Aging and People with Disabilities
Safety, Oversight and Quality
Print Violation: CALMS - 00080700
Provider Information
Evergreen Senior Living Community
3760 N CLAREY ST
Eugene, OR 97402
- Provider ID
- 70M202
- Administrator
- Alisha Rocha-Hills
- Phone
- (541) 607-9525
- ed@evergreensl.com
Violation Details
- Date
- 4/29/2025
- Report number
- CALMS - 00080700
- Type
- Licensing Violation
- Level
- 3 - Moderate harm or potential for serious harm
- Allegation
- Failed to provide oversight and monitoring of change of condition
- Result
- Substantiated
- Findings
- Based on interview and record review, conducted during a site visit on 05/07/25, the facility's failure to document the change, and update the service plan when a resident experiences a change of condition; and ensure a resident monitoring and reporting system is implemented 24-hours a day was substantiated for 1 of 1 sampled residents (#1). Resident 1 experienced sepsis (life-threatening bodily response to an infection) associated with the worsening of a toenail wound. Findings include but are not limited to: During a Compliance Specialist's (CS) onsite visit on 05/07/25, Resident 1 was out of the facility at the local hospital. The CS was unable to interview Resident 1 or make observations during the site visit. During the entrance conference with Staff 1, Staff 2, and Staff 3, they stated Resident 1 was at the local hospital for a right toe amputation. Resident 1’s progress notes revealed the following: - On 11/29/24, the resident had part of his/her toenail, and some infection removed. - On 12/26/24, Resident 1's toe appeared to have worsened since the last visualization. Slough to wound bed, antibiotics completed. Resident continues to verbalize pain at the site; wound care provided. The resident started Home Health for wound care. - On 01/02/25, “The resident’s toe does not appear worse since the last visualization.” The LPN had not used descriptive words to indicate if the toe had gotten better or worsened in the observation note. - The LPN noted, 02/05/25, in the residents’ quarterly evaluation, “Wound to toe was reported. [S/He] was followed by home health (HH), was seen by providers, and eventually an angioplasty was done to promote circulation, wound healing. That showed a marked improvement to the toe wound. Report any of the following to the RN, RCC, and administrator immediately. Any changes, including new rashes, skin tears, cuts, abrasions, bruises, or discomfort. Report any safety concerns, any new pain or increase in pain, please include the type of pain and location." - On 03/06/25, the resident's toe continues to improve since the last visualization and appears resolved at that time. Appears to be a small area near and under the toenail, scabbed area resolved, just appears to be thickened, dry, and slightly darker in appearance, no signs of infection. On 01/06/24 resident had angioplasty, which was due to try and improve circulation and promote wound healing. S/He reported a recent f/u about that, and the provider had told him/her the toe was healed. No longer needs License Nurse following. Discussed notifying staff if painful, worsening or any infection. Will continue to monitor as needed. - On 03/18/25, indicated the Resident Care Coordinator sent two pictures via text as requested by Resident 1’s family member regarding the right toe. - On 03/27/25, the resident was seen for “left [actually right] great toenail" removal. - On 04/24/25, Resident recently had the “left [right] great toenail” removed. Staff soaking and bandage per orders, see EMAR. No signs of infection, no reports of worsening or increased pain. “Less than 1 cm area remains, appears fragile, and is likely still open. Appears to be healing appropriately, is followed by a podiatrist for wound healing. Likely to be resolved within the next week or two.” Will continue to monitor and support as needed. - On 04/29/25 at 11:58 am, the LPN noted, after speaking with the med tech, it had come to our attention that the treatment was not done, and s/he had not known how to correct the incorrect documentation. S/he ran out of time and was unable to do the treatment on 04/26/25. - On 04/29/25, the resident was sent to the hospital to be evaluated, running a 102 Fahrenheit fever. - On 04/30/25, Resident 1 was placed on alert for a wound to her right big toe. The wound had increasingly gotten worse over the last five days; and the resident was admitted to the hospital for sepsis. A review of Resident 1’s current service plan, dated 02/05/25, revealed the following: - Soak the right foot in Epsom Salt for 10 minutes. after soaking, cover the wound with Betadine ointment and dress with a loose band-aid twice daily at 9:00 am and 8:00 pm; and change the toe dressing, clean with saline, alcohol wipes, or wound spray, pat dry, apply a small amount of antibiotic ointment, cover and wrap the toe twice daily at 8:00 am and 8:00 pm. - A temporary service plan (TSP) dated 03/28/25, noted the removal of the right toenail. Instructions stated to monitor “Bleeding, pain, signs of infection, change in gait, and discoloration.” - A treatment order, dated 03/27/25, to soak the toe in warm water with very diluted Epsom salt for 10 minutes twice daily for one week, then switch to once-a-day soaks until drainage stops. Massage the toe after soaks to help decrease scab formation. Apply betadine ointment to the area and cover with a loose band-aid. The treatment order had not been correctly transcribed into the Treatment Administration Records (TARs). Resident 1’s TARs for April 2025 instructed staff to draw hot water into a basin, lightly dilute with Epsom salt, and soak the right foot uncovered for 10 minutes. After soaking, cover the wound with betadine ointment and dress with a loose band-aid or non-stick adhesive with medical tape. Keep dressing on for the first minute of soak, twice daily. - The treatment was not completed for 11 out of 18 occurrences between 04/11/25 until hospitalization on 4/29/25. - A treatment order, dated 04/16/25, directed the facility to soak the right foot in an Epsom salt bath, apply betadine ointment, and band-aid once daily. The treatment order had not been added to the TARs. During an interview on 05/07/25, Staff 4 and Staff 8 stated Staff 9 marked the TARs as having completed treatment for soaking Resident 1’s toe on 04/26/25; however, indicated Staff 9 had not completed the treatment. The facility's failed to ensure a resident monitoring and reporting system was implemented 24-hours a day was substantiated. The facility failed to monitor that treatments were provided as ordered and failed to accurately document on the status of Resident 1's toe. As a result, the toenail area worsened, and Resident 1 was hospitalized with sepsis. The facility failed to document Resident 1's change of condition and failed to update the service plan when a Resident 1 experienced a change of condition; and failed to ensure a resident monitoring and reporting system is implemented 24-hours a day is violation of Oregon Administrative Rules.