Evergreen Health And Rehabilitation Center

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 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 R3 was severely cognitively impaired.

The MDS also identified R3 as needing partial to moderate assistance with personal hygiene.

Review of R3's Care Plan tab in the EMR revealed a care plan dated 7/3/2024 identifying 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 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 R3 refused care for personal hygiene but did have care provided on both days.On 9/3/2025 at 9:35 AM, R3 was observed in his room in bed lying on his right side. 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, R3 was asked if this surveyor could see his nails. 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, R3 was observed coming back from breakfast.

When asking about R3's clothing, 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 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 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 R3's nails and stated staff would take care of R3's nails.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Health and Rehabilitation Center

139 Moran Lake Road, NE Rome, GA 30161

SUMMARY STATEMENT OF DEFICIENCIES

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 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 R1 exit the facility. LPN4 stated that during the medication pass around 8:00 PM that day, another staff member alerted the team that R1 could not be located. LPN4 said that all staff members did a sweep throughout the facility, and 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 R1 exited the facility. RT1 thought R1 was a family member that had been visiting. RT1 verified that no staff alerted him that 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 R1's elopement. SSD was told by the South LPN2 that R1 was found at a gasoline station by Preacher, a person known to the family of R1, near R1's nephew's apartment. R1 was taken to the nephew's apartment, but the nephew was not home.

The family member of R1 was called and was told by Preacher they were taking R1 back to the facility.

Around 10:00 PM on 4/30/2025, a car pulled up to the side door. 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 R1's family member who stated that Preacher found R1 at a gas station near the propane tanks. R1's Family member stated that Preacher took R1 to his nephew's apartment, but no one was there. R1's Family member stated that Preacher was bringing R1 back to the facility.

The Police, Administrator, SSD all see the car pull up to the side of the facility, 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 R1 was given a thorough examination when 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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Health and Rehabilitation Center

139 Moran Lake Road, NE Rome, GA 30161

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/05/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Evergreen Health and Rehabilitation Center

139 Moran Lake Road, NE Rome, GA 30161

SUMMARY STATEMENT OF DEFICIENCIES

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.