EVERGREEN HEALTH AND REHABILITATION CENTER

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.

Administration Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Have a plan that describes the process for conducting QAPI and QAA activities.

Administration Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

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.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide appropriate foot care.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected February 19, 2024

Provide and implement an infection prevention and control program.

Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Post nurse staffing information every day.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

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.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 16, 2022

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Environmental Deficiencies — Deficient, Provider has date of correction, corrected May 26, 2023

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 19, 2023

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 19, 2023

Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 26, 2023

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 26, 2023

Observe each nurse aide's job performance and give regular training.

Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Ensure that residents are free from significant medication errors.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 26, 2023

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

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.

Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 26, 2023

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2019

Provide safe, appropriate pain management for a resident who requires such services.

Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Ensure services provided by the nursing facility meet professional standards of quality.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 26, 2023

Ensure each resident receives an accurate assessment.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2019

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected June 21, 2019

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

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.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 28, 2019