Deficiency Records for Evergreen Crossing and The Lofts
Updated as of June 01, 2020
This is not the most recent data for Evergreen Crossing and The Lofts. For the most recent information, click here.
A list of the most recent deficiencies for Evergreen Crossing and The Lofts. 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 | 2019-12-12 | 2020-01-10 | Y |
| Provide appropriate foot care. | Health | 2019-09-25 | 2019-10-21 | Y |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2019-09-25 | 2019-10-21 | Y |
| Provide and implement an infection prevention and control program. | Health | 2019-09-25 | 2019-10-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-04-04 | 2019-04-05 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-02-22 | 2019-03-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-02-22 | 2019-03-24 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2019-01-31 | 2019-03-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2019-01-31 | 2019-03-06 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2019-01-31 | 2019-03-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-01-31 | 2019-03-06 | N |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-01-09 | 2019-02-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-01-09 | 2019-02-08 | 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 | 2019-01-09 | 2019-02-08 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-01-09 | 2019-02-08 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-01-09 | 2019-02-08 | 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 | 2019-01-09 | 2019-02-08 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-01-09 | 2019-02-08 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-01-09 | 2019-02-08 | 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 | 2019-01-09 | 2019-02-08 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-01-09 | 2019-02-08 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2019-01-09 | 2019-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-09 | 2019-02-08 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-01-09 | 2019-02-08 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-05-03 | 2018-06-02 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2018-03-19 | 2018-03-20 | Y |
| Establish policies and procedures for volunteers. | Fire Safety | 2018-02-14 | 2018-03-16 | N |
| Establish roles under a Waiver declared by secretary. | Fire Safety | 2018-02-14 | 2018-03-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2018-02-14 | 2018-03-16 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2018-02-14 | 2018-03-16 | 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 | 2018-02-14 | 2018-03-16 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2018-02-14 | 2018-03-16 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2018-02-14 | 2018-03-16 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2018-01-25 | 2018-02-24 | 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 | 2018-01-25 | 2018-02-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2018-01-25 | 2018-02-24 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2018-01-25 | 2018-02-24 | 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 | 2018-01-25 | 2018-02-24 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2018-01-25 | 2018-02-24 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2018-01-25 | 2018-02-24 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-01-25 | 2018-02-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-01-25 | 2018-02-24 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-01-25 | 2018-02-24 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-01-25 | 2018-02-24 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-01-25 | 2018-02-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-01-25 | 2018-02-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-11-09 | 2017-11-10 | Y |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-11-09 | 2017-11-10 | Y |
| Ensure that residents are safe from serious medication errors. | Health | 2017-05-30 | 2017-06-12 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2017-05-25 | 2017-06-12 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-02-21 | 2017-03-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2017-02-21 | 2017-03-06 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2017-02-21 | 2017-03-06 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2017-02-21 | 2017-03-06 | N |
| Ensure residents have the right to have a choice over activities, their schedules, and health care according to their interests, assessments, and plans of care. | Health | 2017-02-02 | 2017-02-17 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2017-02-02 | 2017-02-17 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-02-02 | 2017-02-17 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-02-02 | 2017-02-17 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2017-02-02 | 2017-02-17 | N |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2017-02-02 | 2017-02-17 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-02-02 | 2017-02-17 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-02-02 | 2017-02-17 | N |
