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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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