Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Nursing Home during CMS and state inspections, most recent first.
The facility failed to prevent multiple episodes of resident‑to‑resident physical abuse on a dementia unit involving several cognitively impaired residents with known histories of wandering and aggression. In separate incidents, one resident pushed another, causing a fall and head laceration requiring ED treatment; two residents engaged in a confrontation where one grabbed the other’s shoulders and was struck in return; another resident with a history of entering others’ rooms was found in a roommate’s bed and both sustained scratches; and a resident with dementia and poor impulse control swung his walker and struck another resident in the face. Care plans documented behaviors such as wandering, physical and verbal aggression, and triggers for agitation, and called for monitoring, redirection, and protection of others, yet these measures did not prevent the altercations. Staff reported that residents on the unit required close or continuous supervision and expressed concern that at times no staff were free to monitor behaviors when others were on break or occupied in rooms, particularly during evening and night hours.
A resident with dementia, severe cognitive impairment, daily wandering, gait abnormality, and muscle weakness experienced multiple witnessed and unwitnessed falls resulting in head lacerations, a subdural hematoma, hip fracture, rib fractures, and spinal fractures. The facility’s fall policy required assessment and individualized interventions after each fall, but the care plan remained nonspecific, did not identify needed adaptive equipment, and was not updated after a PT evaluation that changed the resident’s ambulation status from independent to requiring supervision or touching assistance. Several falls were not followed by documented IDT review or new fall-prevention interventions, staff attempted distant verbal redirection that led to a missed chair and fall, and a four-wheel walker was introduced despite the resident’s inability to use it safely. CNAs reported the resident ambulated alone, were unsure of alternative safe-walking options, and described challenges providing continuous monitoring, while leadership acknowledged a delay in communicating the new ambulation assistance level to nursing staff.
The facility failed to provide appropriate hot water in bathroom sinks for residents in two units, with temperatures recorded below standard. Additionally, several high back dining room chairs in the secure and main dining rooms had cracks and tears. The maintenance director cited a year-long delay in replacing a circulation pump and chairs, and the facility's repair request system was not operational.
A resident with Alzheimer's and kyphosis was observed leaning in her wheelchair due to improper use of a positioning device. The facility failed to document the device in the care plan and did not educate staff on its correct use, leading to inconsistent positioning. Staff interviews revealed a lack of understanding about the proper positioning of the resident's arm on the device.
A resident in an LTC facility experienced inadequate pain management, with frequent reports of high pain levels despite scheduled medications. The facility failed to provide PRN pain medications or non-pharmacological interventions, leading to unmanaged pain and related behavioral issues. Staff interviews revealed a lack of awareness and action regarding the resident's pain management needs.
The facility failed to properly store and label medications in the medication room. An opened vial of Aplisol lacked an open date, and an expired FluZone vaccine was not removed. The IP and DON confirmed the need for proper labeling and removal of expired medications.
A facility failed to maintain sanitary conditions by allowing a resident's catheter drainage bag to touch the floor, contrary to its policy. Despite staff awareness that the bag should not touch the floor to prevent infections, observations showed the bag in contact with the floor over several days. The resident, with severe cognitive impairments and dependent on staff for daily living activities, had a care plan that did not specify keeping the bag off the floor.
The facility failed to follow its pneumococcal vaccination policies for two residents, leading to a deficiency in their vaccination status. One resident, over 65 with severe cognitive impairment, did not receive the recommended follow-up vaccine after PPSV23. Another resident, under 65 with Parkinson's, had signed consents but did not receive the vaccine until the survey. The IP and DON were unaware of these lapses until the survey, prompting an audit to identify other affected residents.
Failure to Prevent Resident‑to‑Resident Physical Abuse on Dementia Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical abuse by other residents on a dementia (Cottage) unit, despite known histories of wandering and aggression. Facility policy required prevention of all types of abuse, identification and monitoring of residents whose behaviors might lead to conflict, and having trained and qualified staff in sufficient numbers to meet residents’ needs. Several residents had documented patterns of wandering into others’ rooms, physical and verbal aggression, and disruptive behaviors, yet altercations occurred in which residents physically harmed one another. Staff interviews indicated that residents on the Cottage unit required close and continuous supervision and that there were times when no designated staff were available to monitor resident behavior when others were occupied or on break. In one incident, a resident with Alzheimer’s disease, dementia, severe cognitive impairment, daily wandering, and a history of physical and verbal aggression entered into a physical altercation with another resident with dementia and behavioral disturbances. The aggressor pushed the other resident, who lost balance, fell, and struck his head on a chair, resulting in a 4 cm head laceration that required staples in the ED. Records showed that both residents had pre‑existing care plans addressing dementia, wandering, and physical aggression, with interventions such as redirection, removal from situations, and protection of others’ safety. However, on the night shift when the altercation occurred, these measures did not prevent the resident from becoming agitated, exit seeking, entering others’ rooms, and ultimately being involved in a physical altercation that caused injury. Another incident involved two residents with dementia and behavioral issues, where one resident, known to wander, sleep in other residents’ beds, and have a history of physical aggression, was involved in a confrontation with another resident. During a verbal altercation, one resident grabbed the other by the shoulders and pulled her backwards, and the other responded defensively by striking the aggressor’s abdomen with the back of her hand. Both residents were assessed and found to have no injuries. Care plans for these residents documented wandering, physical aggression, and the need for monitoring, redirection, and prevention of escalation, but the altercation still occurred while staff were attempting to redirect them. In a separate event, a resident with dementia and wandering behaviors was found lying in another resident’s bed after staff had recently assisted her to her own bed. The resident whose bed was occupied screamed, and when staff responded, both residents were found to have new scratches (one on the face, one on the forearm) consistent with a physical altercation. The resident who wandered had documented behavior problems of wandering and sleeping in other residents’ beds and a history of physical aggression, with care plan interventions including monitoring for wandering, preventing escalation of aggression, and ensuring she entered the correct room. Despite these identified needs and interventions, she was able to enter another resident’s room and bed, leading to mutual scratching injuries. In another substantiated incident, a resident with Alzheimer’s disease, dementia with behavioral disturbance, poor impulse control, and known triggers related to searching for his wife attempted to enter a female resident’s room in the evening. A CNA observed him swinging his front‑wheel walker toward the resident and striking her in the face with his hand or closed fist, leaving a red mark and pain rated 4/10. The aggressor had a care plan for physical aggression that identified his triggers and required staff to identify behaviors early, document them, and intervene before agitation escalated. Nursing documentation also noted that he had evening and nighttime confusion, aggression, violent behaviors toward staff and other residents, and required constant supervision to redirect him from female residents’ rooms. Nonetheless, he was able to approach and strike another resident. Staff interviews further described that all residents on the Cottage unit required close or continuous monitoring and that some residents needed redirection away from each other to avoid altercations. CNAs reported concerns about resident safety when staff were on breaks or occupied in resident rooms, leaving no designated staff to monitor behaviors. The social services director acknowledged that residents’ behaviors could increase at night and that existing interventions did not include alternatives for night redirection when activities staff were unavailable and when fewer staff were assigned after 10:00 p.m. Across these events, residents with known histories of wandering and aggression, and with care plans specifying monitoring and redirection to protect others, were not adequately protected from or prevented from engaging in physical altercations, resulting in substantiated incidents of resident‑to‑resident physical abuse.
Failure to Implement and Communicate Person-Centered Fall Interventions After Multiple Falls With Injury
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident remained free from accidents by not timely implementing person-centered fall interventions and not updating care plans after multiple falls. The facility’s fall management policy required assessment upon admission, with changes in condition, and after any fall, with individualized interventions and IDT review and revision of the care plan as indicated. For this resident, the fall prevention care plan listed general interventions such as orientation to room, diversionary activities, referral to PT, use of a soft helmet, and provision of adaptive equipment, but did not specify what adaptive equipment or devices were needed. Despite a PT evaluation identifying a change in the resident’s functional status and need for supervision or touching assistance with ambulation, the fall prevention care plan was not updated to reflect this new level of assistance. The resident, an individual over 65 with Alzheimer’s disease, dementia, severe cognitive impairment, disorganized thinking, daily wandering, gait abnormality, muscle weakness, and multiple other diagnoses, experienced several falls with injuries. The record shows a witnessed fall where the resident tripped while two staff assisted him to the restroom, resulting in knee abrasions; the behavior huddle note following this event only addressed behavior interventions and did not include a post-fall review or new fall-prevention interventions. Another witnessed fall occurred when the resident was struck by another resident, causing a head laceration requiring staples in the ED; there was no documentation that the IDT reviewed this fall or recommended fall-prevention interventions. An unwitnessed fall later occurred in the resident’s room, with a hematoma on the back of the head and documentation that the resident wore big, bulky shoes; again, there was no IDT review or new interventions documented. Subsequently, the resident had a witnessed fall in the hallway when staff attempted to redirect him from a distance to sit in a chair; he missed the chair and fell, sustaining arm and elbow injuries. A CT scan later showed a subdural hematoma with midline shift. Nursing documentation noted that a four-wheel walker was provided, but the resident did not use it correctly, became aggressive when cued, and the nurse considered the walker a tripping hazard; the IDT post-fall note from this period contained no additional fall-prevention recommendations beyond a declined request for sleep medication. Another unwitnessed fall occurred in the hallway outside the resident’s room, during which he yelled out in pain and clutched his left hip; hospital records documented a left hip fracture, multiple rib fractures, and thoracic spine fractures. Across these events, staff interviews revealed CNAs were unsure of alternative safe ambulation options, reported that the resident walked around the unit by himself, and described difficulty providing continuous monitoring due to other tasks and lack of coverage during breaks. The DON acknowledged a breakdown or delay in communicating PT’s change in ambulation assistance needs to nursing staff, and there was repeated lack of documented IDT review and revision of the fall care plan after multiple falls with injury.
Deficiencies in Hot Water Access and Dining Room Chair Maintenance
Penalty
Summary
The facility failed to provide a functional, comfortable, and homelike environment for residents in two units. Specifically, the facility did not ensure that residents in certain rooms had access to appropriate hot water in their bathroom sinks. Observations revealed that the hot water in these rooms was consistently cool to the touch, with recorded temperatures ranging from 94.8 to 109.7 degrees Fahrenheit, which is below the expected standard for hot water. Residents reported that the water had always been cold, indicating a persistent issue. The maintenance director acknowledged the problem, attributing it to a circulation pump on the water heater that had not been replaced for a year, despite having the necessary part available. Additionally, the facility failed to maintain high back dining room chairs in both the secure unit dining room and the main dining room, as several chairs were observed to have cracks and tears on the seats. The maintenance director had conducted an audit a year prior, identifying the need for replacement chairs, but had not received approval from corporate management to proceed. The maintenance director also noted that the facility's system for communicating repair requests was not operational, complicating the process of addressing maintenance issues. Despite regular communication with the nursing home administrator, the administrator was unaware of the condition of the dining room chairs.
Inadequate Use of Wheelchair Positioning Device for Resident
Penalty
Summary
The facility failed to ensure that a resident received appropriate treatment and services to maintain or improve her abilities, specifically in the use of a wheelchair positioning device. The resident, who was over 65 years old and had diagnoses including Alzheimer's disease, kyphosis, dysphagia, and hypertension, was dependent on staff for various activities of daily living and used a manual wheelchair for mobility. Observations revealed that the resident was often leaning to her left side in the wheelchair, with her arm not positioned correctly on the specialized positioning device intended to aid in proper seating. The deficiency was noted during multiple observations where the resident was either without the positioning device or had it improperly positioned, leading to her leaning to the left. The Director of Nursing (DON) observed the incorrect positioning and adjusted the resident's arm to rest on the device, indicating that staff were not consistently ensuring the device was used correctly. The resident's care plan did not document the use of the wheelchair positioning device, and there was no evidence that staff had been educated on its proper use. Interviews with staff, including the DON, a restorative nurse aide, an LPN, and a CNA, revealed a lack of understanding and consistency regarding the correct positioning of the resident's arm on the device. While staff were aware of the resident's tendency to lean and the use of the positioning device, they were unable to articulate the correct method for positioning the resident's arm to ensure she sat upright. This lack of documentation and staff education contributed to the deficiency in care for the resident.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #4, who was experiencing significant pain. Despite being on scheduled pain medications, the resident frequently reported high pain levels, ranging from 5 to 10 on a scale of 1 to 10, with an acceptable pain level documented as 3. The resident's care plan included scheduled administration of Tramadol and Acetaminophen, but there were no orders for PRN pain medications to address breakthrough pain. Additionally, the facility did not implement non-pharmacological interventions to help manage the resident's pain, despite the resident expressing that such interventions might be beneficial. Interviews with the resident revealed that she consistently experienced pain levels of 8 out of 10 and felt that the facility did not take her pain seriously. She reported that when she communicated her pain to the nursing staff, she was told to wait for her next scheduled dose of medication, and no alternative interventions were offered. The resident's behavior, which included verbal outbursts and frequent use of the call light, was documented in her records but was not adequately addressed as potentially being related to unmanaged pain. Staff interviews indicated a lack of awareness and action regarding the resident's pain management needs. Certified Nurse Aides (CNAs) and a Licensed Practical Nurse (LPN) acknowledged the resident's daily complaints of pain but did not report any attempts to use non-pharmacological interventions. The Director of Nursing (DON) admitted that the facility could improve in re-educating nurses to offer non-pharmacological interventions and to assess whether pain was contributing to the resident's behaviors. The facility's failure to effectively manage the resident's pain, as outlined in their policy, resulted in the resident experiencing ongoing discomfort and behavioral issues.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals in the medication storage room. During an observation, it was found that a vial of Aplisol, used for tuberculosis testing, was opened but lacked an open date, which is necessary to track its 28-day usability period. Additionally, a pre-filled syringe of FluZone High Dose Quadrivalent flu vaccine with an expiration date of June 2024 was still present in the medication refrigerator, indicating it had not been removed after expiration. Interviews with the infection preventionist (IP) and the director of nursing (DON) revealed that the facility's management team was responsible for conducting weekly and monthly audits to check for expired medications and ensure proper labeling. The IP acknowledged that the Aplisol vial should have been dated upon opening and removed for destruction to prevent accidental administration. The DON confirmed that it was the nurses' responsibility to label medications when opened and that expired medications might not be effective if administered.
Failure to Maintain Sanitary Conditions for Catheter Management
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of infections, specifically concerning the management of a resident's catheter drainage bag. The facility's policy, revised in June 2023, mandates that catheter drainage bags should not rest on the floor to prevent urinary tract infections. However, observations on multiple occasions revealed that the catheter drainage bag of a resident, who was dependent on staff for all activities of daily living and had severe cognitive impairments, was touching the floor while the resident was in bed. This was contrary to the facility's policy and the care plan, which did not explicitly document the need to keep the drainage bag off the floor. Interviews with staff, including a CNA, an LPN, the infection preventionist, and the DON, confirmed that the catheter drainage bag should not touch the floor to prevent contamination and potential infections. Despite this understanding, the deficiency was observed over several days until corrective action was taken by placing the catheter drainage bag in a privacy cover. The failure to adhere to the facility's policy and ensure the catheter drainage bag was properly positioned contributed to the unsanitary condition observed.
Failure to Implement Pneumococcal Vaccination Policies
Penalty
Summary
The facility failed to implement its policies and procedures related to pneumococcal immunizations for two residents, leading to a deficiency in their vaccination status. According to the CDC's recommended immunization schedule, individuals over a certain age who have previously received the PPSV23 vaccine should receive an additional dose of either PCV15 or PCV20 at least one year later. The facility's policy, revised in July 2024, mandates that residents be offered these vaccines unless contraindicated or already immunized, with documentation required in the resident's medical record. Resident #33, over the age of 65, was admitted with several medical conditions, including Down syndrome and severe cognitive impairment. The resident's medical record indicated receipt of the PPSV23 vaccine in December 2022, but there was no documentation of an offer or administration of the subsequent recommended pneumococcal vaccine until the survey in August 2024. The infection preventionist (IP) confirmed that the resident should have received the second dose but was unaware if it had been offered. Resident #346, under the age of 65, was admitted with conditions such as Parkinson's disease and hypertension. The resident had signed consents for the pneumococcal vaccine during previous admissions, but the medical record did not document the administration of the vaccine until the survey. The IP acknowledged that the resident was eligible for the updated vaccine but had not received it prior to the survey. The director of nursing (DON) was unaware of these issues until the survey and initiated an audit to identify other residents who might not have received their vaccinations.
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What surveyors actually found near you
We read the 31 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Alamosa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| San Luis Care Center | 0.6 mi | ★★★★★ | 0 | 0 |
| Colorado Veterans Community Living Ctr At Homelake | 13.6 mi | ★★★★★ | 0 | 0 |
| Rock Creek Rehabilitation And Healthcare Center | 14.7 mi | ★★★★★ | 16 | 0 |
| Rio Grande Rehabilitation And Healthcare Center | 15.9 mi | ★★★★★ | 15 | 1 |
| River Valley Rehabilitation And Healthcare Center | 29 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.