Evergreen Health and Rehabilitation: Nail Care Neglect - GA
The contradiction sat at the center of a complaint inspection completed September 5, 2025.
The resident, identified in inspection records only as Resident 3, had been admitted to the facility with diagnoses including major depression. A cognitive assessment completed in June 2025 gave him a score of five out of 15, placing him in the range of severe cognitive impairment. His care plan identified him as needing partial to moderate assistance with personal hygiene.
An inspector observed him on the morning of September 3, lying in bed on his right side. His fingernails were long and jagged. Brown matter was visible underneath them.
Nearly three hours later, at 12:21 PM, the inspector asked to see his nails again. He showed them. The condition was unchanged.
The facility's electronic records told a different story. A review of documented care from May 8, 2025 through September 4, 2025 showed staff had recorded that Resident 3 received personal hygiene care throughout that period, logged as independent, with limited assistance, or with total assistance. On September 3 and September 4, staff did not document any refusal of care. They documented care as provided on both days.
The facility did have a care plan entry, dated July 2024, addressing the possibility that Resident 3 might refuse care. The listed nursing intervention: encourage him to accept care, and if he refuses, wait and try again later. But when the Assistant Director of Nursing produced that care plan during an interview on the afternoon of September 4, the inspector noted a problem. The refusal plan wasn't written to address personal hygiene specifically. It wasn't written to address nail care at all.
The ADON was standing there when the inspector described what had been observed: the long nails, the jagged edges, the brown matter underneath, visible on September 3 and still present more than 24 hours later. The facility's administrator walked up during that conversation. He was told the same thing. He said staff would take care of it.
On the morning of September 4, before that conversation, the inspector had spoken with Resident 3 as he returned from breakfast. Resident 3 said he had gotten a bath the day before, on Tuesday, and had changed his clothes. His nails, the inspection record indicates, remained in the same condition inspectors had first documented the previous morning.
The inspection cited the facility for failing to ensure staff provided nail care, with a finding of minimal harm or potential for actual harm, affecting a small number of residents.
What the records couldn't resolve was the gap between what staff documented and what an inspector could see with her own eyes on two consecutive mornings. The care logs showed hygiene provided. The nails showed something else. For a man who scored a five out of 15 on a cognitive assessment, who could not reliably advocate for himself or describe what care he had or hadn't received, the written record was the only protection he had.
It logged care he may not have gotten. It didn't log the nails.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 22, 2026 · Our methodology
EVERGREEN HEALTH AND REHABILITATION CENTER in ROME, GA was cited for neglect violations during a health inspection on September 5, 2025.
The contradiction sat at the center of a complaint inspection completed September 5, 2025.
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.