Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Healthcare Center during CMS and state inspections, most recent first.
Pureed diet food was not served at a smooth consistency for safe swallowing. A pan of preprepared pureed ham appeared chopped and separated, and a second pan contained clumps that were verified by the Dietary Manager and Therapy Director. The facility identified five residents on a pureed diet, and the recipe and diet manual stated pureed food should be blended until smooth and have a consistency like moist mashed potatoes or pudding.
A dependent resident with severe cognitive impairment, multiple chronic conditions, and documented fluid needs of approximately 1500–1700 ml/day received significantly less fluid than required over multiple days, with recorded intakes ranging from 600 to 1100 cc/day. On the observed day, the resident was only given about 240 cc of fluid at breakfast and 240 cc at lunch, plus a small amount of water with medications, and was not offered additional fluids while seated in a lounge or after being returned to bed. CNAs and an LPN confirmed they did not provide beverages outside of meals, despite a care plan for dehydration risk and a facility hydration policy requiring sufficient fluids, fresh water availability, and fluids with medication passes.
Failure to report suspected misappropriation of property. A cognitively intact resident with multiple chronic conditions reported that his smart phone was stolen from his bedside table, but no police report was made and no SRI was submitted. Staff acknowledged the missing phone had been discussed and management was notified, while the DON/Administrator later confirmed the incident was not reported because it was believed the phone was lost rather than stolen, despite facility policy requiring suspected abuse, neglect, or misappropriation to be reported within 24 hours.
Failure to thoroughly investigate alleged misappropriation involving a cognitively intact resident’s missing iPhone. The resident said the phone was stolen from his bedside table, police were not called, and he was not asked if he wanted to make a report. Staff searched the room, recliner, and laundry, and an LPN said management was notified when the phone was reported missing. The Administrator confirmed a thorough investigation was not completed and police were not notified, despite policy requiring a DON-led investigation with written statements.
A resident who required substantial to maximal ADL assistance was found with heavy facial hair growth despite preferring to be clean shaven daily with his own electric razor. Staff and record review showed shaving was not consistently provided during scheduled shower/bathing care, with multiple missed opportunities documented and the resident last shaved several days earlier.
A resident with severe cognitive impairment, total dependence for care, incontinence, and a history of a right buttock pressure ulcer developed a new stage II wound on the same area. Staff observed the resident seated in a wheelchair at 45 degrees for prolonged periods without repositioning or incontinence checks, and the resident was later found soiled with urine with a soiled wound dressing. CNAs stated they did not provide repositioning or incontinence care during the observed period, and the DON verified the resident required care every two hours.
Failure to provide timely incontinence care was identified for a dependent resident with severe cognitive impairment, immobility, and chronic conditions including CHF, COPD, DM, and dementia. Staff observed the resident seated in a wheelchair for hours without repositioning or incontinence checks, and the resident was later found soiled with urine and reddened buttock tissue. Both CNAs assigned to the unit stated they had not provided incontinence care or repositioning during the shift, and the DON confirmed the resident required care every 2 hours.
Delayed Follow-Up for Dental Concerns: A resident with DM, HTN, CKD, anxiety, and lymphedema had documented broken and missing teeth, root tips, and oral/dental problems. Dental notes indicated the resident would benefit from full dentures and extractions, but follow-up was not completed after provider changes. The resident later reported tooth pain, mild facial swelling, and difficulty chewing, and staff confirmed he had not been scheduled with an oral surgeon.
EBP were not followed for a resident with an indwelling Foley catheter, multiple pressure ulcers, and other significant diagnoses when a contract phlebotomist attempted to obtain a blood specimen without gown and gloves. A sign at the room entrance indicated EBP were required, and the phlebotomist stated they were unaware of the precaution status and did not wear a gown. The DON confirmed the PPE requirement, and the facility identified 14 residents on EBP.
Pureed Diet Food Not Served at Proper Smooth Consistency
Penalty
Summary
The facility failed to serve pureed foods at a smooth consistency for safe swallowing. During observation, the first pan of preprepared pureed ham appeared chopped and separated rather than smooth, and a test tray of the ham was also not a smooth consistency. The Dietary Manager verified that the first pan was not smooth. A second pan of preprepared pureed ham appeared smoother, but it contained clumps that appeared to be ham rind, and the Dietary Manager verified that both pans had been prepared at the same time but heated separately and that the second pan had clumps of ham. The Therapy Director verified that pureed food should be a creamy smooth texture with no clumps or lumps and confirmed the second pan contained ham clumps. The facility identified five residents to require a pureed diet, and the recipe and diet manual stated that pureed food should be blended until smooth and have a consistency of moist mashed potatoes or pudding.
Failure to Provide Adequate Hydration to Dependent Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate fluids to maintain the health of a dependent resident who was at risk for dehydration. The resident had multiple diagnoses including congestive heart failure, COPD, type 2 diabetes, morbid obesity, chronic respiratory failure, anxiety disorder, hypertension, dementia, chronic peripheral venous insufficiency, osteoarthritis, transient ischemic attack, and dependence on supplemental oxygen. The most recent MDS documented severe cognitive impairment, dependence on staff for all ADLs including transfers and repositioning, incontinence of bowel and bladder, risk for pressure ulcer development, and admission with a stage 2 pressure ulcer. A dietary assessment identified estimated fluid needs of 1496–1700 ml/day and risk for malnutrition, with average meal intake between 26–100%. A nursing care plan was initiated to address risk for dehydration related to diuretic use, with interventions including providing diet as ordered and administering medications per orders. However, documented daily fluid intake from 04/01/26 to 04/07/26 ranged only from 600 to 1100 cc per day, below the resident’s estimated fluid needs. On the observed day, the resident was seated in a wheelchair in the lounge from early morning until mealtimes and was only observed to receive fluids during breakfast and lunch. At breakfast, the resident was provided 240 cc of fluid, and at lunch another 240 cc of fluid, with no additional fluids observed being offered between or outside of these meals while the resident remained in the lounge and then was later taken to bed. CNA staff interviewed confirmed they had not provided any beverages to the resident other than during breakfast and lunch, and each was unaware if the other had offered additional fluids. The LPN reported giving only a small amount of water with morning medications and no further fluids aside from those at meals. This pattern of limited fluid provision conflicted with the facility’s General Hydration Services policy, which states that residents are to be offered sufficient fluids consistent with their needs and preferences, including drinks at meals, fresh water at bedside when appropriate, and fluids with medication passes.
Failure to Report Suspected Misappropriation of Property
Penalty
Summary
The facility failed to report incidents of potential misappropriation involving Resident #27. Resident #27 was admitted with diagnoses including Type Two Diabetes Mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema, and his MDS assessment dated 02/04/26 indicated he was cognitively intact. During interview, the resident stated his smart phone, described as an iPhone 17, had been stolen a few months earlier from his bedside table, and he reported that the police were not called and he was not asked whether he wanted to make a report. He also stated he had not paid the phone bill since the phone went missing. Staff interviews showed the missing phone had been discussed with facility personnel and management was notified, but the Administrator later verified that no self-reported incident had been submitted because the situation was understood to be a lost phone rather than stolen. The Administrator also noted conflicting information about the phone description, while review of the facility's self-reported incidents since 02/15/26 showed no report for the missing iPhone. The facility policy required a suspected abuse, neglect, or misappropriation investigation report to be initiated and reported within 24 hours to the appropriate agencies.
Failure to Thoroughly Investigate Alleged Misappropriation
Penalty
Summary
The facility failed to thoroughly investigate an allegation of misappropriation involving one resident who was cognitively intact and had diagnoses including type 2 diabetes mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. The resident reported that his iPhone had been stolen from his bedside table a few months earlier and stated that police were not called and he was not asked whether he wanted to make a report. He also stated that he believed the phone was stolen rather than lost because he always left it on his bedside table. Interview and observation showed the resident had a new iPhone box in his room, and he reported that his former partner had purchased the phone for $1,400 and that he had been paying the monthly bill until the phone went missing. A CNA stated the resident had told her the phone was either lost or stolen and that staff searched his recliner and laundry without success. An LPN reported that the resident said his phone was missing about a month earlier and management was notified. The Administrator later verified that a thorough investigation had not been completed, stated it had not been alleged that the iPhone was stolen, and confirmed the police had not been notified. Facility policy required the DON or designee to initiate a suspected abuse, neglect, or misappropriation investigation and obtain written, signed, and dated statements from staff, the victim, the reporter, the accused perpetrator, and witnesses.
Failure to Provide Timely Facial Grooming
Penalty
Summary
The facility failed to ensure dependent residents received timely facial grooming for one resident who required substantial to maximal assistance with activities of daily living. Resident #3 was admitted with diagnoses including dementia, anxiety disorder, pseudobulbar affect, major depressive disorder, hypertension, Parkinson's disease, neurocognitive disorder, and schizoaffective disorder. The most current MDS assessment described the resident as having intact cognition, being able to make needs known, having no resistive behavior, having range of motion impairment to both upper and lower extremities, requiring substantial to maximal assistance with ADLs, and using a wheelchair for mobility. A revised nursing plan of care identified ADL self-care deficits and included assistance with personal hygiene, upper and lower body dressing, bathing, and use of assistive devices as needed. During observation, Resident #3 was seen propelling himself in the common corridor, dressed, and with heavy facial hair growth. The resident stated he preferred to be clean shaven daily with his own electric razor and said staff did not shave him as often as he wanted, reporting he had last been shaved about two days earlier. An RN confirmed the resident had heavy beard growth greater than two days and verified an electric razor was in the resident's nightstand. Review of CNA shower sheets showed 10 opportunities for shaving during scheduled shower/bathing care between 03/04/26 and 04/04/26, with shaving documented only four times and not provided six times. The resident's medical record showed showers/bathing were scheduled every Wednesday and Saturday, and the last documented shave was on 04/01/26.
Failure to Provide Pressure Relief and Incontinence Care
Penalty
Summary
Failure to provide pressure relief interventions and incontinence care affected a resident with multiple chronic conditions, including dementia, diabetes, morbid obesity, chronic respiratory failure, chronic peripheral venous insufficiency, and dependence on staff for all activities of daily living. The resident was assessed as severely cognitively impaired, wheelchair dependent, incontinent of bowel and bladder, and at risk for pressure ulcer development. The resident was admitted with a stage II pressure ulcer to the right buttock, which was later documented as healed by the wound care specialist before a new area was identified on the same buttock. The resident’s care plan included turning and repositioning, off-loading measures, and weekly skin checks. A later skin risk assessment listed interventions for turning and repositioning every two hours and bed checks every two hours. Nursing documentation then noted a new stage II pressure ulcer on the right buttock, and the wound care specialist documented the wound as end-stage skin failure with moderate serosanguineous drainage. Subsequent wound measurements showed the wound had increased in size and remained open with drainage. During continuous observation, the resident was seated in a wheelchair positioned at 45 degrees for extended periods, including while in the lounge and dining room, and no repositioning or incontinence checks were observed. When the resident was finally placed back to bed, the resident was found soiled with urine and the wound dressing was also soiled. The DON removed the dressing, noted reddened tissue to the buttock, and the resident stated there was pain to the buttocks. Both CNAs interviewed afterward stated they had not provided incontinence checks, care, or repositioning during the observed period, and the DON verified the resident was dependent for all care and should be repositioned and checked/changed every two hours.
Failure to Provide Timely Incontinence Care
Penalty
Summary
Timely incontinence care was not provided to a dependent resident who was always incontinent of bowel and bladder and required staff assistance for all activities of daily living, transfers, and repositioning. The resident had severe cognitive impairment, range of motion impairment to both upper and lower extremities, used a wheelchair propelled by staff, and had diagnoses including CHF, COPD, Type II DM, morbid obesity, chronic respiratory failure, dementia, and chronic peripheral venous insufficiency. The resident’s care plan directed staff to check for incontinence, wash and dry the perineum, change clothing and disposable briefs as needed, apply barrier cream, and observe for signs and symptoms of UTI. The resident was also identified as at risk for pressure ulcer development and had been admitted with a stage II pressure ulcer. During continuous observation, the resident was placed in a wheelchair and remained seated for extended periods without being repositioned or checked for incontinence. The resident was observed in the east unit lounge from early morning through midday, including transport to and from the dining room, with no attempts noted to reposition or provide incontinence care. When the resident was finally returned to the room and placed in bed, the resident was found soiled with a moderate amount of urine in the brief, and the DON observed reddened tissue to the buttock and removed the soiled brief and dressing. Interviews with both CNAs assigned to the unit confirmed that neither had provided incontinence checks, care, or repositioning for the resident during the shift and each was unaware whether the other had done so. The DON verified the resident was dependent for all care and should be repositioned, checked, and changed for incontinence every two hours.
Delayed Follow-Up for Dental Concerns
Penalty
Summary
The facility failed to ensure timely follow-up for dental concerns for Resident #27, who was cognitively intact and required set-up/clean-up assistance for oral hygiene. The resident’s record showed diagnoses including Type II diabetes mellitus without complications, essential hypertension, hyperlipidemia, chronic kidney disease, anxiety disorder, and lymphedema. MDS assessments identified obvious or likely cavity or broken natural teeth, and the care plan documented oral/dental problems with interventions to complete oral assessments, observe for signs and symptoms of infection and dental problems, and educate the resident about changes in dentition. Dental records showed the resident had missing teeth and root tips, and the dentist noted the resident would benefit from full upper and lower dentures. After a new provider completed an initial assessment, the resident later reported left-sided mouth pain, and telehealth documentation noted left tooth pain, mild left facial swelling, and difficulty chewing. The resident stated he had seen a dentist who recommended extractions and full dentures, but there had been no follow-up. Social Services confirmed the resident had not been scheduled with an oral surgeon for extractions, that the facility had switched dental providers between visits, and that it was unknown why the extraction had not been completed after the earlier dental visit or whether the dentist could complete the extraction.
EBP Not Followed During Blood Specimen Collection
Penalty
Summary
Provide and implement an infection prevention and control program was not ensured when Enhanced Barrier Precautions (EBP) were not followed as ordered for one resident. The resident was admitted with diagnoses including malignant neoplasm of bone, soft tissue, skin, and endocrine glands, malignant neoplasm of brain, Type II diabetes mellitus, neuromuscular dysfunction of bladder, paraplegia, hypertension, coronary artery disease, anxiety disorder, polyneuropathy, cauda equina syndrome, and abdominal aortic aneurysm. The most current MDS noted intact cognition, bilateral lower extremity range of motion impairment, an indwelling urinary catheter, bowel incontinence, a therapeutic diet, and pressure ulcers including one stage III and two stage IV wounds. Physician orders dated 10/13/25 initiated EBP for Foley catheter-related care, and later nursing plans of care also included EBP for catheter care and for care related to a history of or colonization with a multidrug-resistant organism. On 04/08/26 at 6:55 A.M., the resident’s room door was closed and a contract phlebotomist was observed at the bedside attempting to obtain a blood specimen without PPE. A sign outside the room indicated EBP were required, with instructions for staff and doctors to wear gloves and a gown for high-contact care activities and device care, including urinary catheter care and wound care. The phlebotomist stated they were unaware the resident was on EBP and confirmed they did not wear a gown when obtaining the specimen. The DON later confirmed the EBP sign was posted, PPE was available inside the room, and the phlebotomist was required to wear a gown and gloves when obtaining the blood specimen. The facility identified 14 current residents placed on EBP.
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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 Montpelier
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Williams Co Hillside Country L | 7.3 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Bryan | 8.2 mi | ★★★★★ | 19 | 0 |
| Park View Care Center | 11.8 mi | ★★★★★ | 9 | 0 |
| Fairlawn Haven | 16 mi | ★★★★★ | 0 | 0 |
| Pines Of Dekalb | 17.4 mi | ★★★★★ | 2 | 0 |
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