Evergreen Nursing Home

In the surveyor’s words

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

• Actual harm, isolatedF600Feb 5, 2026

  Based on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for five (#5, #7, #4, #2 and #3) of ten residents reviewed for abuse out of 12 sample residents.Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease with behavioral disturbances. Resident #6 had a history of wandering and physical aggression. Resident #6 was admitted on [DATE] with diagnoses of dementia. Resident #5 had a history of physical aggression.On [DATE], Resident #6 and Resident #5 had a physical altercation, where the nurse observed Resident #6 push Resident #5. Resident #5 lost his balanced and fell and hit his head on a chair before he landed on the floor. The nurse observed Resident #5 bleeding from his head. […]

• Actual harm, isolatedF689Feb 5, 2026

  Based on record review and interviews, the facility failed to ensure that one (#5) of the three residents reviewed for accidents out of 12 sample residents remained free from accidents.Specifically, the facility failed to timely implement person centered fall interventions for Resident #5, who had multiple falls with major injury. Resident #5 was admitted on [DATE] with diagnoses of Alzheimer's disease and dementia. Resident #5 sustained a fall on [DATE] and on [DATE]. On [DATE] Resident #5 had a physical therapy evaluation that determined Resident #5 required supervision or touching assistance for ambulation. The change in level of assistance for ambulation was not communicated to nursing staff until [DATE]. During that time, Resident #5 sustained two more falls on [DATE] at [DATE]. […]

• No harm, potential for more than minimal, widespreadF726Feb 2, 2023

  Based on record review and interviews, the facility failed to ensure licensed nurses and certified nurse aides (CNA) were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to ensure nursing staff had completed competencies in the past 12 months prior to providing skilled services as described in the plan of care for three out of three registered nurses (RN), two out of two licensed practical nurses (LPN) and five out of five CNAs reviewed for competencies. Findings include: I. […]

• No harm, potential for more than minimal, widespreadF812Feb 2, 2023

  Based on observations, record review and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; -Cutting boards were free from deep scratches and stains; -Beard restraints were worn in kitchen areas while serving food; and, -To ensure the food was stored and labeled properly. Findings include: I. Improper hand hygiene A. […]

• No harm, potential for more than minimal, isolatedF584Aug 29, 2024

  Based on observations and interviews, the facility failed to provide a functional, comfortable and homelike environment for residents on two of two units. Specifically, the facility failed to: -Ensure the residents residing in room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER] were provided with appropriate hot water in the bathroom sinks; and, -Ensure high back dining room chairs in the secure unit dining room and the main dining room were free from cracks and tears. Findings include: I. Facility policy and procedure The Resident Rights policy and procedure, revised 9/25/23, was provided by the director of nursing (DON) on 8/29/24 at 9:32 a.m. […]