A list of the most recent deficiencies for Evergreen Healthcare Center. 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 | 2023-01-18 | 2023-02-14 | 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 | 2023-01-18 | 2023-02-14 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-01-18 | 2023-02-14 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-01-18 | 2023-02-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-01-18 | 2023-02-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-18 | 2023-02-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-01-18 | 2023-02-14 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-18 | 2023-02-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-01-18 | 2023-02-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-18 | 2023-02-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-01-18 | 2023-02-14 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-12-28 | 2023-02-14 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-27 | 2022-05-13 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-27 | 2022-05-13 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-02-28 | 2022-03-24 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-21 | 2022-01-21 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-12-21 | 2022-01-21 | 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 | 2021-12-21 | 2022-01-21 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-12-21 | 2022-01-21 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-21 | 2022-01-21 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2021-12-21 | 2022-01-21 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-21 | 2022-01-21 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-12-21 | 2022-01-21 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-12-21 | 2022-01-21 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-11-02 | 2021-11-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-02 | 2021-11-26 | Y |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2021-03-18 | 2021-04-13 | 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 | 2021-03-18 | 2021-04-13 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-03-18 | 2021-04-13 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2019-06-24 | 2019-07-26 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-06-24 | 2019-07-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-06-24 | 2019-07-26 | N |
