Evergreen Health and Rehab: Torn Wheelchair Violations - GA
Inspectors documented the condition across multiple chair types, across multiple residents, on a single day of observation. The damage wasn't hidden. Staff confirmed it each time they were asked.
One resident, identified in the report as R15, used a blue geri chair, a specialized reclining chair designed for seniors who need more postural support than a standard wheelchair provides. Both armrests had torn vinyl with foam showing through. Debris was also found sitting in the seat of the chair. A certified nursing assistant confirmed the chair belonged to R15.
R21 used a Broda chair, another type of specialized seating built for residents with complex positioning needs. The vinyl on the front edge of both armrests was torn, again with foam visible underneath. The same nursing assistant confirmed that chair belonged to R21.
A third resident, R24, had frayed vinyl on the left armrest of their wheelchair. The assistant director of nursing looked at it and agreed it needed to be replaced. A fourth resident's wheelchair had torn armrests as well, and the assistant director of nursing confirmed that one too.
Four residents. Four chairs. Every time an inspector pointed to damage, the staff member standing there said yes, that needs to be fixed.
When inspectors spoke with the Maintenance Director that morning, he said he would be the one to handle the repairs. He also described the facility's approach to wheelchair cleaning: the night shift was responsible for routine cleaning, and if a chair was soiled, it would be addressed immediately. He did not explain why chairs with visibly torn and foam-exposed armrests had not already been repaired.
The deficiency was cited under F0584, which covers the requirement that nursing homes maintain a safe, clean, comfortable, and homelike environment. Inspectors rated the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected.
That rating reflects where the violation sits on the regulatory scale, not necessarily what torn foam on a chair means in practice for the person sitting in it for hours each day. Exposed foam on a chair armrest can harbor bacteria, is difficult to disinfect properly, and can cause skin irritation or breakdown for residents whose skin is already fragile. Residents in geri chairs and Broda chairs are typically among the most physically vulnerable in a facility, placed in specialized seating precisely because they cannot easily reposition themselves.
The inspection was complaint-driven, meaning someone raised a concern that prompted regulators to take a closer look. The report does not identify who filed the complaint or what initially prompted it.
What inspectors found when they arrived was straightforward: damaged equipment in use, staff who recognized the damage when shown it, and a maintenance director who learned about the scope of the problem from the inspectors rather than from his own rounds.
The chairs belonged to specific people. R15 sat in that blue geri chair with debris in the seat and foam pushing through both armrests. R21 used the Broda chair with the torn front edges. These were not storage items waiting for repair. They were in active use.
The Maintenance Director said he would take care 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.
Inspectors documented the condition across multiple chair types, across multiple residents, on a single day of observation.
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.