Deficiency Records for Evergreen Health and Rehabilitation Center
Updated as of May 01, 2024
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Deficiency Records for Evergreen Health and Rehabilitation Center
A list of the most recent deficiencies for Evergreen Health and Rehabilitation Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Evergreen Health and Rehabilitation 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? |
|---|---|---|---|---|
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-02-28 | 2024-03-26 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2024-01-10 | 2024-02-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-01-10 | 2024-02-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2024-01-10 | 2024-02-19 | 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 | 2024-01-10 | 2024-02-19 | N |
| Ensure each resident receives an accurate assessment. | Health | 2024-01-10 | 2024-02-19 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-01-10 | 2024-02-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide appropriate foot care. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2024-01-10 | 2024-02-19 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2024-01-10 | 2024-02-19 | N |
| Post nurse staffing information every day. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-01-10 | 2024-02-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-01-10 | 2024-02-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-01-10 | 2024-02-19 | N |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2024-01-10 | 2024-02-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-01-10 | 2024-02-19 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2024-01-10 | 2024-02-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-01-10 | 2024-02-19 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2024-01-10 | 2024-02-19 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-04-25 | 2023-06-19 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-25 | 2023-06-19 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-04-25 | 2023-05-26 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-04-25 | 2023-05-26 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-04-25 | 2023-05-26 | 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 | 2023-04-25 | 2023-05-26 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-04-25 | 2023-05-26 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-04-25 | 2023-05-26 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-04-14 | 2022-05-16 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-04-14 | 2022-05-16 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2022-04-14 | 2022-05-16 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-04-14 | 2022-05-16 | 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 | 2022-04-14 | 2022-05-16 | N |
| Ensure each resident receives an accurate assessment. | Health | 2022-04-14 | 2022-05-16 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-14 | 2022-05-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-14 | 2022-05-16 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-14 | 2022-05-16 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-14 | 2022-05-16 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-04-14 | 2022-05-16 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2022-04-14 | 2022-05-16 | N |
| Post nurse staffing information every day. | Health | 2022-04-14 | 2022-05-16 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-04-14 | 2022-05-16 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-04-14 | 2022-05-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-14 | 2022-05-16 | N |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-04-14 | 2022-05-16 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-07-14 | 2021-08-02 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-06-15 | 2021-08-02 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-07-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-15 | 2021-07-05 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-04-25 | 2019-06-21 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-04-25 | 2019-06-21 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-25 | 2019-06-21 | N |
| 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 | 2019-05-14 | 2019-06-11 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-05-14 | 2019-06-11 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2019-04-25 | 2019-05-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2019-04-25 | 2019-05-28 | N |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2019-04-25 | 2019-05-28 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-04-25 | 2019-05-28 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-04-25 | 2019-05-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2019-04-25 | 2019-05-28 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2019-04-25 | 2019-05-28 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2019-04-25 | 2019-05-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-04-25 | 2019-05-28 | 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 | 2019-04-25 | 2019-05-28 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-25 | 2019-05-28 | 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 | 2019-04-25 | 2019-05-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-04-25 | 2019-05-28 | N |
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