A list of the most recent deficiencies for Everett 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 nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-12-29 | 2024-01-26 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-12-29 | 2024-01-26 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-09-20 | 2023-11-23 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-09-20 | 2023-10-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-09-20 | 2023-10-18 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-20 | 2023-10-18 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-20 | 2023-10-18 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-09-20 | 2023-10-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-20 | 2023-10-18 | N |
| Provide activities to meet all resident's needs. | Health | 2023-09-20 | 2023-10-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-20 | 2023-10-18 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-09-20 | 2023-10-18 | N |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2023-09-20 | 2023-10-18 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-09-20 | 2023-10-18 | N |
| Observe each nurse aide's job performance and give regular training. | Health | 2023-09-20 | 2023-10-18 | N |
| Post nurse staffing information every day. | Health | 2023-09-20 | 2023-10-18 | N |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2023-09-20 | 2023-10-18 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2023-09-20 | 2023-10-18 | N |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2023-09-20 | 2023-10-18 | N |
| Provide or obtain dental services for each resident. | Health | 2023-09-20 | 2023-10-18 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2023-09-20 | 2023-10-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-20 | 2023-10-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-20 | 2023-10-18 | N |
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2023-09-20 | 2023-10-18 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-09-20 | 2023-10-18 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2023-09-20 | 2023-10-18 | N |
| Have the Quality Assessment and Assurance group have the required members and meet at least quarterly | Health | 2023-09-20 | 2023-10-18 | N |
| Keep all essential equipment working safely. | Health | 2023-09-20 | 2023-10-18 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2023-09-20 | 2023-10-18 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-09-20 | 2023-10-18 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-20 | 2023-10-18 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-20 | 2023-10-18 | 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 | 2023-09-20 | 2023-10-18 | Y |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-08-29 | 2023-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-29 | 2023-10-02 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-08-29 | 2023-10-02 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Develop a communication plan. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-08-29 | 2023-09-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-02 | 2023-06-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-02 | 2023-06-08 | Y |
| 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 | 2023-05-02 | 2023-06-08 | 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 | 2023-05-02 | 2023-06-08 | Y |
| Post nurse staffing information every day. | Health | 2023-05-02 | 2023-06-08 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-14 | 2023-03-09 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-01-06 | 2023-02-09 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-03-18 | 2022-04-28 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-03-18 | 2022-04-28 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-01-07 | 2022-02-04 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-07 | 2022-02-04 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-09-21 | 2021-10-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-21 | 2021-10-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-21 | 2021-10-31 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2021-09-21 | 2021-10-31 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2021-09-21 | 2021-10-31 | 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 | 2021-09-21 | 2021-10-31 | N |
| Post nurse staffing information every day. | Health | 2021-09-21 | 2021-10-31 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-09-21 | 2021-10-31 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-09-21 | 2021-10-31 | 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 | 2021-09-21 | 2021-10-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2021-09-21 | 2021-10-31 | 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 | 2021-09-21 | 2021-10-31 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-09-21 | 2021-10-31 | N |
| Ensure meals and snacks are served at times in accordance with resident?s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. | Health | 2021-09-21 | 2021-10-31 | N |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2021-09-21 | 2021-10-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-09-21 | 2021-10-31 | N |
| Have a plan that describes the process for conducting QAPI and QAA activities. | Health | 2021-09-21 | 2021-10-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-09-21 | 2021-10-31 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2021-09-21 | 2021-10-31 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-09-21 | 2021-10-31 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-09-21 | 2021-10-31 | Y |
| Provide activities to meet all resident's needs. | Health | 2021-09-21 | 2021-10-31 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-09-21 | 2021-10-31 | 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 | 2021-09-21 | 2021-10-31 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-09-21 | 2021-10-31 | Y |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-09-21 | 2021-10-31 | Y |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-31 | 2021-10-05 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-31 | 2021-10-05 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-31 | 2021-10-05 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-08-31 | 2021-10-05 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-08-31 | 2021-10-05 | N |
| Respond appropriately to all alleged violations. | Health | 2021-08-26 | 2021-09-22 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-08-26 | 2021-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-26 | 2021-09-22 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-06-25 | 2021-07-27 | 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 | 2021-06-25 | 2021-07-27 | 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 | 2021-06-25 | 2021-07-27 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-06-25 | 2021-07-27 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-06-25 | 2021-07-27 | Y |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-05-06 | 2021-06-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-05-06 | 2021-06-16 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-05-06 | 2021-06-16 | 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 | 2021-05-06 | 2021-06-16 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2019-03-27 | 2019-05-31 | 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 | 2019-03-27 | 2019-05-31 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2019-03-27 | 2019-05-31 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-03-27 | 2019-05-31 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-03-27 | 2019-05-31 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2019-03-27 | 2019-05-31 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-03-27 | 2019-05-31 | 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 | 2019-03-27 | 2019-05-31 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-03-27 | 2019-05-31 | N |
| Provide activities to meet all resident's needs. | Health | 2019-03-27 | 2019-05-31 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-03-27 | 2019-05-31 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2019-03-27 | 2019-05-31 | 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 | 2019-03-27 | 2019-05-31 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-03-27 | 2019-05-31 | N |
| 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 | 2019-03-27 | 2019-05-31 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2019-03-27 | 2019-05-31 | 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 | 2019-03-27 | 2019-05-31 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-03-27 | 2019-05-31 | 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 | 2019-03-27 | 2019-05-31 | 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 | 2019-03-27 | 2019-05-31 | N |
| Ensure that residents are free from significant medication errors. | Health | 2019-03-27 | 2019-05-31 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-03-27 | 2019-05-31 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2019-03-27 | 2019-05-31 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-03-27 | 2019-05-31 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-03-27 | 2019-05-31 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-03-27 | 2019-05-31 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-03-28 | 2019-05-11 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2019-03-28 | 2019-05-11 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2019-03-28 | 2019-05-04 | N |
