Evergreen Post Acute: Abuse Report Buried, Uninvestigated - DE
No investigation. No interviews. No report to the state. The nursing home administrator didn't know the complaint existed. When federal inspectors arrived at Evergreen Post Acute on January 14, 2025, they found the allegation had simply dissolved into the facility's routine, unexamined and unresolved.
The resident, identified in inspection records only as R1, had been admitted to Evergreen Post Acute on January 2, 2025, with a diagnosis of Alzheimer's disease. A cognitive assessment completed the following day scored her an 8 out of 15, placing her in the moderately cognitively impaired range. She had been in the building for three days when the complaint surfaced.
On January 5, a family member, identified in the report as F1, came forward and told staff that a worker had said something unkind to R1. The resident herself had told the family member the staff was being rude. Two employees heard this directly. A licensed practical nurse, identified as E6, was told by F1 that a staff member had been inappropriate with R1. A certified nursing assistant, identified as E7, was told the same thing, that a staff member was "being mean" to R1. Both of them reported what they had heard to their supervisor, identified in the report as E8.
E8 was the person who had the authority to start an investigation. She did not.
She told inspectors, during an interview on January 13, that she had asked F1 to write a statement. She checked the facility schedule to see if she could identify an employee who matched the description F1 had given of the alleged abuser. She said she couldn't find a match. Then she took the written statement, walked to the office of the social worker, identified as E4, and slid it under the door. It was the weekend. E4 wasn't there.
Neither E6 nor E7, the two employees who had heard the complaint firsthand, were asked to write statements. Neither was interviewed by E8. The LPN told inspectors the supervisor "did not request that they write a statement." The CNA said the same: E8 "did not interview them or have them write a statement."
The statement sat under the social worker's door until Monday, January 6, when E4 came in, found it on the floor of her office, and handed it to the assistant director of nursing, identified as E3. What E3 did with it, the inspection report does not say. What is clear is that it went no further in any formal sense.
The nursing home administrator, identified as E1, told inspectors on January 13 that she did not know about the statement F1 had written. She said it had not been brought forward as a formal matter. She noted that R1 had been discharged the following day, January 7, as though the discharge had resolved something. It hadn't. The allegation had been made while R1 was a resident of the facility. The obligation to investigate it didn't expire when she left.
The administrator told inspectors again the following day, January 14, that she had not known about the abuse allegation at all, and acknowledged that an investigation should have been completed.
It never was. Inspectors found no evidence that the facility had reported R1's allegation to the state agency, as required. No investigation had been opened. No findings had been documented. The complaint had traveled from a family member's mouth to a supervisor's hands to a piece of paper to the floor of an empty office, and stopped there.
What makes this sequence difficult to dismiss as a simple administrative failure is how many people were involved and how many points existed at which someone could have changed the outcome. F1 did the right thing. E6 and E7 did the right thing. E8 took a partial step, collecting a statement, and then made a choice that foreclosed everything that was supposed to follow. The social worker received the statement and passed it up the chain. Somewhere between E3 and E1, it vanished.
The resident at the center of all of this had moderate cognitive impairment. She had been in the building for less than a week. She told a family member that a staff member was being rude to her. That family member believed her enough to report it to not one but two employees. The facility's own policy, last updated in May 2024, states that an immediate investigation is warranted when suspicion of abuse occurs. The word "immediate" is in the policy. The investigation never happened.
There is a particular vulnerability that attaches to nursing home residents with dementia. Their accounts of what happens to them are often the only accounts that exist. Staff are present; family members are not. When a resident with Alzheimer's says someone was unkind to her, the mechanism that is supposed to protect her, the mandatory investigation, the state report, the formal record, is also the only way to determine whether something worse occurred or whether it might happen again. When that mechanism doesn't activate, the resident's word disappears. There is no finding. There is no record. There is a statement on the floor of an empty office.
Evergreen Post Acute's administrator sat across from inspectors on January 14 and confirmed what the records already showed: she hadn't known, it hadn't been treated as a formal matter, and an investigation should have happened. The director of nursing was present for that conversation as well.
R1 was already gone by then. She had been discharged on January 7, two days after the complaint was made and the same day, or the day after, the written statement was passed from the social worker to the assistant director of nursing. Whether anyone told her family that the allegation had not been investigated, the inspection report does not say.
What it does say is that a moderately cognitively impaired woman told someone she trusted that a staff member had been cruel to her, that two nurses heard it and did what they were supposed to do, and that the system designed to respond to exactly that kind of report produced nothing. A piece of paper. A closed door. A gap in the record where an investigation should have been.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Post Acute from 2025-01-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
EVERGREEN POST ACUTE in SMYRNA, DE was cited for abuse-related violations during a health inspection on January 14, 2025.
The nursing home administrator didn't know the complaint existed.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.