Evergreen Nursing Home
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1991 Carroll Ave
Alamosa, CO 81101
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Details
| Type of Ownership | For profit - Corporation |
| Participates in Medicare? | Yes |
| Participates in Medicaid? | Yes |
| Certified Beds | 60 |
| Continuing Care? | No |
| Resident Council? | Yes |
| Family Council? | No |
| Multi-Home Chain? | No |
| Located in a Hospital? | No |
| Special Focus Facility? | No |
View: Health Inspections | Quality Measures | Staffing | Fire Inspections
Health Inspections
Most Recent Inspection: 08/27/2009
| Date of last standard health inspection: | 08/27/2009 |
| Quality Indicator Survey | No |
| Dates of Complaint Investigations: | 01/01/2009 - 12/31/2009 |
| Total number of Health Deficiencies for this nursing home: | 13 |
| Average number of Health Deficiencies in CO: | 12 |
| Average number of Health Deficiencies in US: | 8 |
| Range of Health Deficiencies in CO: | 0 - 35 |
Pharmacy Service Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Pattern |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Pattern |
| At least once a month, have a licensed pharmacist check the drugs that each resident takes. | 08/27/2009 | 12/04/2009 | Minimal harm or potential for actual harm | Isolated |
| Properly mark drugs and other similar products. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give professional services that meet a professional standard of quality. | 08/27/2009 | 12/04/2009 | Minimal harm or potential for actual harm | Pattern |
| Give each resident care and services to get or keep the highest quality of life possible. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
| Give each resident enough fluids to keep them healthy and prevent dehydration. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Pattern |
Resident Rights Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give the resident's legal representative the same rights as the resident. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
| Tell each resident who can get Medicaid benefits about 1) which items and services Medicaid covers and which the resident must pay for; or 2) how to apply for Medicaid, along with the names and addresses of State groups that can help. | 08/27/2009 | 12/04/2009 | Minimal harm or potential for actual harm | Isolated |
| Provide written records when a resident is transferred or discharged. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
| Provide enough notice before discharging or transferring a resident. | 08/27/2009 | 09/30/2009 | Minimal harm or potential for actual harm | Isolated |
Inspection, 07/10/2008
Environmental Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that the nursing home area is free of dangers that cause accidents. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
| Have a program to keep infection from spreading. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
Mistreatment Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 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. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
Pharmacy Service Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
| Properly mark drugs and other similar products. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
Quality Care Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Provide activities to meet the needs of each resident. | 07/10/2008 | 08/14/2008 | Minimal harm or potential for actual harm | Pattern |
| Provide social services for related medical problems to help each resident achieve the highest possible quality of life. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
| Give professional services that meet a professional standard of quality. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
| Give each resident care and services to get or keep the highest quality of life possible. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | 07/10/2008 | 08/09/2008 | Minimal harm or potential for actual harm | Isolated |
| Make sure that each resident who enters the nursing home without a catheter is not given a catheter, unless it is necessary. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
| Give proper treatment to residents with feeding tubes to prevent problems (such as aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, nasal-pharyngeal ulcers) and help restore eating skills, if possible. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
| Make sure that each resident's nutritional needs were met. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
Resident Assessment Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Assess the resident when the resident enters the nursing home, in a timely manner. | 07/10/2008 | 08/08/2008 | Potential for minimal harm | Pattern |
| Do an assessment of the resident every year. | 07/10/2008 | 08/08/2008 | Potential for minimal harm | Pattern |
| Check and update (if needed) each resident's assessment every 3 months. | 07/10/2008 | 08/08/2008 | Potential for minimal harm | Pattern |
| Make sure all assessments are accurate, coordinated by an RN, done by the right professional, and are signed by the person completing them. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
| Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Pattern |
| Screen residents when they are first admitted to send them to an area with special care for people with developmental disabilities or mental illness, if needed. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
| Electronically record and report resident status assessments in a timely manner as required in order to monitor resident health and progress. | 07/10/2008 | 08/08/2008 | Potential for minimal harm | Pattern |
| Make sure that doctors see a resident's plan of care at every visit and make notes about progress and orders in writing. | 07/10/2008 | 08/08/2008 | Potential for minimal harm | Pattern |
Resident Rights Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Allow residents to easily see the results of the nursing home's most recent survey. | 07/10/2008 | 07/28/2008 | Potential for minimal harm | Widespread |
| Help and prepare each resident for a safe and easy discharge and transfer from the nursing home. | 07/10/2008 | 07/15/2008 | Minimal harm or potential for actual harm | Isolated |
| Provide services to meet the needs and preferences of each resident. | 07/10/2008 | 08/08/2008 | Minimal harm or potential for actual harm | Isolated |
Inspection, 08/28/2007
Administration Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep accurate and appropriate medical records. | 08/28/2007 | 09/26/2007 | Minimal harm or potential for actual harm | Isolated |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | 08/28/2007 | 10/03/2007 | Minimal harm or potential for actual harm | Isolated |
Inspection, 08/01/2007
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that the nursing home area is free of dangers that cause accidents. | 08/01/2007 | 09/03/2007 | Minimal harm or potential for actual harm | Pattern |
Nutrition and Dietary Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Store, cook, and give out food in a safe and clean way. | 08/01/2007 | 09/03/2007 | Minimal harm or potential for actual harm | Pattern |
Pharmacy Service Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| 1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects. | 08/01/2007 | 09/03/2007 | Minimal harm or potential for actual harm | Isolated |
| Properly mark drugs and other similar products. | 08/01/2007 | 09/03/2007 | Minimal harm or potential for actual harm | Pattern |
Inspection, 02/06/2007
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Protect residents from mistreatment, neglect, and/or theft of personal property. | 02/06/2007 | 02/09/2007 | Actual harm | Isolated |
| 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. | 02/06/2007 | 02/09/2007 | Actual harm | Isolated |
Inspection, 11/10/2006
Environmental Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Make sure that the nursing home area is free of dangers that cause accidents. | 11/10/2006 | 12/15/2006 | Actual harm | Isolated |
Mistreatment Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Keep each resident free from physical restraints, unless needed for medical treatment. | 11/10/2006 | 12/15/2006 | Minimal harm or potential for actual harm | Pattern |
Quality Care Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| Give each resident care and services to get or keep the highest quality of life possible. | 11/10/2006 | 12/15/2006 | Actual harm | Isolated |
Nursing Home Staffing
Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.
| National Average | Average in CO | Golden Living Center, Asheville | |
| RN Staff Only1 | N/A | N/A | 5 out of 5 stars |
| Total Number of Residents | 88 | 76 | 54 |
|
Total, Licensed Nurse Staff Hours per Resident per Day |
1 hour 25 minutes | 1 hour 34 minutes | 1 hour 35 minutes |
|
RN Hours per Resident per Day |
35 minutes | 47 minutes | 54 minutes |
|
LPN/LVN Hours per Resident per Day |
49 minutes | 48 minutes | 40 minutes |
|
CNA Hours per Resident per Day |
2 hours 24 minutes | 2 hours 16 minutes | 2 hours 20 minutes |
1 The star rating a nursing home received for the information it provided about its Registered Nurse (RN) staffing. RNs have between 2 and 6 years of education.
Quality Measures
Information comes from data that the nursing home reports to its state agency. It contains the nursing home staffing hours for a two-week period prior to the time of the state inspection. CMS receives this data and converts it into the number of staff hours per resident per day.
Long-Term Residents
| Percent of high-risk long-stay residents who have pressure sores | 15% |
| Percent of long-stay residents given influenza vaccination during the flu season | 90+% |
| Percent of long-stay residents who are more depressed or anxious | 6% |
| Percent of long-stay residents who had a urinary tract infection | 10% |
| Percent of long-stay residents who have moderate to severe pain | 2% |
| Percent of long-stay residents who have/had a catheter inserted and left in their bladder | 1% |
| Percent of long-stay residents who spend most of their time in bed or in a chair | 3% |
| Percent of long-stay residents who were assessed and given pneumococcal vaccination | 90+% |
| Percent of long-stay residents who were physically restrained | 6% |
| Percent of long-stay residents whose ability to move about in and around their room got worse | 8% |
| Percent of long-stay residents whose need for help with daily activities has increased | 16% |
| Percent of low-risk long-stay residents who have pressure sores | 0% |
| Percent of low-risk long-stay residents who lose control of their bowels or bladder | 32% |
Short-Term Residents
| Percent of long-stay residents who lose too much weight | 9% |
| Percent of short-stay residents given influenza vaccination during the flu season | 90+% |
| Percent of short-stay residents who had moderate to severe pain | 4% |
| Percent of short-stay residents who have delirium | 2% |
| Percent of short-stay residents who have pressure sores | 13% |
| Percent of short-stay residents who were assessed and given pneumococcal vaccination | 90+% |
Fire Safety Inspections
Lists the fire safety requirements that the nursing home failed to meet. Fire safety results are not included in the nursing home's Overall Rating.
Most Recent Inspection: 09/17/2009
| Automatic Sprinkler Systems in all required areas | partially sprinklered |
| Date of last standard fire safety inspection: | 09/17/2009 |
| Dates of Complaint Investigations: | 01/01/2009 - 12/31/2009 |
| Total number of Fire Safety Deficiencies for this nursing home: | 2 |
| Average number of Fire Safety Deficiencies in CO: | 1 |
| Average number of Fire Safety Deficiencies in US: | 4 |
| Range of Fire Safety Deficiencies in CO: | 0 - 1 |
Corridor Walls and Doors Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| corridor and hallway doors that block smoke. | 09/17/2009 | 10/13/2009 | Minimal harm or potential for actual harm | Isolated |
Medical Gases and Anesthetizing Areas Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| proper fire barriers, ventilation and signs for the transport of oxygen. | 09/17/2009 | 10/16/2009 | Minimal harm or potential for actual harm | Isolated |
Inspection, 08/08/2008
Automatic Sprinkler Systems Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| automatic sprinkler systems that have been maintained in working order. | 08/08/2008 | 09/03/2008 | Minimal harm or potential for actual harm | Widespread |
Exits and Egress Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| exits that are accessible at all times. | 08/08/2008 | 09/05/2008 | Minimal harm or potential for actual harm | Pattern |
Fire Alarm Systems Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| properly maintained smoke detectors. | 08/08/2008 | 09/03/2008 | Minimal harm or potential for actual harm | Widespread |
Furnishings and Decorations Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| restrictions on the use of flammable curtains. | 08/08/2008 | 09/03/2008 | Minimal harm or potential for actual harm | Pattern |
Illumination and Emergency Power Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| emergency lighting that can last at least 1 1/2 hours. | 08/08/2008 | 09/03/2008 | Minimal harm or potential for actual harm | Widespread |
Inspection, 08/28/2007
Automatic Sprinkler Systems Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| automatic sprinkler systems that have been maintained in working order. | 08/28/2007 | 09/27/2007 | Minimal harm or potential for actual harm | Pattern |
Electrical Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| properly installed electrical wiring and equipment. | 08/28/2007 | 09/27/2007 | Minimal harm or potential for actual harm | Isolated |
Furnishings and Decorations Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| restrictions on the use of flammable curtains. | 08/28/2007 | 09/27/2007 | Minimal harm or potential for actual harm | Widespread |
Medical Gases and Anesthetizing Areas Deficiencies |
||||
| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| proper fire barriers, ventilation and signs for the transport of oxygen. | 08/28/2007 | 09/27/2007 | Minimal harm or potential for actual harm | Isolated |
Smoke Compartmentation and Control Deficiencies |
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| Deficiency | Inspection Date | Correction Date | Level of Harm | Residents Affected |
| walls or barriers that prevent smoke from passing through and would resist fire for at least one hour. | 08/28/2007 | 09/27/2007 | Minimal harm or potential for actual harm | Isolated |
