Deficiency Records for Evergreen Commons Rehabilitation and Nursing Ctr
Updated as of June 01, 2019
This is not the most recent data for Evergreen Commons Rehabilitation and Nursing Ctr. For the most recent information, click here.
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? |
|---|---|---|---|---|
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2017-12-06 | 2018-01-31 | N |
| Have protected exits that allow the resident to escape the building. | 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 |
| 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 |
| 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 ne | 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 |
| 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 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-03-09 | 2017-04-27 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-03-09 | 2017-04-27 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-03-09 | 2017-04-27 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2017-03-09 | 2017-04-27 | Y |
| Develop a post-discharge plan with the resident and family for the resident's care after leaving the nursing home. | Health | 2017-03-09 | 2017-04-27 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-03-09 | 2017-04-27 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-09 | 2017-04-27 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-03-09 | 2017-04-27 | Y |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2017-03-09 | 2017-04-27 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-09 | 2017-04-27 | Y |
| Proper stairway enclosures and vertical shafts. | Fire Safety | 2016-07-29 | 2016-09-12 | N |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2016-07-29 | 2016-09-12 | N |
| Record of quarterly fire drills for each shift under varying conditions. | Fire Safety | 2016-07-29 | 2016-09-12 | N |
| An approved automatic sprinkler system connected to the fire alarm system. | Fire Safety | 2016-07-29 | 2016-09-12 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-07-29 | 2016-09-12 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2016-07-29 | 2016-09-12 | N |
| Provide housekeeping and maintenance services. | Health | 2016-07-29 | 2016-09-12 | N |
| Coordinate assessments with the pre-admission screening and resident review program for mentally-ill and mentally-retarded patients. | Health | 2016-07-29 | 2016-09-12 | N |
| Ensure residents maintain acceptable nutritional status. | Health | 2016-07-29 | 2016-09-12 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-07-29 | 2016-09-12 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2016-07-29 | 2016-09-12 | N |
| Make sure that the facility is administered in an acceptable way that maintains the well-being of each resident . | Health | 2016-07-29 | 2016-09-12 | N |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2016-07-29 | 2016-09-12 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-07-29 | 2016-09-12 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-07-29 | 2016-09-12 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2016-07-29 | 2016-09-12 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-07-29 | 2016-09-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-07-29 | 2016-09-12 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-07-29 | 2016-09-12 | Y |
| Walls that prevent smoke from passing through and would resist fire for at least one hour. | Fire Safety | 2015-06-04 | 2015-07-13 | N |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2015-06-04 | 2015-07-13 | N |
| Provide housekeeping and maintenance services. | Health | 2015-06-04 | 2015-07-13 | N |
| Ensure each resident receives an accurate assessment by a qualified health professional. | Health | 2015-06-04 | 2015-07-13 | N |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2015-06-04 | 2015-07-13 | N |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2015-06-04 | 2015-07-13 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2015-06-04 | 2015-07-13 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2015-06-04 | 2015-07-13 | N |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2015-06-04 | 2015-07-13 | N |
