CMS Inspection Results for EVANGELICAL MANOR

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.

• 02/20/2009 Health Survey for EVANGELICAL MANOR

Administration
Deficiency	Scope	Level of Harm
Follow all laws and professional standards.	Widespread	Minimal harm or potential for actual harm
Environmental
Deficiency	Scope	Level of Harm
Keep all essential equipment working safely.	Widespread	Minimal harm or potential for actual harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Have a program to keep infection from spreading.	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.	Isolated	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
Store, cook, and give out food in a safe and clean way.	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
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm
Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary.	Isolated	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
Resident Rights
Deficiency	Scope	Level of Harm
Keep each resident's personal and medical records private and confidential.	Isolated	Minimal harm or potential for actual harm
Allow residents to easily see the results of the nursing home's most recent survey.	Widespread	Potential for minimal harm

 

• 02/10/2009 Fire Safety Survey for EVANGELICAL MANOR

Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Isolated	Minimal harm or potential for actual harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Isolated	Minimal harm or potential for actual harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exit stairways and towers that are smoke proof.	Pattern	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Isolated	Minimal harm or potential for actual harm

 

• 03/06/2008 Fire Safety Survey for EVANGELICAL MANOR

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Potential for minimal harm
portable fire extinguishers.	Pattern	Potential for minimal harm
Corridor Walls and Doors
Deficiency	Scope	Level of Harm
corridor and hallway doors that block smoke.	Isolated	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Widespread	Potential for minimal harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
walls or barriers that prevent smoke from passing through and would resist fire for at least one hour.	Pattern	Potential for minimal harm

 

• 02/22/2008 Health Survey for EVANGELICAL MANOR

Environmental
Deficiency	Scope	Level of 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
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.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that follow each resident's written care plan.	Isolated	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

 

• 03/27/2007 Health Survey for EVANGELICAL MANOR

Environmental
Deficiency	Scope	Level of Harm
Make sure that the nursing home area is free of dangers that cause accidents.	Pattern	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Make sure that each resident's nutritional needs were met.	Isolated	Minimal harm or potential for actual harm

 

• 02/07/2007 Fire Safety Survey for EVANGELICAL MANOR

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Pattern	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
a two-hour-resistant firewall in common walls.	Pattern	Potential for minimal harm
approved construction type or materials.	Pattern	Potential for minimal harm
Building Service Equipment
Deficiency	Scope	Level of Harm
heating and ventilation systems that have been properly installed according to the manufacturer's instructions.	Widespread	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Pattern	Minimal harm or potential for actual harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Potential for minimal harm
Miscellaneous
Deficiency	Scope	Level of Harm
fire safety features required by current fire safety codes.	Pattern	Potential for minimal harm
Vertical Openings
Deficiency	Scope	Level of Harm
protected exits that allow the resident to escape the building.	Pattern	Potential for minimal harm
proper stairway enclosures and vertical shafts.	Pattern	Potential for minimal harm