A list of the most recent deficiencies for Evenglow Lodge. 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? |
|---|---|---|---|---|
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2023-12-06 | 2024-01-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-12-06 | 2024-01-13 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-11-29 | 2023-12-21 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-29 | 2023-12-21 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-11-29 | 2023-12-21 | 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 | 2023-11-29 | 2023-12-21 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-11-29 | 2023-12-21 | 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 | 2023-11-29 | 2023-12-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-11-29 | 2023-12-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-11-29 | 2023-12-21 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-11-29 | 2023-12-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-11-29 | 2023-12-21 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-29 | 2023-12-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-11-29 | 2023-12-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-11-29 | 2023-12-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-09-23 | 2022-11-02 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-09-23 | 2022-10-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-20 | 2021-12-16 | N |
| Address patient/client population and determine types of services needed. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Provide emergency officials' contact information. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-02 | 2021-09-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-01 | 2021-09-17 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-09-01 | 2021-09-17 | 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 | 2021-09-01 | 2021-09-17 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-06-16 | 2021-07-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-16 | 2021-07-16 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-06-16 | 2021-07-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-06-16 | 2021-07-16 | Y |
