Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Health And Rehabilitation Center during CMS and state inspections, most recent first.
Unlabeled, undated, and expired foods were found in a South unit nourishment refrigerator, including resident-labeled leftovers, open beverages, and an expired carton of milk. The DM confirmed foods should be labeled and dated when opened or placed in the refrigerator, while staff gave differing accounts of who was responsible for cleaning and maintaining the refrigerator; the facility policy required refrigerated food to be labeled, dated, and monitored for use by date or discarded.
A facility failed to include appeal rights, instructions for filing an appeal, and appeals agency contact information on hospital transfer notices for two residents. One resident with pneumonia became confused, had AMS, an O2 sat of 78%, became nonresponsive, and was sent by ambulance to the hospital; another resident with OA and adult failure to thrive had a short-term hospital discharge. The SSD and Administrator stated the facility did not provide the appeal information because they were told it was not required.
Surveyors found that several facility areas, including the clean linen room, overflow linen room, biohazard room, and medication room, were not maintained in a clean, orderly, or sanitary manner. Observations included clutter, debris, dirty floors, improperly stored supplies, and unsanitary conditions in refrigerators and laundry areas. The Housekeeping Director confirmed the poor condition of the clean linen room.
Surveyors found that the facility failed to maintain a clean, safe, and homelike environment, with observations of soiled and cluttered hallways, resident rooms, shower rooms, and the dining area. Multiple mobility chairs had torn upholstery, and resident equipment and furniture were dirty or in disrepair. Housekeeping practices did not ensure adequate cleaning, as evidenced by dirty mop water and persistent debris in resident and common areas.
Expired insulin pens and vials were found on two medication carts, with some lacking proper labeling and others past their expiration dates. Medication room refrigerators were left unlocked, and narcotic lock boxes containing lorazepam were not affixed to shelving as required. Additionally, one refrigerator was found dirty. LPNs and the ADON confirmed these deficiencies and acknowledged that storage and labeling practices did not meet facility policy.
A resident with severe cognitive impairment and a need for assistance with personal hygiene was observed to have long, jagged, and dirty fingernails over multiple days, despite documentation indicating care was provided and no recorded refusals. The care plan addressed general refusals but did not specifically address nail care, leading to inadequate hygiene for the resident.
A resident with severe cognitive impairment and a history of wandering eloped from the facility when an LPN opened a secured door for a recreational therapist, who then held the door open, allowing the resident to exit unsupervised. The therapist was unaware the individual was a resident, and staff did not alert him to prevent the exit. The resident was later found off facility property and returned without injury. The incident was captured on video, confirming lapses in supervision and monitoring.
A resident with mental health diagnoses was not referred for a required PASARR Level II screening due to a communication breakdown among staff. The facility's policy mandates coordination with the PASARR program, but the Social Service Director was not informed of the resident's schizoaffective disorder diagnosis, which should have prompted the screening. This oversight could result in the resident not receiving necessary specialized services.
The facility failed to follow care plans for residents receiving oxygen therapy, administering incorrect oxygen rates and neglecting to clean oxygen concentrators as required. Observations and staff interviews confirmed these deficiencies, with discrepancies in medical records and unclean equipment noted. The care plans included specific interventions that were not consistently adhered to, leading to these issues.
The facility failed to maintain respiratory equipment and administer oxygen as per physician orders for several residents. Observations revealed unclean oxygen concentrators and incorrect oxygen flow rates, with staff acknowledging these issues. Residents with severe cognitive impairment and chronic conditions were affected, highlighting lapses in equipment maintenance and adherence to medical orders.
Unlabeled, Undated, and Expired Foods in Nourishment Refrigerator
Penalty
Summary
The facility failed to ensure foods stored in one of two nourishment refrigerators on the South unit were labeled, dated when opened, and not expired. During an observation, the nourishment refrigerator contained three Styrofoam bowls of applesauce or pudding that were neither labeled nor dated, four plastic containers of food leftovers labeled with a resident's name but not dated, an open can of Coke with a straw sticking out and uncovered, and several open beverage and food items including Diet Pepsi, Coke Zero, orange juice, and coffee creamer that were not labeled or dated. During a later observation with the Dietary Manager, the same refrigerator still contained the unlabeled and undated bowls, the undated resident-labeled leftovers, and an expired carton of milk. The Dietary Manager confirmed that foods in the nourishment refrigerator should be labeled with the resident's name and dated when opened or placed in the refrigerator, and that expired foods should be removed. Staff interviews identified differing responsibilities for maintaining the nourishment refrigerators, with the DM stating dietary was not involved, the DON stating she checked temperatures daily but did not clean or remove expired foods, and other nursing staff stating the charge nurse or night shift charge nurse was responsible for cleaning and maintaining the refrigerators. The facility policy stated refrigerated food shall be labeled, dated, and monitored for use by date, frozen, or discarded, and that the night shift supervisor/charge nurse is responsible for cleaning out nourishment room refrigerators twice per week.
Transfer Notices Missing Appeal Information
Penalty
Summary
The facility failed to ensure written notice to the resident or resident representative for hospital transfers included a statement of appeal rights, instructions for filing an appeal, and contact information for the appeals agency for two residents reviewed for hospitalization. The facility policy titled, Transfer and Discharge, dated July 2025, stated the transfer/discharge notice would include the specific reason and basis for transfer or discharge, the effective date, the specific location to which the resident was to be transferred or discharged, and the phone number of the representative of the Office of the State Long-Term Care Ombudsman, but it did not address the requirement to provide appeal rights information, instructions for filing an appeal, or appeals agency contact information. Resident R91 was admitted with a diagnosis of pneumonia. A progress note dated 09/27/25 documented that the resident was confused, had altered mental status, an O2 saturation of 78%, became nonresponsive, and was sent by ambulance to the hospital for evaluation and treatment. The Resident Transfer Form for that transfer did not contain appeal rights information, instructions for filing an appeal, or appeals agency contact information. Resident R79, admitted with osteoarthritis and adult failure to thrive, had a short-term discharge to a hospital with anticipation of readmission. The Resident Transfer Form and Notice of Transfer for that discharge did not include appeal information or ombudsman information. During interviews, the SSD and Administrator stated the facility did not provide appeals information on the transfer form and said they had been told by the appeals agency that it was not required.
Failure to Maintain Sanitary and Orderly Environment in Multiple Facility Areas
Penalty
Summary
Surveyors observed multiple areas of the facility that were not maintained in a clean, orderly, or sanitary manner. At the nurse's station near the South Hall shower room, empty cardboard boxes, a plastic cup, and scattered debris including a cotton ball and paper were found on the floor. Between the supplement room and the locked medication room, opened and unopened boxes of nutritional supplements were stacked on the floor. Inside the medication room, items were cluttered on the counter, a medication box was overfilled, and debris and crumbs were present on the floor and under cabinets. The nourishment room refrigerator was in disarray, with sticky substances and a need for cleaning noted inside both the refrigerator and freezer. In the Biohazard Room, a hopper contained standing dark gray water and had a black substance around the rim, and was not secured to the structure. Trash, debris, and an accumulation of dirt and grime were present on the floor and baseboards. Chemicals, sharps containers, and biohazard bags were stored on the floor, and the entire floor had a buildup of dark grime. An attached overflow laundry room had laundry on the floor, dirt and grime buildup, dead bugs, cobwebs, and light coming in around the exit door. The clean laundry room also had laundry on the floor, some with brown stains, plastic bags of laundry, IV poles and other equipment stored on the floor, and a brownish buildup of grime. The Housekeeping Director confirmed the condition of the clean linen room and accepted responsibility during an interview.
Failure to Maintain Clean, Safe, and Homelike Environment
Penalty
Summary
Surveyors identified multiple failures by the facility to maintain a safe, clean, comfortable, and homelike environment as required by policy. Observations included soiled and debris-laden areas in both the North and South hallways, resident rooms, shower rooms, and the main dining room. Specific findings included dirty blinds, windowsills with cobwebs and dead insects, soiled stop sign banners on resident room doors, and missing floor tiles with debris in the shower room. The shower room was also cluttered with boxes and storage units, and bathtubs contained debris and trash. Ceiling tiles above the nurse's station were stained and discolored, with one tile showing a large area of black substance. The dining room had scattered debris, food splatters on tables and walls, dirty blinds, and chairs with accumulated grime and dust. In resident rooms, several deficiencies were noted. One resident's wheelchair had a torn cushion with exposed foam and accumulated dirt and food particles on the wheel spokes and bed frame. The bedside table contained an empty pickle jar, a can of squirt cheese without a lid, and crumbs, while the drawers were heavily soiled with food and spillage. Another resident's overbed table had open snack items and soda bottles, with crumbs and debris around and under the bed. A third resident's bed control had exposed wires and was nonfunctional, and a urinal three-fourths full of urine was left on the bedside table. The overbed table was sticky with dried brown substances, and the floor had a buildup of dirt, grime, and food debris. Additional observations included soiled banners on room doors and a plastic bag left at the base of a hallway door. Resident equipment was also found in poor condition. Multiple mobility chairs, including Broda and geri chairs, had torn vinyl armrests with exposed foam, and debris was observed in the seat of one chair. The maintenance director confirmed responsibility for repairs, and the night shift was reportedly responsible for cleaning wheelchairs. Housekeeping practices were questioned, as mop water was observed to be dirty, and the frequency of changing mop heads and water did not align with observed conditions. Deep cleaning schedules and checklists were in place, but actual cleaning did not meet the standards outlined, as evidenced by the persistent dirt and debris in resident rooms and common areas.
Expired Medications and Improper Storage of Controlled Substances
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as evidenced by the presence of expired insulin pens and vials on two of four medication carts reviewed. Observations revealed that some insulin pens were missing resident names, open dates, and expiration dates, and some vials were past their expiration dates but remained in use. Additionally, some insulin vials were not labeled with the date they were opened, and unopened vials that required refrigeration were not stored as directed. Staff interviews confirmed that these insulins were expired and should not have been used, and that labeling and storage practices did not align with facility policy. Further deficiencies were identified in the medication rooms, where both the North Hall and South Hall medication room refrigerators were found unlocked, and the narcotic lock boxes inside were not affixed to the shelving as required. The narcotic lock boxes contained multiple vials of lorazepam, a Schedule IV controlled substance. The South Hall medication room refrigerator was also noted to be dirty, with debris and a yellowish sticky substance present. Staff confirmed these findings and acknowledged that the refrigerators should have been locked and the narcotic boxes properly secured.
Failure to Provide Nail Care for Cognitively Impaired Resident
Penalty
Summary
Staff failed to provide adequate nail care for a resident who was severely cognitively impaired and required partial to moderate assistance with personal hygiene. The resident was admitted with diagnoses including major depression and had a Brief Interview for Mental Status (BIMS) score of five out of 15, indicating severe cognitive impairment. Documentation in the electronic medical record showed that the resident received varying levels of assistance with personal hygiene, and there was no documentation of refusal of care during the period reviewed. Despite this, observations on multiple occasions revealed that the resident's fingernails were long, jagged, and had a brown substance underneath. The care plan for the resident addressed general refusals of care but did not specifically address personal hygiene or nail care. Interviews with facility staff confirmed that the care plan was not specific to nail care, and staff were notified of the resident's nail condition. The lack of specific interventions and failure to provide necessary nail care resulted in the resident having dirty, untrimmed, and unclean nails over an extended period.
Failure to Prevent Elopement of Resident with Cognitive Impairment
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including dementia with behavioral disturbance, anxiety disorder, and schizophrenia, eloped from the facility without supervision. The resident had a documented history of wandering, was assessed as being at risk for elopement, and had a care plan in place that included frequent monitoring, use of an elopement risk book, and exit alarms. Despite these interventions, the resident was able to leave the facility unsupervised. The incident took place when an LPN opened a secured side door to admit a recreational therapist. As the LPN walked away, the therapist held the door open, allowing the resident to exit the facility. The therapist was not aware that the individual was a resident and believed they were a family member. No staff member alerted the therapist to the resident's status or the need to prevent their exit. The resident was not noticed missing until later during a medication pass, prompting a facility-wide search and notification of the administrator, police, and family. The resident was eventually found off facility property by an acquaintance of the family and returned to the facility without evidence of physical injury. The facility's video surveillance captured the incident, showing the resident exiting past both staff members, but the video lacked a date and time stamp. Staff interviews confirmed that the required supervision and monitoring were not maintained at the time of the incident, resulting in the resident's unsupervised elopement.
Failure to Conduct PASARR Level II Screening
Penalty
Summary
The facility failed to refer a resident for a pre-admission screening and resident review (PASARR) Level II screening, which is required for individuals with mental disorders or related conditions. The resident in question, identified as R61, was admitted with diagnoses including anxiety disorder, major depressive disorder, and schizoaffective disorder. Despite these diagnoses, the resident's electronic medical record and Minimum Data Set (MDS) assessment indicated that a PASARR Level II evaluation had not been conducted. This oversight was contrary to the facility's policy, which mandates coordination with the PASARR program to ensure appropriate care and services. Interviews with facility staff revealed a breakdown in communication regarding the resident's mental health diagnoses. The Social Service Director (SSD) was not informed of the schizoaffective disorder diagnosis, which should have triggered a PASARR Level II request. The Director of Nursing (DON) and the MDS Coordinator were responsible for notifying the SSD of such diagnoses, but this did not occur. The MDS/Care Plan Coordinator acknowledged the lapse in communication, which could result in the resident not receiving necessary specialized services. The DON confirmed that the lack of communication could lead to adverse outcomes for the resident, such as mental health issues requiring emergency room visits or hospitalization.
Failure to Follow Oxygen Therapy Care Plans
Penalty
Summary
The facility failed to adhere to the care plans for residents receiving oxygen therapy, specifically in administering the correct oxygen rate and maintaining the cleanliness of oxygen concentrators. For two residents, the facility did not follow the physician-ordered rate of oxygen, administering higher levels than prescribed. This discrepancy was observed in the medical records and confirmed through staff interviews, where it was acknowledged that the oxygen was not administered as per the physician's orders. Additionally, the facility did not maintain the oxygen concentrators as required by the care plans. Observations revealed that the concentrators had accumulated dust and dirt, indicating that the filters were not cleaned weekly as ordered by the physicians. Staff interviews confirmed the neglect in cleaning the equipment, and it was noted that the tasks were either documented as refused or completed without actual verification. The care plans for the residents included specific interventions for oxygen therapy, such as cleaning the equipment and administering oxygen at the prescribed rate. However, these interventions were not consistently followed, leading to deficiencies in care. The staff interviews highlighted a lack of awareness and adherence to the care plans, contributing to the observed deficiencies.
Deficiencies in Oxygen Therapy Management
Penalty
Summary
The facility failed to maintain respiratory equipment in a sanitary manner and administer oxygen according to physician orders for several residents. For one resident, the oxygen concentrator was observed to have accumulated dust and dirt on both the external slats and the internal filter, despite a physician's order specifying weekly cleaning. Interviews with nursing staff confirmed the equipment's unclean state and acknowledged the responsibility for its maintenance, yet the necessary cleaning was not documented or performed as required. Another resident, who had severe cognitive impairment and required oxygen therapy, was found to have an oxygen concentrator with a filter vent covered in a gray substance. The resident's treatment administration record indicated that the cleaning and tubing changes were documented as refused on one occasion, but completed on others. However, observations showed the equipment remained unclean, and the responsible nurse could not recall the resident refusing the maintenance tasks, suggesting a lapse in documentation and follow-up. Additionally, two residents were receiving oxygen at a higher flow rate than prescribed by their physicians. One resident with chronic obstructive pulmonary disease was observed receiving oxygen at 3.5 liters per minute, contrary to the physician's order of 2 liters per minute. The nursing staff confirmed the discrepancy and acknowledged the potential adverse effects of excessive oxygen for residents with COPD. Similarly, another resident's oxygen concentrator was set at 3 liters per minute instead of the ordered 2 liters per minute, with staff confirming the incorrect setting and the resident stating that only nurses adjusted the flow rate.
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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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Nursing homes near Rome
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Winthrop Health And Rehabilitation | 3.5 mi | ★★★★★ | 4 | 0 |
| Fifth Avenue Health Care | 3.7 mi | ★★★★★ | 9 | 0 |
| Etowah Landing | 4.3 mi | ★★★★★ | 7 | 0 |
| Pruitthealth - Rome | 4.7 mi | ★★★★★ | 7 | 0 |
| Magnolia Place Nursing And Rehabilitation | 5.4 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 July 2026) and official state health department websites.