A list of the most recent deficiencies for Evergreen Manor Senior Care Ce. 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? |
|---|---|---|---|---|
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-10-11 | 2023-10-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-22 | 2023-06-01 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-22 | 2023-06-01 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-22 | 2023-06-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-22 | 2023-06-01 | 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 | 2022-12-13 | 2023-01-11 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-14 | 2023-01-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-12-14 | 2023-01-11 | 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 | 2022-12-13 | 2023-01-10 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-12-13 | 2023-01-10 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-12-13 | 2023-01-10 | 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 | 2022-12-13 | 2023-01-10 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-12-13 | 2023-01-10 | N |
| Ensure each resident receives an accurate assessment. | Health | 2021-09-23 | 2021-10-27 | 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 | 2021-09-23 | 2021-10-27 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-23 | 2021-10-27 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-09-30 | 2021-10-27 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2019-09-18 | 2019-12-04 | 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 | 2019-09-18 | 2019-10-15 | 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 | 2019-09-18 | 2019-10-15 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2019-09-18 | 2019-10-15 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2019-09-18 | 2019-10-15 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-09-18 | 2019-10-15 | N |
| Respond appropriately to all alleged violations. | Health | 2019-09-18 | 2019-10-15 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-09-18 | 2019-10-15 | 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 | 2019-09-18 | 2019-10-15 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2019-09-18 | 2019-10-15 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-18 | 2019-10-15 | 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 | 2019-09-18 | 2019-10-15 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-09-18 | 2019-10-15 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-09-18 | 2019-10-15 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2019-09-18 | 2019-10-15 | 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 | 2019-09-18 | 2019-10-15 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-09-18 | 2019-10-15 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-09-18 | 2019-10-15 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-09-18 | 2019-10-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-11 | 2019-10-15 | N |
