Evergreen Health and Rehab: Resident Elopement Failures - GA
The door had been opened by a licensed practical nurse, LPN4, to let in a visitor. The visitor walked in. LPN4 walked away. Nobody watched the door close.
According to the inspection report, the visitor, identified only as RT1, held the door as the resident, referred to as R1, slipped past him and out into the evening. RT1 told inspectors he assumed R1 was a family member who had been visiting. No staff had told him otherwise. He let the door go and went about his business inside the facility.
LPN4, interviewed on September 3, told inspectors she never saw R1 exit. She said she first learned R1 was missing around 8:00 PM, when another staff member raised the alarm during a medication pass. Staff swept the building. R1 was not there. LPN4 then called the administrator, the Social Services Director, and the police.
By the time the search began, R1 had already been found, though not by anyone at the facility.
The Social Services Director told inspectors she learned that R1 had turned up at a gas station near his nephew's apartment, located by a man the family knew only as Preacher. Preacher took R1 to the nephew's apartment, but no one was home. So Preacher drove R1 back to the facility himself.
Around 10:00 PM, a car pulled up to the side door of Evergreen. R1 got out and walked back in. The car drove away. The police were already inside the building. So were the administrator and the Director of Nursing. They all watched the car leave.
The charge nurse on the South unit, LPN2, had received a call from R1's family member at 9:45 PM. The family member said Preacher had found R1 at a gas station near the propane tanks. That detail, near the propane tanks, appears in the inspection report without elaboration. It does not need one.
The Social Services Director asked the family member that night how to reach Preacher. The family member said they did not have a phone number. The SSD asked again who Preacher was. "That's Preacher," the family member said. Four subsequent attempts to contact the family went unanswered.
The facility examined R1 when he returned. The progress notes from that night document a thorough examination. No physical trauma. No physical injury.
The inspection, conducted September 5, 2025, and triggered by a complaint, turned up a secondary problem with the facility's own records. Staff initially told inspectors that video footage of the incident no longer existed because the system recorded over footage after ten days. The incident had happened in late April. The inspection came in early September. By that math, the video should have been gone for months.
It wasn't. On September 4, the administrator and the maintenance director produced the footage. The maintenance director had a copy in an email he had sent to the police department. The video showed LPN4 opening the side door, RT1 entering, and R1 walking past both of them and out of the building. The footage carried no date stamp and no time stamp. The sun was setting in the background.
The deficiency was cited at a level of minimal harm or potential for actual harm, one of the lower severity designations in the federal rating system. The characterization applies to outcomes, not to what could have happened differently that night. R1 was found. R1 came back uninjured. A stranger named Preacher, whose last name nobody recorded and whose phone number nobody had, made sure of it.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Health and Rehabilitation Center from 2025-09-05 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: June 29, 2026 · Our methodology
EVERGREEN HEALTH AND REHABILITATION CENTER in ROME, GA was cited for violations during a health inspection on September 5, 2025.
The door had been opened by a licensed practical nurse, LPN4, to let in a visitor.
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.