CMS Inspection Results for EVERGREEN AT CC HEALTH & REHAB

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 12/05/2008 Health Survey for EVERGREEN AT CC HEALTH & REHAB

Administration
Deficiency	Scope	Level of Harm
Give or get lab tests to meet the needs of residents.	Isolated	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Pattern	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Pattern	Minimal harm or potential for actual harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Pattern	Minimal harm or potential for actual harm
Store, cook, and give out food in a safe and clean way.	Pattern	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Provide social services for related medical problems to help each resident achieve the highest possible quality of life.	Pattern	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Develop/implement required procedures for the administration of immunizations.	Pattern	Potential for minimal harm
Resident Assessment
Deficiency	Scope	Level of Harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide care in a way that keeps or builds each resident's dignity and self respect.	Isolated	Minimal harm or potential for actual harm
Help and prepare each resident for a safe and easy discharge and transfer from the nursing home.	Isolated	Minimal harm or potential for actual harm
Let residents give themselves their drugs if they are able.	Isolated	Minimal harm or potential for actual harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 12/02/2008 Fire Safety Survey for EVERGREEN AT CC HEALTH & REHAB

Illumination and Emergency Power
Deficiency	Scope	Level of Harm
emergency lighting that can last at least 1 1/2 hours.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
smoke barrier doors that can resist smoke for at least 20 minutes.	Isolated	Minimal harm or potential for actual harm

 

• 12/21/2007 Health Survey for EVERGREEN AT CC HEALTH & REHAB

Environmental
Deficiency	Scope	Level of Harm
Keep a resident apart from the others if the resident has an infection that can spread.	Isolated	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Isolated	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
Keep each resident free from physical restraints, unless needed for medical treatment.	Isolated	Minimal harm or potential for actual harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
1) Provide 3 meals daily at regular times; or 2) serve breakfast within 14 hours after dinner; or 3) offer a snack at bedtime each day.	Widespread	Minimal harm or potential for actual harm
Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature.	Widespread	Minimal harm or potential for actual harm
Pharmacy Service
Deficiency	Scope	Level of Harm
Properly mark drugs and other similar products.	Isolated	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give each resident enough fluids to keep them healthy and prevent dehydration.	Isolated	Actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Give professional services that meet a professional standard of quality.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide services to meet the needs and preferences of each resident.	Isolated	Minimal harm or potential for actual harm
Immediately tell the resident, doctor, and a family member if: the resident is injured, there is a major change in resident's physical/mental health, there is a need to alter treatment significantly, or the resident must be transferred or discharged.	Isolated	Minimal harm or potential for actual harm

 

• 12/19/2007 Fire Safety Survey for EVERGREEN AT CC HEALTH & REHAB

Exits and Egress
Deficiency	Scope	Level of Harm
corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm

 

• 01/09/2007 Fire Safety Survey for EVERGREEN AT CC HEALTH & REHAB

Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
corridors or aisles that are unobstructed and are at least 8 feet in width.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm

 

• 01/05/2007 Health Survey for EVERGREEN AT CC HEALTH & REHAB

Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Isolated	Minimal harm or potential for actual harm
Get rid of garbage properly.	Pattern	Potential for minimal harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Provide activities to meet the needs of each resident.	Pattern	Minimal harm or potential for actual harm
Give each resident care and services to get or keep the highest quality of life possible.	Isolated	Minimal harm or potential for actual harm
Give the right treatment and services to residents who have mental or social problems adjusting.	Isolated	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide services to meet the needs and preferences of each resident.	Pattern	Minimal harm or potential for actual harm