Evergreen Health And Rehabilitation Center
Inspection Findings
F-Tag F0584
F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
rests torn with the vinyl in need of repair. The ADON observed the chair and confirmed that the arm rests needed to be replaced.Resident R24's left wheelchair arm rest, at the end, was observed to have frayed vinyl. The ADON confirmed the arm rest was in need of repair. Resident R15's blue geri chair (geriatric chairs, or geri chairs, are specialized reclining chairs for seniors who require more support or versatility than a conventional wheelchair or regular chair can provide) was observed with both armrests having torn vinyl covering exposing the foam padding underneath. Debris was also observed in the seat of the chair. Certified Nursing Assistant (CNA) 4 confirmed the chair belonged to Resident R15. The vinyl covering on the front edge of both arm rests of Resident R21's Broda chair was observed to be torn with foam showing. CNA4 verified the chair belonged to Resident R21. During an interview on 9/5/2025 at 9:38 AM with the Maintenance Director, when notifying him of
observations where arm rests on Broda and Geri chairs were found with torn vinyl covering, he stated he would be the one to repair those. When asked about wheelchairs and routine cleaning of those, he stated that the night shift was responsible for that cleaning. He added that if one was soiled, it would be taken care of immediately.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health and Rehabilitation Center
139 Moran Lake Road, NE Rome, GA 30161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0677
F 0677
Provide care and assistance to perform activities of daily living for any resident who is unable.
Level of Harm - Minimal harm or potential for actual harm
Based on observations, record review, and resident and staff interviews, the facility failed to ensure staff provided nail care for one of four residents (Resident (R) 3) observed for the provision of ADL (activities of daily living) care out of a total sample of 24 residents resulting in dirty, long, and jagged nails.Findings include:Review of the admission Record located in the electronic medical record (EMR) was admitted to
this facility with diagnoses including but not limited to major depression. Review of Resident R3's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 6/20/2025 identified him as having a Brief
Interview for Mental Status (BIMS) score of five out of 15, indicating Resident R3 was severely cognitively impaired.
The MDS also identified Resident R3 as needing partial to moderate assistance with personal hygiene. Review of Resident R3's Care Plan tab in the EMR revealed a care plan dated 7/3/2024 identifying Resident R3's refusal for care.
Nursing interventions include: Encourage resident to accept care. If refusal occurs, wait and approach at a later time. Review of the documentation in the electronic software utilized by the facility for documenting care, the task for Personal Hygiene from 5/8/2025 through 9/4/2025 was reviewed. During this time frame, documentation revealed that Resident R3 received care and was either independent, received limited assistance, or received total assistance in the receipt of personal hygiene. The staff did not document during the 9/3/2025 to 9/4/2025 timeframe that Resident R3 refused care for personal hygiene but did have care provided on both days.On 9/3/2025 at 9:35 AM, Resident R3 was observed in his room in bed lying on his right side. Resident R3's fingernails were observed to be long and jagged with a brown substance observed underneath the nails. On 9/3/2025 at 12:21 PM, Resident R3 was asked if this surveyor could see his nails. Resident R3 showed the surveyor his nails and the nails were in the same condition as the previous observation. On 9/4/2025 at 8:28 AM, Resident R3 was observed coming back from breakfast. When asking about Resident R3's clothing, Resident R3 stated he got a bath the previous day (Tuesday) and changed his clothing.During an interview on 9/4/2025 at 3:40 PM, the Assistant Director of Nursing (ADON) provided the care plan regarding refusals for Resident R3. While the care plan addressed refusals, it was not specific to personal hygiene or nail care. The ADON was notified that on 9/3/2025 and up to the time of this conversation, that Resident R3's nails had been observed to be long and jagged, with brown matter underneath. The Administrator walked up to this conversation and was notified as well about Resident R3's nails and stated staff would take care of Resident R3's nails.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health and Rehabilitation Center
139 Moran Lake Road, NE Rome, GA 30161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
stated that after ten days, the videos were recorded over, so the video of the incident no longer existed. On 9/4/2025 at 11:30AM, the Administrator and the Maintenance Director (MD) produced the video of the incident. The MD had a copy of the video in an email he sent to the police department. The video showed LPN4 opening the side door to admit RT1 and Resident R1 walking past both, exiting the facility. The video did not contain a date stamp or a time stamp, but it did show the sun setting in the background.Interview on 9/3/2025 at 3:45PM, LPN4 stated she opened the door for RT1. [RT1] walked in as I was walking away. At no time did LPN4 see Resident R1 exit the facility. LPN4 stated that during the medication pass around 8:00 PM that day, another staff member alerted the team that Resident R1 could not be located. LPN4 said that all staff members did a sweep throughout the facility, and Resident R1 could not be located. LPN4 then notified the Administrator, the Social Services Director, the police department, and the family member.Interview on 9/4/2025 at 12:45 PM by telephone, RT1 stated that around 6:30 PM or 7:00 PM he arrived at the facility and LPN4 opened the door and walked away. As LPN4 was walking away, RT1 held the door as Resident R1 exited the facility. RT1 thought Resident R1 was a family member that had been visiting. RT1 verified that no staff alerted him that Resident R1 was a resident and not to let him exit.Interview on 9/3/2025 at 10:00 AM, the Social Services Director (SSD) stated that she was notified on 4/30/2025 of Resident R1's elopement. SSD was told by the South LPN2 that Resident R1 was found at a gasoline station by Preacher, a person known to the family of Resident R1, near Resident R1's nephew's apartment. Resident R1 was taken to the nephew's apartment, but the nephew was not home. The family member of Resident R1 was called and was told by Preacher they were taking Resident R1 back to the facility. Around 10:00 PM on 4/30/2025, a car pulled up to the side door. Resident R1 exited the car and was admitted to the facility. The car drove away while the police were inside the facility, along with the Administrator, the Director of Nursing, and the SSD. The SSD called the family member that evening and asked who Preacher was and how could the SSD contact him. The Family member stated that was Preacher but did not have a phone number. SSD asked again who Preacher was and the family member stated, That's Preacher.Interview with LPN2, who was the charge nurse on the South unit, on 9/3/2025 at 4:00 PM, she stated that she received a phone call
on 4/30/2025 at 9:45 PM from Resident R1's family member who stated that Preacher found Resident R1 at a gas station near
the propane tanks. Resident R1's Family member stated that Preacher took Resident R1 to his nephew's apartment, but no one was there. Resident R1's Family member stated that Preacher was bringing Resident R1 back to the facility. The Police, Administrator, SSD all see the car pull up to the side of the facility, Resident R1 exits the car and enters the facility.
The car drives away.Review of EMR under the Progress Notes dated 4/30/2025 indicate that Resident R1 was given
a thorough examination when Resident R1 returned. There was no evidence of physical trauma or physical injury.Four attempts were made to contact the family member. No response was received.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health and Rehabilitation Center
139 Moran Lake Road, NE Rome, GA 30161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0761
F 0761 Level of Harm - Minimal harm or potential for actual harm
observation that the insulins were expired and should not have been used. LPN 8 further stated that insulin should be refrigerated until opened.During an interview on 9/5/2025 at 9:35 AM, the Assistant Director of Nursing (ADON) stated that insulins should not be used after the expiration date and the medication room refrigerators were to be locked.
Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/05/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health and Rehabilitation Center
139 Moran Lake Road, NE Rome, GA 30161
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0921
Federal health inspectors cited EVERGREEN HEALTH AND REHABILITATION CENTER in ROME, GA for a deficiency under regulatory tag F-F0921 during a complaint investigation conducted on 2025-09-05.
Category: Environmental Deficiencies
The facility was found deficient in the following area: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Scope/Severity Level F: widespread, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 5 deficiencies cited during this inspection of EVERGREEN HEALTH AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-11-20.
EVERGREEN HEALTH AND REHABILITATION CENTER in ROME, GA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in ROME, GA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVERGREEN HEALTH AND REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.