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Deficiency Records for Evergreen Post Acute
A list of the most recent deficiencies for Evergreen Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Evergreen Post Acute. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-30 | 2024-07-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-05-30 | 2024-07-24 | N |
| 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. | Health | 2024-05-30 | 2024-07-24 | N |
| 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. | Health | 2024-05-30 | 2024-07-24 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-05-30 | 2024-07-24 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2024-05-30 | 2024-07-24 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2024-05-30 | 2024-07-24 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-05-30 | 2024-07-24 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-05-30 | 2024-07-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-05-30 | 2024-07-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2024-05-30 | 2024-07-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-05-30 | 2024-07-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-05-30 | 2024-07-24 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-30 | 2024-07-24 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2024-05-30 | 2024-07-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2024-05-30 | 2024-07-24 | N |
| 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. | Health | 2024-05-30 | 2024-07-24 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2024-05-30 | 2024-07-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-30 | 2024-07-24 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-30 | 2024-07-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-05-30 | 2024-07-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-06-20 | 2024-07-24 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-06-20 | 2024-07-24 | N |
| 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. | Health | 2023-04-11 | 2023-05-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-04-11 | 2023-05-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-11 | 2023-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-11 | 2023-05-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-04-11 | 2023-05-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-04-11 | 2023-05-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-04-11 | 2023-05-19 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-11 | 2023-05-19 | N |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2023-04-11 | 2023-05-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-11 | 2023-05-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-04-11 | 2023-05-19 | N |
| 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. | Health | 2023-04-11 | 2023-05-19 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-19 | 2023-02-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-19 | 2023-02-20 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2022-11-07 | 2022-12-21 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-07 | 2022-12-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-07 | 2022-12-21 | Y |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2022-11-07 | 2022-12-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-11-07 | 2022-12-21 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-11-07 | 2022-12-21 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2020-01-17 | 2020-02-13 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-01-17 | 2020-02-13 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2020-01-17 | 2020-02-13 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2020-01-17 | 2020-02-13 | N |
| Provide activities to meet all resident's needs. | Health | 2020-01-17 | 2020-02-13 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2020-01-17 | 2020-02-13 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-01-17 | 2020-02-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-01-17 | 2020-02-13 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2020-01-17 | 2020-02-13 | N |
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