A list of the most recent deficiencies for Everett Transitional Care Services. 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 appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-07-26 | 2023-08-29 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-08 | 2023-03-20 | 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 | 2023-02-08 | 2023-03-20 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-02-08 | 2023-03-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-02-08 | 2023-03-20 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-08 | 2023-03-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-02-08 | 2023-03-20 | 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 | 2023-02-08 | 2023-03-20 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-02-08 | 2023-03-20 | 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 | 2023-02-08 | 2023-03-20 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-08 | 2023-03-20 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-02-08 | 2023-03-20 | N |
| Provide or obtain dental services for each resident. | Health | 2023-02-08 | 2023-03-20 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-02-08 | 2023-03-20 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-02-08 | 2023-03-20 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-02-08 | 2023-03-20 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-02-08 | 2023-03-20 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-02-08 | 2023-03-20 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-02-08 | 2023-03-20 | Y |
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Develop a communication plan. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Provide emergency officials' contact information. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Provide primary/alternate means for communication. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Provide a means of sharing information on occupancy/needs. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Have restrictions on the use of highly flammable decorations. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-02-01 | 2023-03-02 | N |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2022-09-29 | 2022-11-04 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-12 | 2022-08-05 | Y |
| 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 | 2022-07-12 | 2022-08-05 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-07-12 | 2022-08-05 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2021-10-08 | 2021-11-01 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2021-10-08 | 2021-11-01 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-10-08 | 2021-11-01 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2020-05-19 | 2020-06-05 | 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 | 2020-05-19 | 2020-06-05 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2020-05-19 | 2020-06-05 | 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 | 2020-05-19 | 2020-06-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-05-19 | 2020-06-05 | N |
