Deficiency Records for Evergreen Crossing and The Lofts
Updated as of November 01, 2021
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? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-10 | 2021-09-14 | Y |
| 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 | 2021-09-10 | 2021-09-14 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-09-10 | 2021-09-14 | 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 | 2021-09-10 | 2021-09-14 | Y |
| 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 | 2021-09-10 | 2021-09-14 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-07-23 | 2021-09-14 | Y |
| 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 | 2021-07-23 | 2021-09-14 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-07-23 | 2021-08-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-07-23 | 2021-08-21 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-07-23 | 2021-08-21 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-02-24 | 2021-03-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-02-24 | 2021-03-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-02-24 | 2021-03-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-02-24 | 2021-03-23 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-02-18 | 2021-03-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-11-07 | 2020-11-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-20 | 2020-11-19 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2020-08-17 | 2020-09-11 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2020-08-17 | 2020-09-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2020-08-17 | 2020-09-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2020-08-17 | 2020-09-11 | Y |
| Provide properly protected cooking facilities. | Fire Safety | 2020-08-10 | 2020-08-20 | N |
| Have an externally vented heating system. | Fire Safety | 2020-08-10 | 2020-08-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-08-17 | 2020-08-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2020-03-09 | 2020-06-30 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2020-03-09 | 2020-06-30 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-03-09 | 2020-06-30 | N |
| Ensure each resident receives an accurate assessment. | Health | 2020-03-09 | 2020-06-30 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2020-03-09 | 2020-06-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2020-03-09 | 2020-06-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2020-03-09 | 2020-06-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2020-03-09 | 2020-06-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2020-03-09 | 2020-06-30 | 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 | 2020-03-09 | 2020-06-30 | 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 | 2020-03-09 | 2020-06-30 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2020-03-09 | 2020-06-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2020-03-09 | 2020-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-03-09 | 2020-06-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-05-14 | 2020-06-29 | Y |
| 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 |
| 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 appropriate pressure ulcer care and prevent new ulcers from developing. | 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 |
