Evergreen Center for Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Evergreen Center for Health & Rehabilitation, in the surveyor’s own words.

• Actual harm, patternF686Sep 2, 2026

  Based on observations, review of clinical records, review of facility documentation, review of facility policy/procedure, and interviews, for nine of twelve sampled residents (Residents #5, #9, #91 #105, #107, #115#122, #142, #151) reviewed for facility acquired pressure injuries, the facility to accurately assess, treat, and implement timely interventions for residents at risk for the development of pressure injuries, resulting in the development of avoidable pressure injuries and the worsening of the pressure injuries resulting in harm. The findings include:Resident #122's diagnoses included cellulitis of left and right lower limbs, generalized muscle weakness, and difficulty walking. […]

• Actual harm, isolatedF689Aug 6, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #1) reviewed for falls, the facility failed to ensure the resident's side-rail was locked into place prior to directing the resident to turn onto their left side in bed resulting in a fall with injury. The findings include:Based on review of clinical records , facility documentation, facility policy and interviews for one (1) of three (3) sampled residents (Resident #1) who required assistance of one (1) staff member with bed mobility, the facility failed to ensure the resident's side-rail was locked into place prior to directing the resident to turn in bed which resulted in the resident falling out of bed and sustaining injuries. […]

• No harm, potential for more than minimal, widespreadF755Sep 2, 2026

  Based on observations, review of the clinical record, review of facility documentation, review of facility policy/procedures and interviews the facility failed to maintain an effective system of controlled substance receipt, accountability, reconciliation, storage, disposition, destruction, and documentation. The facility failed to ensure that controlled substance disposition records (CSDRs) were reconciled and accurately reflected the electronic health record (EHR); failed to maintain required signatures documenting receipt, shift-to-shift accountability, return and/or destruction of controlled substances; failed to maintain adequate security of emergency controlled substance keys; and failed to maintain complete and accurate controlled substance records. […]

• No harm, potential for more than minimal, widespreadF940Sep 2, 2026

  Based on clinical record reviews, review of facility documentation, review of facility policies and procedures, and staff interviews, the facility failed to develop and/or implement an effective training program to ensure nursing staff received education necessary to provide care and services related to the prevention, identification, and treatment of pressure ulcers/injuries. The findings inlcude:The review of the Facility Assessment, last updated 4/1/26, found that at any given time, 15 to 20 residents in the facility were dependent on staff for all mobility needs, which increased their risk of pressure ulcer/injury development. […]

• No harm, potential for more than minimal, widespreadF880Nov 22, 2024

  Based on review of the infection control program, observations, review of facility policy and staff interviews, the facility failed to ensure all staff members were knowledgeable in identifying residents requiring Enhanced Barrier Precautions (EBP) and proficient in utilizing proper personal protective equipment while providing care for residents requiring EBP. The findings included: a. On 11/19/24 at 12:17 PM during the survey identified no enhanced barrier signs outside resident bedroom doors reported by surveyors. […]