Inspection Results » Evergreen Commons Rehabilitation and Nursing Center

Health Inspection on December 6, 2017 ^[1]

1. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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. (Corrected 2018-01-31)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2018-01-31)
   • Provide and implement an infection prevention and control program. (Corrected 2018-01-31)
   • 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. (Corrected 2018-01-31)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2018-01-31)
   • Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. (Corrected 2018-01-31)
   • Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. (Corrected 2018-01-31)
   • Provide enough food/fluids to maintain a resident's health. (Corrected 2018-01-31)

2. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • 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 ne (Corrected 2018-01-31)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2018-01-31)
   • Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. (Corrected 2018-01-31)
   • Ensure each resident receives an accurate assessment. (Corrected 2018-01-31)
   • Reasonably accommodate the needs and preferences of each resident. (Corrected 2018-01-31)
   • Not hire anyone with a finding of abuse, neglect, exploitation, or theft. (Corrected 2018-01-31)
   • Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Corrected 2018-01-31)

3. Widespread: No actual harm with potential for minimal harm

   • 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. (Corrected 2018-01-31)