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Deficiency Records for Evergreen Healthcare Center
A list of the most recent deficiencies for Evergreen Healthcare Center. 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 Healthcare Center. 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? |
---|---|---|---|---|
Provide enough food/fluids to maintain a resident's health. | Health | 2023-01-18 | 2023-02-14 | 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 | 2023-01-18 | 2023-02-14 | N |
Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-18 | 2023-02-14 | N |
Implement a program that monitors antibiotic use. | Health | 2023-01-18 | 2023-02-14 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-18 | 2023-02-14 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-18 | 2023-02-14 | Y |
Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-02-14 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-02-14 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-02-14 | Y |
Ensure that residents are free from significant medication errors. | Health | 2023-01-18 | 2023-02-14 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-02-14 | Y |
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-27 | 2022-05-13 | Y |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-27 | 2022-05-13 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-02-28 | 2022-03-24 | Y |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-21 | 2022-01-21 | N |
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-21 | 2022-01-21 | N |
Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2021-12-21 | 2022-01-21 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-21 | 2022-01-21 | N |
Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-21 | 2022-01-21 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-21 | 2022-01-21 | N |
Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-21 | N |
Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-21 | 2022-01-21 | N |
Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-02 | 2021-11-26 | Y |
Respond appropriately to all alleged violations. | Health | 2021-11-02 | 2021-11-26 | Y |
Conduct testing and exercise requirements. | Fire Safety | 2019-06-24 | 2019-07-26 | N |
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-24 | 2019-07-26 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-24 | 2019-07-26 | N |
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