Deficiency Records for Evansville Manor Nursing and Rehab, LLC
Updated as of March 01, 2024
A list of the most recent deficiencies for Evansville Manor Nursing and Rehab, LLC. 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? |
|---|---|---|---|---|
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-06-28 | 2023-08-21 | 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 | 2023-06-29 | 2023-07-28 | N |
| PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-06-29 | 2023-07-28 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-29 | 2023-07-28 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-06-29 | 2023-07-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-29 | 2023-07-28 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-06-29 | 2023-07-28 | 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 | 2023-06-29 | 2023-07-28 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-06-29 | 2023-07-28 | Y |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-06-28 | 2023-07-28 | 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 | 2023-06-28 | 2023-07-28 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2023-06-28 | 2023-07-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-05-09 | 2023-06-05 | 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 | 2023-05-09 | 2023-06-05 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-05-09 | 2023-06-05 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-05-09 | 2023-06-05 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-05-09 | 2023-06-05 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-05-09 | 2023-06-05 | Y |
| Post nurse staffing information every day. | Health | 2023-05-09 | 2023-06-05 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-05-09 | 2023-06-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-09 | 2023-06-05 | Y |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-04-22 | 2022-10-24 | N |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2022-07-18 | 2022-08-12 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-04-22 | 2022-06-30 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-21 | 2022-05-21 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-21 | 2022-05-21 | N |
| Implement a program that monitors antibiotic use. | Health | 2022-04-21 | 2022-05-21 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-04-21 | 2022-05-21 | 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 | 2022-04-21 | 2022-05-21 | N |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-04-21 | 2022-05-21 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-04-22 | 2022-05-21 | 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 | 2022-04-22 | 2022-05-21 | 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 | 2022-04-22 | 2022-05-21 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-04-22 | 2022-05-21 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-04-22 | 2022-05-21 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-04-22 | 2022-05-21 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-04-22 | 2022-05-21 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-04-22 | 2022-05-21 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-04-22 | 2022-05-21 | N |
| Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy. | Health | 2022-02-15 | 2022-03-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-15 | 2022-03-11 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-11-11 | 2021-12-06 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-11 | 2021-12-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-09-02 | 2021-09-22 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-24 | 2021-09-21 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-02 | 2021-06-21 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-06-02 | 2021-06-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-16 | 2021-03-17 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-02-11 | 2021-03-10 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-02-11 | 2021-03-10 | N |
| Respond appropriately to all alleged violations. | Health | 2021-02-11 | 2021-03-10 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-02-11 | 2021-03-10 | 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 | 2021-02-11 | 2021-03-10 | N |
| Implement a program that monitors antibiotic use. | Health | 2021-02-11 | 2021-03-10 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2021-02-11 | 2021-03-10 | N |
| Have exits that are accessible at all times. | Fire Safety | 2021-02-11 | 2021-03-10 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-02-11 | 2021-03-10 | N |
| Have power receptacles that are properly grounded. | Fire Safety | 2021-02-11 | 2021-03-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2021-02-11 | 2021-03-10 | N |
