Harm Scope/Severity: D

Resident Assessment and Care Planning Deficiencies

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Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

F0657 Potential Harm Scope/Severity: E

Resident Assessment and Care Planning Deficiencies

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Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

See full violation history →

Staffing

0.51
RN hrs/res/day
0.98
LPN hrs/res/day
2.54
CNA hrs/res/day
3.73
Weekend hrs/res/day
50%
Total nurse turnover
68%
RN turnover

A nurse checks on each resident roughly every 6.0 hours on average.

Fines & Penalties

  • Fine Apr 16, 2025
    $17,345
  • Fine May 29, 2024
    $76,811
Total $94,156

Ownership

For profit - Limited Liability company Chain: PRESTIGE HEALTHCARE ADMINISTRATIVE SERVICES
  • EVPA HOLDINGS LLC

    5% OR GREATER DIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    100% Organization
  • COPPER DE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    NO PERCENTAGE PROVIDED Organization
  • GOLD DE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    NO PERCENTAGE PROVIDED Organization
  • SILVER DE TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    NO PERCENTAGE PROVIDED Organization
  • STAR DE I HOLDINGS LLC

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    NO PERCENTAGE PROVIDED Organization
  • STAR DE I TRUST

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    NO PERCENTAGE PROVIDED Organization
  • ELLENBOGEN, MOSS

    5% OR GREATER INDIRECT OWNERSHIP INTEREST

    Since since 02/01/2025

    NO PERCENTAGE PROVIDED Individual
  • RASTOGI, RITU

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    Individual
  • ROCHESTER, JESSICA

    OPERATIONAL/MANAGERIAL CONTROL

    Since since 01/01/2025

    Individual

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