Facility Watch Inspection records for every certified US nursing home

Evergreen Post Acute

3034 South Dupont Blvd
Smyrna, DE 19977
(302) 653-5085

CCN
085020
Certified beds
151
Ownership
For profit - Limited Liability company
Chain
Prestige Healthcare Administrative Services

Nurse staffing

3.69
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.46 hours per resident per day

Nursing staff turnover: 52% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 17, 2025

23 citations · from a complaint investigation · Health
B
F0761 No actual harm with potential for minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0578 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0582 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0603 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0623 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0637 No actual harm with potential for more than minimal harm · Isolated

Assess the resident when there is a significant change in condition

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0656 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0660 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0676 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0677 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0808 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0881 No actual harm with potential for more than minimal harm · Isolated

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected June 3, 2025
D
F0883 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected June 3, 2025
E
F0584 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected June 3, 2025
E
F0657 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected June 3, 2025
E
F0812 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected June 3, 2025
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected June 3, 2025
G
F0760 Actual harm · Isolated

Ensure that residents are free from significant medication errors.

Past Non-Compliance · corrected September 18, 2024

Inspected January 14, 2025

2 citations · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected January 22, 2025
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected January 22, 2025

Inspected May 30, 2024

27 citations · from a complaint investigation · Health
D
F0550 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0578 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0585 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0610 No actual harm with potential for more than minimal harm · Isolated

Respond appropriately to all alleged violations.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0641 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0644 No actual harm with potential for more than minimal harm · Isolated

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0645 No actual harm with potential for more than minimal harm · Isolated

PASARR screening for Mental disorders or Intellectual Disabilities

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0656 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0677 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0711 No actual harm with potential for more than minimal harm · Isolated

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0756 No actual harm with potential for more than minimal harm · Isolated

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0757 No actual harm with potential for more than minimal harm · Isolated

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0773 No actual harm with potential for more than minimal harm · Isolated

Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results.

Deficient, Provider has date of correction · corrected July 24, 2024
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0657 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected July 24, 2024
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 24, 2024
F
F0812 No actual harm with potential for more than minimal harm · Widespread

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

Deficient, Provider has date of correction · corrected July 24, 2024
G
F0686 Actual harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected July 24, 2024
G
F0689 Actual harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected July 24, 2024
G
F0690 Actual harm · Isolated

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected July 24, 2024
G
F0692 Actual harm · Isolated

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected July 24, 2024

Inspected April 11, 2023

12 citations · Health
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0623 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0677 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0684 No actual harm with potential for more than minimal harm · Isolated

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

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0698 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0730 No actual harm with potential for more than minimal harm · Isolated

Observe each nurse aide's job performance and give regular training.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0759 No actual harm with potential for more than minimal harm · Isolated

Ensure medication error rates are not 5 percent or greater.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0760 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are free from significant medication errors.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0790 No actual harm with potential for more than minimal harm · Isolated

Provide routine and 24-hour emergency dental care for each resident.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected May 19, 2023
D
F0887 No actual harm with potential for more than minimal harm · Isolated

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Deficient, Provider has date of correction · corrected May 19, 2023
E
F0812 No actual harm with potential for more than minimal harm · Pattern

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

Deficient, Provider has date of correction · corrected May 19, 2023

Penalties

DateTypeAmount
April 17, 2025Fine$17,345
May 30, 2024Fine$76,811

Ownership transfers

EffectiveSellerBuyer
02/01/2025Green Valley SNF LLCEvergreen Post Acute LLC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.