Deficiency Records for Evergreen Crossing and The Lofts
Updated as of June 01, 2023
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 smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-02-27 | 2023-05-15 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2023-02-27 | 2023-05-15 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-02-27 | 2023-04-24 | 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 | 2023-02-27 | 2023-04-24 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-02-27 | 2023-04-24 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-03 | 2023-03-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-02-03 | 2023-03-07 | 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 | 2023-02-03 | 2023-03-07 | 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 | 2023-02-03 | 2023-03-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-03 | 2023-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-03 | 2023-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-03 | 2023-03-07 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Develop a communication plan. | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-08-22 | 2022-10-16 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-08-22 | 2022-10-14 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-08-22 | 2022-09-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-08-22 | 2022-09-02 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2022-08-22 | 2022-08-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-07-14 | 2022-08-10 | Y |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-07-14 | 2022-08-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-07-14 | 2022-08-10 | N |
| Provide appropriate foot care. | Health | 2022-07-14 | 2022-08-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-07-14 | 2022-08-10 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-07-14 | 2022-08-10 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-07-14 | 2022-08-10 | 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 | 2022-07-14 | 2022-08-10 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-07-14 | 2022-08-10 | 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 | 2022-07-14 | 2022-08-10 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2022-07-14 | 2022-08-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-07-14 | 2022-08-10 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2022-07-14 | 2022-08-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-07-14 | 2022-08-10 | 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 | 2022-07-14 | 2022-08-10 | Y |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Develop a communication plan. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Have corridors or aisles that are unobstructed and are at least 8 feet in width. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-02-28 | 2022-04-20 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-31 | 2022-03-14 | N |
| Honor the resident's right to manage his or her financial affairs. | Health | 2022-01-31 | 2022-03-07 | 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 | 2022-01-31 | 2022-03-07 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-31 | 2022-03-07 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-01-31 | 2022-03-07 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-01-31 | 2022-03-07 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-01-31 | 2022-03-07 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-01-31 | 2022-03-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-31 | 2022-03-07 | 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 | 2022-01-31 | 2022-03-07 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-01-31 | 2022-03-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-01-31 | 2022-03-07 | 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 | 2022-01-31 | 2022-03-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-01-31 | 2022-03-07 | N |
| Keep all essential equipment working safely. | Health | 2022-01-31 | 2022-03-07 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-01-31 | 2022-03-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-03 | 2022-03-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-31 | 2022-03-03 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-01-31 | 2022-03-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-01-31 | 2022-03-03 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-01-31 | 2021-12-22 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-10-25 | 2021-11-20 | 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 | 2021-10-25 | 2021-11-20 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-25 | 2021-11-20 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2021-10-25 | 2021-11-20 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-25 | 2021-11-20 | Y |
| 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 |
| 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 |
