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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 | 2024-09-19 | 2024-10-03 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-10-23 | 2023-11-29 | 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 | 2023-10-23 | 2023-11-29 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-23 | 2023-11-29 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-23 | 2023-11-29 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-10-23 | 2023-11-29 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-10-23 | 2023-11-29 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-10-23 | 2023-11-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-10-23 | 2023-11-29 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-10-24 | 2023-11-29 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-10-24 | 2023-11-29 | 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 | 2023-04-24 | 2023-05-24 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-08-15 | 2022-09-22 | 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 | 2022-08-15 | 2022-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-08-15 | 2022-09-22 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-15 | 2022-09-22 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-08-15 | 2022-09-22 | N |
| Post nurse staffing information every day. | Health | 2022-08-15 | 2022-09-22 | 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 | 2022-08-15 | 2022-09-22 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-08-15 | 2022-09-22 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-15 | 2022-09-22 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-15 | 2022-09-22 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-15 | 2022-09-22 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2022-08-09 | 2022-09-22 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-12-29 | 2022-02-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-12-29 | 2022-02-01 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-29 | 2022-02-01 | Y |
| Post nurse staffing information every day. | Health | 2021-12-29 | 2022-02-01 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-06-04 | 2019-07-16 | 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 | 2019-06-04 | 2019-07-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-06-04 | 2019-07-16 | N |
| Respond appropriately to all alleged violations. | Health | 2019-06-04 | 2019-07-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-06-04 | 2019-07-16 | 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 | 2019-06-04 | 2019-07-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-06-04 | 2019-07-16 | 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 | 2019-06-04 | 2019-07-16 | N |
| Provide activities to meet all resident's needs. | Health | 2019-06-04 | 2019-07-16 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-06-04 | 2019-07-16 | N |
| 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 | 2019-06-04 | 2019-07-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-04 | 2019-07-16 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-06-04 | 2019-07-16 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2019-06-04 | 2019-07-16 | 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 | 2019-06-04 | 2019-07-16 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-06-04 | 2019-07-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-06-04 | 2019-07-16 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2019-05-31 | 2019-07-16 | 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 | 2019-05-31 | 2019-07-16 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-31 | 2019-07-16 | N |
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