Evergreen Care Center

In the surveyor’s words

From the most serious findings on record at Evergreen Care Center, in the surveyor’s own words.

• Actual harm, isolatedF699Mar 11, 2025

  Based on observation, interview and record review the facility failed to provide Trauma informed care (an approach to delivering care that involves understanding, recognizing and responding to the effects of all types of trauma) for one of nine sampled residents (Resident 1) when Resident 1 verbalized a history of being a survivor of trauma upon admission on 2/18/25 and the facility staff did not recognize the severity of the trauma and did not implement effective interventions to avoid triggers (specific stimuli or events that cause an intense emotional reaction or psychological response) that impacted Resident 1. […]

• No harm, potential for more than minimal, widespreadF727Mar 11, 2025

  Based on interview and record review the facility failed to designate and employ a full time Director of Nursing (DON) for the facility from 12/2024 to 3/2025. This failure had the potential for all residents to result in inadequate residents ' care planning and supervision of the nursing department which placed all residents ' health and safety at risk. Findings: During an interview on 3/11/25 at 4:38 p.m. with the Administrator (ADM) and Assistant Administrator (AADM), the ADM and AADM stated there was no DON assigned to the facility since 12/2024. The ADM and AADM stated there was a DON that was supposed to start working full time in the facility, but due to unforeseen circumstances, the DON did not begin employment with the facility. […]

• No harm, potential for more than minimal, widespreadF812May 17, 2024

  Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety when: 1. One of three kitchen personnel, [NAME] (CK) 2 did not use a surface sanitizer with the correct concentration when wiping the food preparation table. 2. One of three kitchen personnel, CK 1 did not take the temperature reading of food items after the items were heated in the microwave before serving it to one of 47 residents. 3. […]

• No harm, potential for more than minimal, patternF774Jun 17, 2025

  Based on interview and record review, the facility failed to assist residents in making transportation arrangements to and from their provider appointments for three of seven sampled residents (Residents 24, 29 and 40) when: 1. Residents 24 and Resident 40 missed their scheduled appointments due to the transportation arriving late and was not the preferred transportation company requested by Resident 24. This failure resulted in Resident 24 and Resident 40 having to re-schedule their appointments for later dates and caused anger and frustration to Resident 24 and Resident 40's Responsible Party (RP). 2. Resident 29 was not picked up from his appointment by the scheduled transportation company. On 5/21/25 Resident 29 left for a 1:00 p.m. appointment at 12:45 p.m. […]

• No harm, potential for more than minimal, patternF550Feb 26, 2025

  Based on interview and record review, the facility failed to ensure resident rights were exercised for two of four sampled residents (Resident 1 and Resident 2), when Resident 1 and Resident 2 were denied the opportunity to reheat their food brought in by family past 7:00 p.m. This failure resulted in Resident 1 and Resident 2's rights not having access to reheat their food past 7:00 p.m. causing anger by not recognizing Resident 1 and Resident 2's individuality and autonomy. […]