Evercare at University

In the surveyor’s words

From the most serious findings on record at Evercare at University, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Oct 21, 2025

  Based on interview, observation, and record review, the Facility failed to ensure residents were free from sexual abuse for 1 of 3 residents (R2) reviewed for abuse in the sample of 6. This failure resulted in R2 being sexually abused by R3 on 10/5/25 and again on 10/6/25.This Immediate Jeopardy began on 10/5/25 at 5:30 PM when V7, Certified Nursing Assistant (CNA), witnessed R3 sexually abusing R2. The Facility did not report or investigate this, and no interventions were put in place to protect R2 from R3. The following day, on 10/6/25 at approximately 9:00 AM, R3 entered R2's room and sexually abused R3 again. V1, Administrator, was notified of the Immediate Jeopardy on 10/17/25 at 12:02 PM. […]

• Immediate jeopardy, isolatedF684May 9, 2025

  Based on interview and record review the Facility failed to assess and treat a change of condition for 1 of 3 residents (R2) reviewed for change of condition. This failure resulted in R2 having a significant change in condition for several hours without interventions that ultimately required an emergency transfer in which her family called 911 and R2 experienced respiratory distress, was intubated en route to the hospital and placed on a mechanical ventilator. The Immediate Jeopardy began on 5/2/2025 when R2 began to experience respiratory/breathing issues and was not sent to the hospital in a timely manner. […]

• Immediate jeopardy, isolatedF602Jan 31, 2024

  Based on interview and record review the facility failed to protect residents from employee misappropriation of resident funds and exploitation for one of 7 residents (R51) reviewed for misappropriation of resident property in the sample of 42. This failure resulted in an Immediate Jeopardy when V22, Certified Nursing Assistant, (CNA), began using R51's debit card without his permission on March 2, 2023, accruing more than $11,000.00 in charges. When R51 became aware, he was upset and worried about taking care of future expenses and needs. The Immediate Jeopardy began on 3/02/23, when V22 began using R51's debit card without R51's permission. […]

• Actual harm, patternF755May 28, 2024

  Based on interview and record review the facility failed to administer medications as ordered for residents (R1, R2, R3, R12) of 4 residents reviewed in a sample of 12. This failure resulted in R1 and R3 experiencing severe pain. Findings include: R1's face sheet, dated 5/23/24, documented that R1 was admitted on [DATE] with diagnoses of quadriplegia, hypertension, COPD (Chronic Obstructive Pulmonary Disease), spinal stenosis, intervertebral disk degeneration, osteoarthritis, and cirrhosis of the liver. R1's MDS (Minimum Data Set) dated 5/27/24 documented R1 is cognitively intact. On 5/23/24 at 6:40 AM, R1 stated that at the beginning of the week B hall did not have a nurse and that he did not receive any of his morning or noon medications. […]

• Actual harm, isolatedF689Aug 20, 2026

  Based on interview, observation, and record review, the facility failed to ensure fall prevention interventions were implemented in 1 of 4 residents (R9) when reviewed for falls in the sample of 12. This failure resulted in R9 sustaining a fall that resulted in a laceration requiring hospital evaluation and staples.Findings Include:On 8/19/26, R9 was observed in his room in a low bed, against the right wall with a floor mat to the left of R9's bed. R9 was unable to provide any details of his falls.R9's Face Sheet, undated, documents, R9 has the following diagnoses: Osteoarthritis, Parkinson's Disease, and Right Shoulder Dislocation.R9's Fall Risk Assessment, dated 6/22/26, documents R9 is at risk for falls.R9's Minimum Data Set, dated [DATE], documents R9 has severe cognitive impairment,… […]