Evergreen Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Sep 16, 2025

  Based on observation, staff interview, and record review, the facility did not ensure adequate supervision was provided for 1 resident (R) (R1) of 5 residents reviewed for elopement.R1 was at risk for wandering and elopement. On 8/15/25, R1 exited the facility unsupervised and was found lying on the side of the road 0.3 miles from the facility. The facility failed to ensure all exit doors alarmed and did not have a system in place to ensure doors were secure and an audible alarm functioned.The facility's failure to provide adequate supervision for a resident assessed to be at risk for elopement and who exited the facility and was discovered laying on the side of a road and to ensure a properly functioning alarm system led to a finding of immediate jeopardy that began on 8/8/25. […]

• Actual harm, isolatedF686Jul 29, 2026

  Based on observation, interview, and record review, the facility did not ensure the necessary care and services were provided to prevent pressure injuries from developing and/or promote healing for 1 resident (R) (R5) of 3 sampled residents.R5 developed an unstageable pressure injury on the coccyx after admission to the facility. The facility did not ensure wound care and repositioning were completed or pressure relieving boots were applied as ordered. In addition, R5's air mattress was not set at the appropriate setting. […]

• Actual harm, isolatedF689Mar 19, 2025

  Based on observation, staff and resident interview, and record review, the facility did not ensure the provision of adequate supervision and assistance devices to prevent accidents for 3 residents (R) (R1, R4, and R3) of 3 sampled residents. On 10/24/24, R1 had a fall with injury while smoking outside without supervision. R1 sustained a head laceration and was transferred to the emergency room (ER). A smoking assessment indicated R1 could smoke independently unsupervised, however, R1 needed assistance with locomotion and could not independently get to or return from the smoking area. In addition, R1 did not have a smoking care plan at the time of the fall. R4 fell from a lift chair on 12/27/24. The facility did not reassess R4 for lift chair safety following the fall. R3 fell on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812May 10, 2023

  Based on observation, staff interview, and record review, the facility did not ensure food was stored and prepared in a sanitary manner. This practice had the potential to affect all 42 residents residing in the facility. The facility did not monitor and document food cooling temperatures. The facility did not monitor and document food holding temperatures. Staff did not test quaternary sanitizing solution per manufacturer's instructions. The facility did not monitor warewashing temperatures to ensure minimum wash temperatures were reached to prevent the spread of foodborne illness. Findings include: During an initial tour of the kitchen on 5/8/23 at 8:09 AM, Dietary Manager (DM)-C stated DM-C was unsure what standard of the practice the facility followed. […]

• No harm, potential for more than minimal, patternF812Jul 29, 2026

  Based on observation, interview, and record review, the facility did not ensure food was labeled and stored appropriately. This practice had the potential to affect more than 4 of the 41 residents residing in the facility. Food stored in a resident refrigerator contained unlabeled and undated items.Findings include:The facility's Use and Storage of Food Brought in by Family or Visitors policy, dated 12/14/22, indicates: It is the right of the residents of this facility to have food brought in by family or other visitors; however, the food must be handled in a way to ensure the safety of the resident .All food items that are already prepared by the family or a visitor brought in must be labeled with the contents and dated .The facility may refrigerate labeled and dated prepared items in the… […]