Evergreen Woods

In the surveyor’s words

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

• Immediate jeopardy, isolatedF806Jul 22, 2025

  Based on interview and record review, the facility failed to ensure residents with allergies were provided foods that were free from allergens for 1 of 9 residents, Resident #1, sampled who had food allergies. Resident #1 had a documented severe fish allergy. The dietary department prepared Resident #1's meal tray which consisted of a fish entree; due to interruptions that occur during the tray line, the meal tray was delivered to the floor. At approximately 12:00 PM, Staff D, Certified Nursing Assistant (CNA), delivered the meal tray to Resident #1. At approximately 12:30 PM, Resident #1's meal tray was collected by Staff D, CNA, and realized the meal tray contained fish. […]

• No harm, potential for more than minimal, widespreadF812May 5, 2021

  Based on observation, interview, and policy and procedure review, the facility failed to ensure food was served in accordance with professional standards for food service safety, failed to ensure kitchen equipment was maintained in clean and sanitary condition, and failed to ensure food was stored in a clean and sanitary manner and equipment was maintained in clean and sanitary condition for 2 of 2 nourishment rooms, which could potentially affect the entire facility population of 97 residents. (Photographic evidence obtained) Findings: 1. […]

• No harm, potential for more than minimal, widespreadF761Feb 18, 2021

  Based on observation, interview, and policy and procedure review the facility failed to ensure that all drugs and biologicals used in the facility were stored and labeled in accordance with current professional standards in 6 of 6 medication carts reviewed. Findings: During the facility tour at 4:50 AM a medication cart (Medication Cart #1) in the 300 hallway was observed opened and unlocked with no staff in attendance. Staff D, Certified Nursing Assistant (CNA) was observed walking by the cart to enter a resident's room, she exited the room at 5:05 AM, the licensed staff was still not at the cart. At 5:06 AM the open medication cart was brought to the attention of the Risk Manager (RM) who verified that the cart was opened as well as the top drawers opened revealing unsecured medications. […]

• No harm, potential for more than minimal, patternF684May 21, 2025

  Based on observation, interview, and record review, the facility failed to ensure residents received care and services in accordance with professional standards of practice for medication administration via Gastrostomy Tube (G-tube) for 1 of 3 residents reviewed for enteral medication administration (Resident #56), for 1 of 1 resident reviewed for intravenous (IV) medication administration (Resident #420), and for 3 of 6 residents reviewed for wound care (Residents #51, #419, and #421). Findings include: 1) During an observation on 5/19/2025 at 8:25 AM, Resident #421 had a foam-bordered dressing to her left elbow, which was dislodged and dated 5/16/2025. […]

• No harm, potential for more than minimal, patternF695May 21, 2025

  Based on observation, interview, record review, the facility failed to ensure residents received respiratory care as ordered by physician order for 3 of 5 residents reviewed for respiratory services (Residents #62, #69, and #270). Findings include: 1) During an observation on 5/18/2025 at 10:02 AM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an observation on 5/18/2025 at 1:30 PM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an observation on 5/19/2025 at 9:12 AM, Resident #270 was lying in bed, receiving no oxygen. There was no oxygen concentrator in his room. During an interview on 5/19/2025 at 9:12 AM, Resident #270 stated, I don't use oxygen. […]