Deficiency Records for Evergreen Commons Rehabilitation and Nursing Ctr
Updated as of March 01, 2024
A list of the most recent deficiencies for Evergreen Commons Rehabilitation and Nursing Ctr. 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 food/fluids to maintain a resident's health. | Health | 2023-04-04 | 2023-05-19 | Y |
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-09 | 2022-05-09 | 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 | 2021-09-01 | 2021-10-19 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-09-01 | 2021-10-19 | N |
Dispose of garbage and refuse properly. | Health | 2021-09-01 | 2021-10-19 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2021-09-01 | 2021-10-19 | N |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-09-01 | 2021-10-19 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2021-09-01 | 2021-10-19 | N |
Provide and implement an infection prevention and control program. | Health | 2021-07-30 | 2021-09-21 | N |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-04-22 | 2021-06-15 | Y |
Respond appropriately to all alleged violations. | Health | 2021-04-22 | 2021-06-15 | 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 | 2019-08-26 | 2019-10-25 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2019-08-26 | 2019-10-25 | 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 | 2019-08-26 | 2019-10-25 | N |
Dispose of garbage and refuse properly. | Health | 2019-08-26 | 2019-10-25 | N |
Provide and implement an infection prevention and control program. | Health | 2019-08-26 | 2019-10-25 | N |
Provide properly protected cooking facilities. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-26 | 2019-10-25 | N |
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2017-12-06 | 2018-01-31 | N |
Reasonably accommodate the needs and preferences of each resident. | Health | 2017-12-06 | 2018-01-31 | 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 | 2017-12-06 | 2018-01-31 | N |
Not hire anyone with a finding of abuse, neglect, exploitation, or theft. | Health | 2017-12-06 | 2018-01-31 | N |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2017-12-06 | 2018-01-31 | N |
Ensure each resident receives an accurate assessment. | Health | 2017-12-06 | 2018-01-31 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-12-06 | 2018-01-31 | N |
Provide enough food/fluids to maintain a resident's health. | Health | 2017-12-06 | 2018-01-31 | 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 | 2017-12-06 | 2018-01-31 | 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 | 2017-12-06 | 2018-01-31 | 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 | 2017-12-06 | 2018-01-31 | 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 | 2017-12-06 | 2018-01-31 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2017-12-06 | 2018-01-31 | 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 | 2017-12-06 | 2018-01-31 | N |
Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2017-12-06 | 2018-01-31 | N |
Provide and implement an infection prevention and control program. | Health | 2017-12-06 | 2018-01-31 | N |
Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-12-06 | 2018-01-31 | N |
Have an enclosure around a vertical opening shaft. | Fire Safety | 2017-12-06 | 2018-01-31 | N |
Install an approved automatic sprinkler system. | Fire Safety | 2017-12-06 | 2018-01-31 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-12-06 | 2018-01-31 | N |
Ensure proper usage of power strips and extension cords. | Fire Safety | 2017-12-06 | 2018-01-31 | N |