A list of the most recent deficiencies for Evergreen Nursing Home. 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? |
|---|---|---|---|---|
| Use approved construction type or materials. | Fire Safety | 2023-02-28 | 2023-03-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-28 | 2023-03-23 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-02-28 | 2023-03-22 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-28 | 2023-03-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-28 | 2023-03-21 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-28 | 2023-03-21 | 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 | 2023-02-28 | 2023-03-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-28 | 2023-03-20 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-02 | 2023-03-16 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-02-02 | 2023-03-03 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-02-02 | 2023-03-03 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-02-02 | 2023-03-03 | N |
| Establish methods for sharing information. | Fire Safety | 2023-02-02 | 2023-03-03 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-02-02 | 2023-03-03 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2023-02-02 | 2023-02-24 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-02-02 | 2023-02-24 | N |
| Use approved construction type or materials. | Fire Safety | 2021-11-09 | 2022-02-15 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-09 | 2022-01-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-09 | 2022-01-17 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2021-11-09 | 2021-12-28 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-11-09 | 2021-11-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-09 | 2021-11-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-11-09 | 2021-11-22 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2021-10-21 | 2021-11-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-11-09 | 2021-11-11 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-10-21 | 2021-11-08 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-10-21 | 2021-11-05 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2021-10-21 | 2021-11-05 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-10-21 | 2021-11-05 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-06-27 | 2019-07-31 | 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 | 2019-07-15 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-06-04 | 2019-07-05 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-06-27 | 2019-06-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-06-27 | 2019-06-28 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-06-04 | 2019-06-24 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2019-06-04 | 2019-06-19 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-06-04 | 2019-06-17 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-06-04 | 2019-06-05 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-06-04 | 2019-06-05 | N |
