Evenglow Lodge

Inspection findings

1. Sep 5, 2024 Health · 12 findings
   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

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

     Corrected Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

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

     Corrected Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     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 Oct 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Sep 27, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Sep 26, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 27, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Sep 27, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Sep 27, 2024 · CMS fire safety

2. Nov 29, 2023 Health · 15 findings
   • Not serious Scope/severity D

     F0554 Resident Rights Deficiencies

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

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0580 Resident Rights Deficiencies

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

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

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

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0688 Quality of Life and Care Deficiencies

     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.

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

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

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0698 Quality of Life and Care Deficiencies

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

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     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.

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

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

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0881 Infection Control Deficiencies

     Implement a program that monitors antibiotic use.

     Corrected Dec 21, 2023 · CMS health inspection

   • Not serious Scope/severity E

     K0341 Smoke Deficiencies

     Install a fire alarm system that can be heard throughout the facility.

     Corrected Jan 13, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0918 Gas, Vacuum, and Electrical Systems Deficiencies

     Have generator or other power source capable of supplying service within 10 seconds.

     Corrected Jan 13, 2024 · CMS fire safety

3. Sep 23, 2022 Fire Safety · 2 findings
   • Not serious Scope/severity F

     E0039 Emergency Preparedness Deficiencies

     Conduct testing and exercise requirements.

     Corrected Nov 2, 2022 · CMS fire safety

   • Not serious Scope/severity E

     K0351 Smoke Deficiencies

     Install an approved automatic sprinkler system.

     Corrected Oct 5, 2022 · CMS fire safety

Owners and managers (as published by CMS)

• ARNOLD, SHARON — trustee of the snf, NOT APPLICABLE, since 07/01/2015
• ARNOLD, SHARON — managing control - governing body, NOT APPLICABLE, since 07/01/2015
• DUNNING, VIRGINIA — managing control - governing body, NOT APPLICABLE, since 01/01/2023
• FLESSNER, CAROL — trustee of the snf, NOT APPLICABLE, since 01/25/1992
• FLESSNER, CAROL — managing control - governing body, NOT APPLICABLE, since 01/25/1992
• GESCHWIND, RICHARD — managing control - governing body, NOT APPLICABLE, since 01/27/2003
• GESCHWIND, RICHARD — trustee of the snf, NOT APPLICABLE, since 01/27/2003
• HILLMAN, MALINDA — managing control - governing body, NOT APPLICABLE, since 01/01/2021
• HILLMAN, MALINDA — trustee of the snf, NOT APPLICABLE, since 01/01/2021
• KINATE, ALBERTA — managing control - governing body, NOT APPLICABLE, since 01/26/2009
• KINATE, ALBERTA — trustee of the snf, NOT APPLICABLE, since 01/26/2009
• MCCOY, DOUGLAS — managing control - governing body, NOT APPLICABLE, since 01/25/1992
• MCCOY, DOUGLAS — trustee of the snf, NOT APPLICABLE, since 01/25/1992
• RAY, DARRIN — adp of the snf, NOT APPLICABLE, since 10/01/2023
• RAY, DARRIN — indirect ownership interest, NOT APPLICABLE, since 10/01/2023
• TAYLOR, HARLAN — trustee of the snf, NOT APPLICABLE, since 01/24/1980
• TAYLOR, HARLAN — managing control - governing body, NOT APPLICABLE, since 01/24/1980
• TREWARTHA, JOHN — trustee of the snf, NOT APPLICABLE, since 07/01/2015
• TREWARTHA, JOHN — managing control - governing body, NOT APPLICABLE, since 07/01/2015
• WALTER, ROBERT — managing control - governing body, NOT APPLICABLE, since 01/01/2021
• WEGNER, CYNTHIA — adp of the snf, NOT APPLICABLE, since 08/16/2021
• WEGNER, CYNTHIA — corporate director, NOT APPLICABLE, since 08/16/2021
• WEGNER, CYNTHIA — direct ownership interest, NOT APPLICABLE, since 08/16/2021
• WEGNER, CYNTHIA — operational/managerial control, NOT APPLICABLE, since 08/16/2021