Evergreen Health and Rehabilitation Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF921Sep 5, 2025

  Based on observations and staff interviews, the facility failed to ensure a safe, functional, sanitary, comfortable environment in the clean linen room, the overflow Linen Room, the Biohazard Room, and the South Hall Medication Room were maintained in an clean, orderly, and sanitary manner.Findings include:Observation on 9/3/2025 at 8:55 AM, at the nurse's station near the shower room on the South Hall revealed empty cardboard boxes along the wall. A plastic cup and scattered debris to include a cotton ball and paper were observed on the floor of the nurse's station. […]

• No harm, potential for more than minimal, patternF812Jan 9, 2026

  Based on observations, staff interviews, and facility policy review, the facility failed to ensure foods stored in one of two nourishment refrigerators (South unit) were labeled, dated when opened, and not expired. This failure placed the residents on the South unit at risk for transmission of foodborne illness.Findings include:During an observation on 01/07/26 at 1:10 PM in the South unit, the nourishment refrigerator contained:A. Three Styrofoam bowls containing applesauce or pudding. Neither were labeled or dated.B. Four plastic containers containing food leftovers that were labeled with a resident's name but were not dated.C. An open can of Coke with a straw sticking out of the opening which was uncovered, not labeled, and not dated. D. […]

• No harm, potential for more than minimal, patternF584Sep 5, 2025

  Based on observations, record review, staff interviews, and review of the facility policy titled, Routine Cleaning and Disinfection, the facility failed to ensure a safe, clean, comfortable, homelike environment in the North and South hallways, resident rooms for four of 24 sampled residents (Resident (R)3, R4, R20, and R5), resident shower rooms, resident equipment for five of 24 sampled Rs (R22, R25, R24, R15, and R21), and the main dining room were maintained in a safe, clean, comfortable and clutter-free manner to create a homelike environment.Findings include:Review of the facility's policy titled Routine Cleaning and Disinfection dated 9/1/2022 states, Policy: It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe,… […]

• No harm, potential for more than minimal, patternF761Sep 5, 2025

  Based on observations, staff interviews, record review, and facility policy review, the facility failed to ensure expired insulin pens and insulin vials were removed from two of four medication carts (South Hall long and South Hall short) reviewed. In addition, the facility failed to ensure two of two medication room refrigerators (North Hall and South Hall) were locked and the schedule II lock box (containing narcotics that have a high incidence of abuse) were affixed to shelving, as required. This failure had the potential of medication diversion to residents, staff or visitors, and residents receiving ineffective medications. […]

• No harm, potential for more than minimal, isolatedF628Jan 9, 2026

  Based on record review, staff interviews, and facility policy review, the facility failed to ensure written notice to the resident or representative of the transfer to the hospital included a statement of the appeal rights, information on how to file an appeal, and appeals contact information for two of four residents (Resident (R) 91 and R79) reviewed for hospitalization in a sample of 23 residents. This failure created the potential for a lack of understanding of appeal rights should the resident not be permitted to return or disagree with the reason for transfer, potentially causing confusion or distress upon transfer.Findings include:Review of the facility's policy titled, Transfer and Discharge, dated July 2025, revealed, The facility's transfer/discharge notice will be provided to… […]