A list of the most recent deficiencies for Evergreen Nursing and Rehab 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? |
|---|---|---|---|---|
| Establish policies and procedures for volunteers. | Fire Safety | 2023-09-05 | 2023-09-25 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2023-09-05 | 2023-09-25 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-09-05 | 2023-09-25 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-05 | 2023-09-25 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-05 | 2023-09-25 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-09-01 | 2023-09-21 | 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 | 2023-09-01 | 2023-09-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-09-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-01 | 2023-09-21 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-09-01 | 2023-09-21 | 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 | 2023-01-11 | 2023-01-13 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-09-29 | 2022-10-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-29 | 2022-10-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-29 | 2022-10-24 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-09-29 | 2022-10-24 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-09-29 | 2022-10-24 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-09-29 | 2022-10-09 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-09-29 | 2022-10-03 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-02 | 2022-09-02 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-02 | 2022-09-02 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-02 | 2022-09-02 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-02 | 2022-09-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-20 | 2022-06-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-20 | 2022-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-18 | 2022-05-09 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-04-18 | 2022-05-07 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-18 | 2022-05-06 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-04-18 | 2022-05-06 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-04-18 | 2022-05-01 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2022-03-16 | 2022-04-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-10-26 | 2021-11-02 | Y |
| Install proper backup exit lighting. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2021-07-14 | 2021-07-23 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-07-14 | 2021-07-23 | 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 | 2021-07-15 | 2021-07-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-15 | 2021-07-21 | N |
