A list of the most recent deficiencies for Avantara Evergreen Park. 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? |
|---|---|---|---|---|
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-02-09 | 2024-02-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-02-09 | 2024-02-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-11-30 | 2023-12-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-28 | 2023-10-09 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-06 | 2023-09-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-06 | 2023-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-06-06 | 2023-09-23 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2023-06-06 | 2023-09-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-06 | 2023-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-06-06 | 2023-09-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-21 | 2023-09-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-15 | 2023-07-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-06 | 2023-06-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-06 | 2023-06-23 | 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 | 2023-04-06 | 2023-04-28 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-06 | 2023-04-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-04-06 | 2023-04-28 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2023-04-06 | 2023-04-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-04-06 | 2023-04-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-06 | 2023-04-28 | 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 | 2023-04-06 | 2023-04-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-04-06 | 2023-04-28 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-04-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-04-06 | 2023-04-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Install proper backup exit lighting. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-04-12 | 2023-04-28 | 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 | 2023-04-12 | 2023-04-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-04-12 | 2023-04-28 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-02-09 | 2023-02-24 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-02-09 | 2023-02-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-09 | 2023-02-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-09 | 2023-02-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-10-13 | 2022-10-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-13 | 2022-10-26 | Y |
| Provide routine and 24-hour emergency dental care for each resident. | Health | 2022-10-13 | 2022-10-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-07-11 | 2022-07-25 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-14 | 2022-06-22 | 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 | 2022-06-14 | 2022-06-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2022-06-14 | 2022-06-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-05-13 | 2022-05-20 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-05-13 | 2022-05-20 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2022-05-13 | 2022-05-20 | 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 | 2022-05-13 | 2022-05-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-05-13 | 2022-05-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-13 | 2022-05-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-05-13 | 2022-05-20 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-05-13 | 2022-05-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-05-13 | 2022-05-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-05-13 | 2022-05-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-05-13 | 2022-05-20 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-23 | 2022-03-01 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-01-23 | 2022-03-01 | Y |
| Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident?s advance directives. | Health | 2022-01-23 | 2022-03-01 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-23 | 2022-03-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-23 | 2022-03-01 | 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 | 2022-01-23 | 2022-03-01 | Y |
| 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 | 2022-01-23 | 2022-03-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-23 | 2022-03-01 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-10-27 | 2021-11-01 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-10-12 | 2021-10-15 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-12 | 2021-10-15 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-07-18 | 2021-07-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-05-27 | 2021-06-02 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-05-27 | 2021-06-02 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-05-27 | 2021-06-02 | Y |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2021-05-27 | 2021-06-02 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-04-27 | 2021-05-27 | Y |
| Allow resident to participate in the development and implementation of his or her person-centered plan of care. | Health | 2021-04-05 | 2021-04-07 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2021-04-05 | 2021-04-07 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-04-05 | 2021-04-07 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-04-05 | 2021-04-07 | Y |
| Report COVID19 data to residents and families. | Health | 2021-04-05 | 2021-04-07 | Y |
| Address subsistence needs for staff and patients. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Establish policies and procedures for sheltering. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Implement emergency and standby power systems. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-02-07 | 2020-02-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-02-06 | 2020-02-20 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2020-02-06 | 2020-02-20 | N |
