Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 House Health Center during CMS and state inspections, most recent first.
A cognitively intact resident with contractures and a care plan for malnutrition risk, including a regular diet with large portions, was sent to an early morning dermatology appointment without receiving breakfast or a bagged lunch. Nursing assistant documentation showed the resident did not receive breakfast or lunch that day, and the resident later reported being at the appointment for a long time, receiving no food, and feeling hungry upon return. The NA assigned to the resident and the DON both acknowledged that no meals were provided at the facility and no meal was prepared to take along, resulting in the resident going from the prior evening’s dinner until early afternoon the next day without nourishment.
A resident with dementia and a percutaneous cholecystostomy drain, placed after gallbladder perforation and cholecystitis, had a physician order and care plan directing that the drainage bag be kept secure, drained to gravity, and monitored each shift per facility policy. Surveyors found that the drainage bag was instead pinned to the call light, which was attached to an elevated bed rail, preventing proper gravity drainage. An LPN reported observing this improper setup, and both the NP and DON stated the drain should not be attached to the call light; the DON was unable to provide evidence that the facility’s percutaneous drainage catheter management policy had been implemented.
Failure to Report Unscheduled Fire and Evacuation Plan Implementation: The facility did not ensure that an unscheduled implementation of the fire and evacuation plan was reported immediately to RIDOH. A community complaint alleged that the fire dept responded to a reported fire and that smoke was seen coming from a heater with an electrical fire behind its control panel. The DON acknowledged the fire dept response and could not provide evidence of immediate reporting to the state agency.
Heating Units Blocked by Recliners: Surveyors found that recliners in two resident rooms were positioned too close to fixed installed heating units, with one recliner about 2 inches from the unit and the other also failing to maintain the required 8-inch clearance. A resident with intact cognition stated the recliner had been in the same spot for at least a year, and the Maintenance Director acknowledged the clearance issue.
A resident with severe cognitive impairment and Alzheimer's disease was subjected to inappropriate touching and kissing by another resident with moderate cognitive impairment. The incident was witnessed by an LPN, and interviews with staff and family confirmed the affected resident could not consent. The facility was unable to demonstrate that it had protected the resident from abuse, as required by policy.
Surveyors found that the facility failed to follow food safety protocols in the main kitchen. Three cases of Vital Cuisine Mightyshakes were stored without thawing dates, and chicken salad was left at room temperature, reaching 70°F, contrary to safety guidelines. The Food Service Director acknowledged these lapses in food safety practices.
A resident with diabetic ulcers did not receive heel off-loading boots as ordered by a physician, despite expressing a desire to wear them. Observations showed the resident without the boots on multiple occasions. An LPN admitted to documenting the boots as in place when they were not, and the ADON could not provide evidence of compliance with professional standards.
A resident with malnutrition and diabetes experienced a significant weight loss of 10.8 lbs over two weeks, which was not reported to the physician or RD as required by facility policy. The resident reported feeling hungry at night, and the RD was unaware of the weight loss until informed by a surveyor. The facility's failure to follow its weight monitoring policy led to the resident not maintaining acceptable nutritional status.
The facility failed to maintain accurate medical records for two residents. An LPN documented administering medications that were not given to a resident with heart failure, and another LPN inaccurately recorded the application of off-loading boots for a diabetic resident with a foot ulcer. Both instances involved incorrect documentation of care provided.
The facility failed to maintain an effective infection prevention and control program, as observed in two residents on contact precautions and improper storage of a nebulizer mask. A housekeeper and a nursing assistant entered rooms without required PPE, and a nebulizer mask was not stored properly. Staff acknowledged these oversights, and the ADNS could not provide evidence of a maintained infection control program.
Resident Sent to Medical Appointment Without Meals or Bagged Lunch
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was treated with dignity and in a manner that maintained quality of life when sent out for a scheduled medical appointment. A cognitively intact resident, with contractures of both hips and knees and a care plan identifying risk for malnutrition with an ordered regular diet and large portions, was sent to an early morning dermatology appointment. Electronic medical record documentation by nursing assistants showed the resident did not receive breakfast or lunch on the day of the appointment. The community complaint alleged the resident was sent out without breakfast, remained at the dermatology office until approximately 11:00 AM, and that no return transportation had been arranged, resulting in the resident not returning to the facility until after 1:00 PM. During interviews, the resident reported being at the dermatology office for a long time, not receiving breakfast or a bagged lunch, and feeling hungry upon return to the facility. The NA assigned to the resident that day acknowledged the resident was not provided breakfast or lunch at the facility. The Unit Manager documented that the dermatology provider called at 11:50 AM to report the procedure was finished. The DON further acknowledged that the resident was not provided breakfast or lunch by the facility while out at the appointment and that no meal was prepared for the resident to take along. As a result, the resident went from dinner the previous evening until after 1:00 PM the following day, an approximate 20-hour period, without receiving food from the facility.
Improper Management of Percutaneous Drainage Catheter
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care for a percutaneous drainage catheter in accordance with professional standards of practice and facility policy for one resident. The facility’s policy on Percutaneous Drainage Catheter Management required that the drainage system be positioned below the level of the fluid collection to allow gravity drainage, that the drainage bag be properly secured to the patient’s gown as necessary, and that catheter integrity and securement be documented. The resident was admitted with diagnoses including perforation of the gallbladder, cholecystitis, and dementia, and had a percutaneous cholecystostomy drain in place. A care plan and physician’s order directed that the drainage bag be kept secure, drained to gravity, and monitored every shift. Surveyor review of a community complaint and subsequent staff interviews revealed that the resident’s drainage bag was secured to the call light with a safety pin, and the call light was attached to an elevated bed rail, which prevented the system from draining by gravity as ordered. An LPN reported observing the resident in bed with the drainage bag improperly secured in this manner. The nurse practitioner and the Director of Nursing both stated that their expectation was that the drain should not be attached to the call light. The Director of Nursing also could not provide evidence that the facility implemented its Percutaneous Drainage Catheter Management policy, confirming that the resident’s drain had been attached to the call light contrary to policy and professional standards.
Failure to Report Unscheduled Fire and Evacuation Plan Implementation
Penalty
Summary
The facility failed to ensure that the unscheduled implementation of the fire and evacuation plan was reported immediately to the Rhode Island Department of Health. A community-reported complaint alleged that the fire department responded to the facility for a reported fire and that smoke was observed coming from a heater that had experienced an electrical fire behind its control panel. During a surveyor interview, the Director of Nursing Services acknowledged that the Fire Department responded to an unscheduled implementation of the fire and evacuation plan on 10/18/2025, but she was unable to provide evidence that the facility reported the event immediately to RIDOH.
Heating Units Blocked by Recliners
Penalty
Summary
The facility failed to ensure that the resident environment remained as free of accident hazards as possible related to fixed installed heating devices in 2 of 3 resident rooms observed. A community-reported complaint alleged that the fire department responded to the facility for a reported fire and that smoke was observed coming from a heater that had experienced an electrical fire behind its control panel. Review of the heater maintenance manual showed that a minimum of eight inches of clearance is required from the unit to furniture, beds, or other objects for proper operation, and that severe airflow restrictions can damage unit components. During surveyor observations, a recliner in Resident ID #1’s room was partially blocking the fixed installed heater and was approximately 2 inches from the unit. Resident ID #1’s quarterly MDS assessment showed a BIMS score of 13 out of 15, indicating intact cognition, and the resident stated that the recliner had been in the same location in the room for at least a year. A second observation in Resident ID #2’s room showed that the recliner was also blocking the fixed installed heating unit and did not maintain the required clearance of more than eight inches. In a later interview, the Maintenance Director acknowledged that the recliners for Resident ID #1 and Resident ID #2 were closer than 8 inches from the fixed installed heating units.
Failure to Protect Cognitively Impaired Resident from Sexual Abuse
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment from sexual abuse by another resident. On 4/19/2025, a Licensed Practical Nurse observed a resident with moderately impaired cognition inappropriately touching and kissing a resident who was not alert and aware, as evidenced by a BIMS score of 5 out of 15 and a diagnosis of Alzheimer's disease. The incident was reported to the Rhode Island Department of Health, and documentation confirmed that the resident who was touched could not consent to intimate contact due to cognitive impairment. The facility's own policy defines sexual abuse as non-consensual sexual contact, including unwanted intimate touching, especially when the resident lacks the capacity to consent. Interviews with staff, the resident's family, and facility leadership confirmed that the resident was unable to consent and that the family did not approve of any intimate relationship. The resident who committed the act was sent for psychiatric evaluation, and the facility moved this resident to a different unit. However, the facility was unable to provide evidence that adequate measures were in place to prevent the incident or to keep the cognitively impaired resident free from abuse, resulting in a failure to protect the resident as required.
Food Safety Protocols Not Followed in Kitchen
Penalty
Summary
The facility failed to ensure proper food storage and preparation practices in the main kitchen, as observed by surveyors. During an inspection, it was noted that three cases of Vital Cuisine Mightyshakes were stored in the walk-in refrigerator without any indication of when they were placed there for thawing. This lack of dating contravenes the product's label instructions, which specify that the product should be used within 14 days of thawing. The Food Service Director (FSD) acknowledged that the dietary staff did not date the product when it was placed in the refrigerator, indicating a lapse in adherence to food safety protocols. Additionally, the facility did not comply with the RI Food Code 2018 Edition regarding the temperature control of safety foods. A surveyor observed chicken salad sitting at room temperature on a work table in the main kitchen, with a temperature reading of 70 degrees Fahrenheit, which is above the recommended safe temperature. The FSD admitted that the staff failed to follow the policy for monitoring and recording the temperature of the chicken salad, as well as adhering to the Hazard Analysis and Critical Control Points (HACCP) plan. This oversight in monitoring critical control points for food safety was identified during the surveyor's interview with the FSD.
Failure to Follow Physician's Orders for Diabetic Ulcer Care
Penalty
Summary
The facility failed to ensure that services provided met professional standards of practice by not following a physician's order for a resident with diabetic ulcers. The resident, who was admitted with type II diabetes mellitus and a non-pressure chronic ulcer of the left foot, had a care plan that included the use of heel off-loading boots while in bed. Despite this, surveyor observations on multiple occasions revealed that the resident was in bed without the boots. The resident expressed a desire to wear the boots and noted that staff did not ask if they wanted to wear them. During an interview, a Licensed Practical Nurse admitted that the boots were not in place and that she had documented them as being in place despite their absence. The Assistant Director of Nursing Services acknowledged that staff should apply the boots as ordered and could not provide evidence that the facility met professional standards in following physician orders. This deficiency was noted for one of the two residents reviewed with diabetic ulcers.
Failure to Monitor and Address Significant Weight Loss
Penalty
Summary
The facility failed to adhere to its policy regarding weight monitoring and notification, resulting in a deficiency related to the nutritional status of a resident. The resident, who was admitted with diagnoses including protein-calorie malnutrition and diabetes mellitus, experienced a significant weight loss of 10.8 pounds over a two-week period. Despite the facility's policy requiring notification of significant weight changes to the physician or registered dietitian, there was no evidence that such notification occurred. The resident's care plan, which aimed to prevent significant unintentional weight loss, was not effectively implemented. The resident, who had intact cognition, reported feeling hungry at night, indicating a potential issue with the adequacy of food provided. The registered dietitian was unaware of the resident's weight loss until informed by the surveyor, highlighting a communication breakdown within the facility. The assistant director of nursing services acknowledged the failure to follow the facility's weight loss policy, which contributed to the resident not maintaining acceptable parameters of nutritional status.
Inaccurate Medication and Treatment Documentation
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for two residents. For one resident, who was admitted with a diagnosis including heart failure, the facility did not properly administer medications as ordered. During a medication administration task, a Licensed Practical Nurse (LPN) provided a nasal spray to the resident, which was found to be empty, and failed to administer Bumex as prescribed. Despite this, the LPN documented that both medications were administered. Upon interview, the LPN admitted to not administering the medications and acknowledged the incorrect documentation. For another resident with type II diabetes mellitus and a non-pressure chronic ulcer of the left foot, the facility did not follow physician orders to apply heel off-loading boots while the resident was in bed. The resident was observed multiple times without the boots, yet the Treatment Administration Record indicated the order was completed. An LPN confirmed the boots were not in place and admitted to inaccurately documenting that they were. The Assistant Director of Nursing Services expressed an expectation for staff to follow physician orders and document accurately.
Infection Control Deficiencies in Contact Precautions and Equipment Storage
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by surveyor observations and staff interviews. Two residents, identified as being on contact precautions, were not properly managed according to the facility's policy and CDC guidelines. Resident ID #32, diagnosed with Parkinson's Disease and on contact precautions for vomiting, was observed in a room where a housekeeper entered without wearing the required gown. The housekeeper and a Licensed Practical Nurse acknowledged the oversight. Similarly, Resident ID #64, who was readmitted with parainfluenza, was in a room where a nursing assistant entered without wearing a gown or gloves, despite the resident being on contact precautions for influenza. The nursing assistant admitted to not knowing the reason for the precautions, and the oversight was confirmed by another staff member. Additionally, the facility failed to adhere to proper infection control practices concerning the storage of a nebulizer mask for Resident ID #12, who was readmitted with chronic obstructive pulmonary disease. The nebulizer mask was repeatedly observed on the resident's bed instead of being stored in a clean, dry plastic bag as recommended by the National Heart, Lung, and Blood Institute. This was confirmed by a Licensed Practical Nurse and the Assistant Director of Nursing Services, who both acknowledged the mask should have been bagged after use. The Assistant Director of Nursing Services was unable to provide evidence that the facility maintained an infection prevention and control program to prevent the transmission of communicable diseases and infections. This lack of adherence to infection control protocols for residents on contact precautions and improper storage of medical equipment highlights significant deficiencies in the facility's infection control practices.
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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 Providence
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hattie Ide Chaffee Home | 1 mi | ★★★★★ | 0 | 0 |
| Adviniacare Orchard, Llc | 1.3 mi | ★★★★★ | 12 | 2 |
| Harris Health Center Llc | 1.4 mi | ★★★★★ | 13 | 0 |
| Adviniacare Waterview Villas, Llc | 1.4 mi | ★★★★★ | 12 | 0 |
| Eastgate Nursing & Rehabilitation Center | 1.7 mi | ★★★★★ | 6 | 0 |
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