Deficiency Records for Evergreen Commons Rehabilitation and Nursing Ctr
Updated as of April 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? |
|---|---|---|---|---|
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-11 | 2024-03-05 | N |
| Keep all essential equipment working safely. | Health | 2024-01-11 | 2024-03-05 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2024-01-11 | 2024-03-05 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-11 | 2024-03-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-11 | 2024-03-05 | 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 | 2024-01-11 | 2024-02-15 | 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 | 2024-01-11 | 2024-02-12 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-11 | 2024-02-08 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-11 | 2024-02-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-11 | 2024-01-11 | N |
| 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 |
