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EVERGREEN COMMONS REHABILITATION AND NURSING CTR Inspection Report, Violations & Safety Grade (EAST GREENBUSH, New York)

1070 LUTHER ROAD, EAST GREENBUSH, New York 12061

Phone: 5184794662

CMS Overall:2/5

Overview & Bed Count

Certified Beds
240
Avg Residents/Day
233.4
Ownership
For profit - Corporation
Provider Type
Medicare and Medicaid
County
Rensselaer
Sprinkler Systems
Yes
Special Focus
None
Abuse Citation
No

CMS Star Ratings

Overall2/5
Health2/5
Staffing2/5
Quality3/5

Nurse Staffing Check

MetricThis FacilityNew York AvgDifference
RN Hours per Resident per Day0.410.73-0.32
Total Nurse Hours per Resident per Day2.913.69-0.77
CMS Staffing Rating2/52.9/5-
Nursing Staff Turnover47.8%40.3%-

Health Citation History

21 health citations on record

DateCategoryDescriptionSeverity
2026-07-03Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.G – Actual Harm
2026-07-03Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2026-03-19Freedom from Abuse, Neglect, and Exploitation DeficienciesTimely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.D – Moderate Harm Potential
2026-03-19Freedom from Abuse, Neglect, and Exploitation DeficienciesRespond appropriately to all alleged violations.D – Moderate Harm Potential
2026-03-19Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2024-01-11Resident Rights DeficienciesHonor 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.E – Moderate Harm Potential
2024-01-11Pharmacy Service DeficienciesEnsure 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.E – Moderate Harm Potential
2024-01-11Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2024-01-11Environmental DeficienciesKeep all essential equipment working safely.E – Moderate Harm Potential
2024-01-11Environmental DeficienciesMake sure there is a pest control program to prevent/deal with mice, insects, or other pests.E – Moderate Harm Potential
2024-01-11Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2024-01-11Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2024-01-11Quality of Life and Care DeficienciesProvide safe and appropriate respiratory care for a resident when needed.D – Moderate Harm Potential
2021-09-01Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2021-09-01Resident Rights DeficienciesHonor 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.D – Moderate Harm Potential
2021-09-01Nutrition and Dietary DeficienciesDispose of garbage and refuse properly.D – Moderate Harm Potential
2019-08-26Resident Rights DeficienciesHonor 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.D – Moderate Harm Potential
2019-08-26Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2019-08-26Pharmacy Service DeficienciesImplement 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.D – Moderate Harm Potential
2019-08-26Nutrition and Dietary DeficienciesDispose of garbage and refuse properly.D – Moderate Harm Potential
2019-08-26Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential

Fire Safety Citation History

12 fire safety citations on record

DateCategoryDescriptionSeverity
2024-01-11Smoke DeficienciesHave an enclosure around a vertical opening shaft.E – Moderate Harm Potential
2024-01-11Smoke DeficienciesEnsure smoke barriers are constructed to a 1 hour fire resistance rating.E – Moderate Harm Potential
2021-09-01Smoke DeficienciesInstall an approved automatic sprinkler system.E – Moderate Harm Potential
2021-09-01Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.E – Moderate Harm Potential
2021-09-01Gas, Vacuum, and Electrical Systems DeficienciesEnsure that testing and maintenance of electrical equipment is performed.E – Moderate Harm Potential
2019-08-26Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.E – Moderate Harm Potential
2019-08-26Gas, Vacuum, and Electrical Systems DeficienciesEnsure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.E – Moderate Harm Potential
2019-08-26Smoke DeficienciesProvide properly protected cooking facilities.D – Moderate Harm Potential
2019-08-26Miscellaneous DeficienciesTo conduct inspection, testing and maintenance of fire doors by qualified individuals.D – Moderate Harm Potential
2019-08-26Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.D – Moderate Harm Potential
2019-08-26Gas, Vacuum, and Electrical Systems DeficienciesEnsure that testing and maintenance of electrical equipment is performed.D – Moderate Harm Potential
2019-08-26Gas, Vacuum, and Electrical Systems DeficienciesHave proper medical gas storage and administration areas.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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