Evergreen Healthcare Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jan 18, 2023

  Based on medical record review, review of a Self-Reported Incident (SRI), staff interviews, review of the local police report, review of the facility investigation, review of email and policy review, the facility failed to ensure one resident (Resident #28) was free from physical abuse by facility staff. This resulted in Immediate Jeopardy and serious negative psychosocial harm, based on a reasonable person's response of fear and anxiety, for Resident #28, who has severe cognitive impairment, when Licensed Practical Nurse (LPN) #431 physically walked Resident #28 back a couple steps to a wall, held her against the wall with her right forearm, and placed her left hand on the resident's throat in response to behaviors Resident #28 was exhibiting, causing Resident #28 to start screaming and… […]

• Actual harm, isolatedF689Jan 18, 2023

  Based on staff interview, review of the medical records, review of hospital records, and review of the facility policy, the facility failed to implement fall interventions for one (#26). This resulted in Actual Harm when Resident #26's bed was not placed in the low position, the resident fell out of bed and suffered a dislocated left little finger. This affected one (Resident #26) of four residents reviewed for falls. Additionally, the facility failed to ensure post-fall assessments were completed and falls were tracked on the facility's incident log. This affected three (#26, #244, and #245) of four residents reviewed for falls. The facility census was 44. Findings include: 1. Review of the medical record for Resident #26 revealed an admitted [DATE]. […]

• No harm, potential for more than minimal, widespreadF880Feb 28, 2022

  Based on observations, staff interviews, review of the staff schedule, review of the staff Coronavirus Disease 2019 (COVID-19) screening log, and review of the policies, the facility failed to implement proper infection control practices when staff were not wearing Personal Protective Equipment (PPE) including gowns and eye protection appropriately. Additionally, the facility failed to ensure staff completed the screening log upon entry to the facility. Additionally, the facility failed to handle linens and trash from quarantined room separately from residents not on transmission based precautions. This had the potential to affect all residents who were not diagnosed with COVID-19. The facility identified 40 residents not diagnosed with COVID-19. […]

• No harm, potential for more than minimal, widespreadF727Mar 18, 2021

  Based on record review and interview, the failed to ensure a registered nurse was on duty eight hours a day, seven days a week. This had the potential to affect all residents who resided in the facility. The facility census was 38. Findings include: Review of facility nursing schedules dated 03/13/21 and 03/14/21 revealed no Registered Nurse was on duty at any time during the day. Review of an email from the Administrator dated 03/18/21 at 4:24 P.M. verified there was no RN coverage for 03/13/21 and 03/14/21 as was required. This deficiency substantiates Complaint Numbers OH 029 and OH 796.

• No harm, potential for more than minimal, patternF805Apr 9, 2026

  Based on observation, staff interview, review of recipe, and review of diet and nutrition manual the facility failed to serve pureed foods at a smooth consistency for safe swallowing. This had the potential to affect five (#3, #16, #20, #22, and #34) residents who the facility identified to require a pureed diet. The facility census was 44. Observation on 04/08/26 at 11:48 A.M. of the first pan of preprepared pureed ham revealed the pureed ham appeared chopped and was separated, not a smooth consistency. Observation of a test tray of the pureed ham revealed the pureed ham was not a smooth consistency.Interview on 04/08/26 at 11:50 A.M. with Dietary Manager #302 verified the first pan of pureed ham was not smooth. Observation on 04/08/26 at 11:55 A.M. […]