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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Commons Rehabilitation And Nursing Ctr during CMS and state inspections, most recent first.
A resident with dementia, prior femur fracture, and severe cognitive impairment had a care plan identifying fall risk and requiring use of proper footwear/non-skid socks, along with floor mats and bed in low position. The resident was dependent on staff to don and doff footwear. During a night shift, a CNA provided incontinence care and documented that the resident did not have appropriate footwear on, and an LPN also documented that the resident lacked appropriate footwear. Later, the resident was found nude, face down on the floor next to the bed on a floor mat, and subsequently complained of hip pain; imaging confirmed a femoral fracture. There was no documentation that non-skid socks were in place at the time of the fall or that the resident had refused them, indicating the care-planned intervention for non-skid footwear was not implemented.
A resident with chronic kidney disease on dialysis, cellulitis, and metastatic endometrial cancer left for hemodialysis alert and communicative and returned hours later slumped in a wheelchair, unresponsive, and soon pronounced deceased. Facility video, a friend’s written statement, and staff interviews showed that the resident became disoriented and distressed at dialysis, was reportedly unresponsive when brought out by dialysis staff, and arrived back at the facility limp and drooling. The dialysis communication sheets for two treatments had no entries from the dialysis center, and multiple attempts by nursing leadership to reach the dialysis provider were unsuccessful, leaving the events during treatment unexplained. Despite facility policies requiring reporting and investigation of incidents not consistent with routine care and situations where abuse or care plan violations could not be ruled out, no internal investigation was conducted and the incident was not reported to the New York State Department of Health.
A resident with CKD on dialysis, cellulitis, and metastatic endometrial cancer left for hemodialysis alert, upright, and communicating, with oxygen in place. Facility policy required a dialysis communication book with an Interfacility Report completed by facility staff before transport and by the dialysis unit before return, but the dialysis sections for this and a prior treatment were left blank. On return, video and a friend’s statement showed the resident slumped, limp, drooling, and unresponsive, with staff unable to obtain vital signs and an RN confirming no pulse, mottling, and cyanosis before the resident was pronounced dead. Despite policies requiring thorough investigation of all unusual occurrences and potential injuries of unknown source, and despite unsuccessful attempts to reach the dialysis center, facility leadership, including the DON and Administrator, acknowledged that no investigation or incident report was completed into the events at dialysis or during transport that preceded the resident’s death.
A resident with chronic kidney disease on dialysis, cellulitis, and metastatic endometrial cancer received intermittent O2 therapy without a physician’s order or related care plan interventions, contrary to facility policy requiring a specific medical order and respiratory care plan. MAR and vital sign records documented the resident on 2L O2 on multiple occasions, including pre-dialysis, and staff reported the resident returning from dialysis on portable O2, being supplied with O2 tanks for trips, and having O2 in place at the time of death. The Administrator acknowledged that an O2 order should have been in place.
Failure to Implement Care-Planned Non-Skid Footwear Leading to Fall and Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident’s right to be free from neglect by not implementing a care-planned intervention requiring proper footwear/non-skid socks to prevent falls. The facility’s abuse/neglect policy defined neglect as the failure to provide goods and services necessary to avoid physical harm, pain, mental anguish, or emotional distress, and required investigation of all potential neglect incidents. The resident had a care plan for being at risk for falls that included bilateral floor mats, encouraging the resident to wear proper footwear/non-skid socks, maintaining the bed in the lowest position, providing a call bell and frequently used items within reach, a perimeter mattress, early get up, and PT/OT evaluation as needed. The resident had diagnoses including dementia, a left femur fracture, and an acute gastric ulcer with hemorrhage, and was assessed as having severe cognitive impairment, being able to be understood but rarely/never understanding others. The care plan for ADLs/mobility documented that the resident was dependent on a mechanical lift with two staff for sit-to-chair transfers and required one-person assistance to put on and take off footwear. On the night of the incident, a CNA documented that they had provided incontinence care approximately 30–40 minutes before the fall and indicated on the incident statement that the resident did not have appropriate footwear on at that time. Another staff statement from an LPN also indicated that the resident did not have appropriate footwear on. At approximately 4:10 AM, the resident was found on the floor next to the bed, face down, nude, with a small amount of feces observed, lying on or near a floor mat with the bed in the lowest position. An RN assessment initially documented no apparent injury and neurological checks within normal limits, with the resident denying pain and no pain observed in the extremities. However, a later post-fall RN assessment documented that the resident complained of right hip pain and had facial grimacing with range of motion, and an x-ray subsequently showed a right femoral fracture. There was no documented evidence that the resident was wearing non-skid socks at the time of the fall, and no documentation that the resident had refused to wear them, despite the care plan intervention to encourage proper footwear/non-skid socks.
Failure to Report Unexplained Death Following Dialysis to State Authorities
Penalty
Summary
The deficiency involves the facility’s failure to report an alleged incident related to possible abuse, neglect, exploitation, or mistreatment to the New York State Department of Health as required, following the death of a resident who had been transported to and from dialysis. Facility policy required that all occurrences not consistent with routine operations and resident care that had or may have caused physical injury or harm be reported, reviewed, and thoroughly investigated, including completion of an Accident/Incident Report and, when applicable, abuse investigation materials. The policy also specified that injuries of unknown origin and incidents where the facility could not rule out abuse or a care plan violation must be reported to the Department of Health and that the Director of Investigations and Administrator be notified as soon as possible. Despite these requirements, there was no documented evidence that the events surrounding this resident’s death were reported to the state. The resident had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was assessed as minimally cognitively impaired and able to understand and be understood. On the day of the incident, the resident left the facility around late morning for hemodialysis and returned in the early evening. Video footage showed the resident leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A second video showed the resident returning from dialysis slumped to the left, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the driver or the friend who was waiting. The friend later documented that the resident arrived at the dialysis center uncomfortable, crying, and disoriented but still able to state their name, address, and recognize the friend, and that upon pickup after treatment the resident appeared unconscious, was not moving, and did not respond. Upon arrival back at the facility, the friend reported that the resident was limp and drooling and brought them to the nursing station, where staff quickly attended. Nursing staff attempted to obtain vital signs and a fingerstick; the fingerstick was believed to be within normal limits, but the blood pressure machine was not reading, and staff could not recall if an oxygen saturation reading was obtained. Multiple nurses observed that the resident was unresponsive, pulseless, with blue lips and mottling of the hands and fingers, and the resident was pronounced deceased shortly after return. The dialysis communication sheet showed that facility staff had documented pre-dialysis vital signs, but the section to be completed by the dialysis center was blank for this and the prior treatment, and attempts by the ADON and other staff to reach the dialysis center by phone were unsuccessful. The DON acknowledged there was no facility investigation into what happened at dialysis, stated that because the resident arrived with no pulse or respirations and had a DNR there was nothing to investigate, and reported that it did not occur to them that the incident should have been reported to the Department of Health. The Administrator similarly stated that no investigation was done because it was believed the resident had died at dialysis, and only in hindsight acknowledged they should have looked into it further. There was no documentation of a report to the state despite the unexplained circumstances and lack of information from the dialysis provider. The facility’s own policies on reporting and investigating incidents and on renal dialysis required thorough documentation, communication with the dialysis center, and reporting of incidents where the facility could not rule out abuse or a care plan violation. Staff interviews revealed that CNAs did not document in the dialysis communication book, that the dialysis center had not been completing its portion of the communication sheets for this resident’s treatments, and that there was no checklist or documentation of what items were sent with the resident to dialysis. The Director of Transportation confirmed that transport drivers were not medically trained and might not recognize subtle changes in condition. Despite these gaps and the unexplained change in the resident’s condition between departure and return, the facility did not initiate an internal investigation or report the incident to the New York State Department of Health as required by policy and regulation.
Failure to Investigate Resident Death Following Dialysis and Missing Interfacility Documentation
Penalty
Summary
The deficiency involves the facility’s failure to investigate an alleged incident related to a resident’s death following a dialysis treatment, despite policies requiring thorough investigation of all occurrences not consistent with routine operations and care. Facility policy on Reporting and Investigating Resident Accident/Incidents required that all such occurrences, including those that may have caused physical injury or harm, be reported, reviewed, and thoroughly investigated, with completion of an Accident/Incident Report, review of the care plan and CNA profile, and appropriate notifications. The policy also referenced federal regulation 42 CFR 483.13 regarding injuries of unknown source and outlined that incidents with injury without known incident and where abuse or care plan violation could not be ruled out must be reported to the New York State Department of Health and to the Director of Investigations and Administrator. Despite these requirements, there was no documented evidence that the facility conducted any investigation into the circumstances surrounding the resident’s condition upon return from dialysis and subsequent death. The resident involved had chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium, and was minimally cognitively impaired but able to understand and be understood. On the day in question, the resident left the facility around 11:00 AM for hemodialysis and was observed on video at noon leaving the facility in a wheelchair, upright, with an oxygen tank, and communicating with staff and the transport driver. A facility policy on Renal Dialysis required that residents be sent with a communication book containing an Interfacility Report completed prior to transport, and that the dialysis unit complete its section and a Dialysis Information Sheet before the resident’s return. However, the Dialysis Communication Sheet for that day, and for the prior dialysis visit, showed that the dialysis center’s section was left blank. Later that day, video showed the resident returning around 6:00 PM slumped to the left in the wheelchair, wrapped in a blanket, wearing a mask with oxygen tubing visible, and not interacting with the transport driver or the friend who met them. The friend’s written statement documented that the resident arrived at the dialysis center uncomfortable, crying, and disoriented but still able to state their name, address, and recognize the friend. The friend further documented that when they returned to pick the resident up, the resident appeared unconscious, was not moving, and did not respond, and that dialysis staff reported the resident had been crying and yelling and then fell asleep during treatment. Upon arrival back at the facility, the friend noted the resident was limp and drooling and brought them to the nursing station, where staff quickly attended to the resident. Multiple staff interviews confirmed that upon return from dialysis, the resident was unresponsive, with staff unable to obtain vital signs and a nurse confirming the resident was pulseless with blue lips and mottling of the hands and fingers. The resident was pronounced deceased shortly after arrival. Staff, including the ADON and an RN, attempted to call the dialysis center but were unable to reach anyone, and there was no other resident using that dialysis facility for comparison. The DON and Administrator both acknowledged that no facility investigation was conducted into what happened to the resident at dialysis or during transport, and there was no documentation of what items were sent with the resident or any checklist used. The DON stated that because the resident arrived with no pulse or respirations and had a Do Not Resuscitate order, there was nothing to investigate, and the Administrator stated that no investigation was done because it was believed the resident had died at dialysis. This lack of investigation into an unusual occurrence involving a resident’s death, in the context of missing dialysis documentation and unanswered calls to the dialysis center, constituted the cited deficiency under 10 NYCRR 415.4(b)(3).
Oxygen Therapy Provided Without Physician Order or Care Plan
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident receiving oxygen therapy had a corresponding physician’s order and care plan interventions, as required by facility policy and professional standards. The facility’s oxygen therapy policy dated 3/2012 required a medical order specifying liter flow, route, and frequency, initiation of an “At Risk for Compromised Respiratory Care” care plan with appropriate interventions, and allowed nurses to initiate oxygen only in an emergency with an order obtained within 24 hours. Resident #1, admitted with chronic kidney disease on dialysis, cellulitis of the right lower leg, and malignant neoplasm of the endometrium with metastasis, was documented as minimally cognitively impaired and able to understand and be understood. Record review showed no documented physician’s order for oxygen administration and no documented interventions or goals related to oxygen use in the care plan. Despite the absence of an order, multiple records and staff interviews confirmed that the resident was on oxygen intermittently during the admission. Medication Administration Records documented that on at least two pre-dialysis occasions at 11:00 AM, the resident was using 2 liters of oxygen, and vital sign records showed the resident on 2 liters of oxygen on multiple additional dates. Staff interviews corroborated that the resident routinely used oxygen: the Assistant DON reported seeing the resident returning from dialysis wearing oxygen from a portable tank; an RN stated they removed oxygen from the resident’s face when pronouncing the resident deceased; an LPN reported the resident was wearing oxygen upon arrival to the unit from dialysis; and another RN stated they typically send two oxygen tanks with residents for dialysis or longer trips. The Administrator acknowledged there should have been an order for oxygen, confirming that the resident received oxygen therapy without the required medical order and associated care planning.
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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 East Greenbush
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rosewood Rehabilitation And Nursing Center | 1.4 mi | ★★★★★ | 55 | 2 |
| St Margarets Center | 4.4 mi | ★★★★★ | 0 | 0 |
| Hudson Park Rehabilitation And Nursing Center | 4.5 mi | ★★★★★ | 0 | 0 |
| Van Rensselaer Manor | 4.8 mi | ★★★★★ | 22 | 0 |
| Delmar Center For Rehabilitation And Nursing | 5.3 mi | ★★★★★ | 17 | 0 |
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