Evergreen Woods

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF761Oct 28, 2021

  Based on observations, facility policy review and staff interviews for one of one medication rooms and two of two medication carts, reviewed for medication storage, the facility failed to ensure medications were not accessible to non-licensed persons. The findings include: An observation on 10/26/2021 at 3:10 PM identified the medication room door was open wide and was held open by a wedge-type of magnetic door holder under the bottom of the door. Additional observation identified no licensed staff were in the medication room or within view of the medication room. Further, located inside the unattended medication room were two medication carts that were both observed to be unlocked. […]

• No harm, potential for more than minimal, patternF812Sep 4, 2025

  Based on observations, review of facility policy, and interviews, the facility failed to prepare and serve food in a sanitary manner due to the lack of a hair restraint. The findings include: Observation in the kitchen on 8/29/25 at 9:30 AM with the Executive Chef, identified Dietary Aide #1 preparing cold sandwiches for lunch service later that day without the benefit of wearing a beard restraint. Interview with Dietary Aide #1 on 8/29/25 at 9:30 AM identified he was unsure if the facility had beard restraints for staff with facial hair but was pretty sure they didn't. […]

• No harm, potential for more than minimal, patternF812Dec 22, 2023

  Based on a tour of the Dietary Department, review of facility policy, and staff interview, the facility failed to ensure expired food was discarded. The findings included: During the initial tour of the Dietary Department on [DATE] at 11:30 AM with the Executive Chef, the following was identified in dry storage: a. one 32-ounce box of baking soda with an expiration date of [DATE]. b. four 28-ounce bags of refried pinto beans with an expiration date of [DATE]. c. five 10-ounce boxes of Couscous with an expiration date of [DATE]. Interview with the Director of Food Services on [DATE] at 10:30 AM identified that the Closing Manager was responsible to check for expiration dates daily and to discard expired food. […]

• No harm, potential for more than minimal, isolatedF600Sep 4, 2025

  Based on interviews, review of clinical records, facility documentation, and facility policy for 1 of 2 sampled residents, (Resident #51) reviewed for abuse, the facility staff failed to ensure treatment in a dignified manner. The findings include:Resident #51's diagnoses included acute systolic (congestive) heart failure, impingement syndrome and pain of the right shoulder, and venous stasis dermatitis with blistering.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial/moderate assistance for toileting hygiene, and supervision or touching assistance for transfers.The Resident Care Plan (RCP) dated 8/28/2025 identified Activities of Daily Living… […]

• No harm, potential for more than minimal, isolatedF609Sep 4, 2025

  Based on review of the clinical record, facility documentation, policy, and interviews for 1 of 2 sampled residents, (Resident #51) reviewed for abuse, the facility failed to report an allegation of abuse to the State Agency (SA) within the required time frame. The findings include:Resident #51's diagnoses included acute systolic (congestive) heart failure, impingement syndrome of the right shoulder, pain in the right shoulder, and venous stasis dermatitis with blistering.The admission Minimum Data Set (MDS) assessment dated [DATE] identified Resident #51 had a Brief Interview of Mental Status (BIMS) score of 15 indicating no cognitive impairment, required partial/moderate assistance for toileting hygiene, and supervision or touching assistance for transfers.The Resident Care Plan (RCP)… […]