Deficiency Records for Evergreen Commons Rehabilitation and Nursing Ctr

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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