Evergreen Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Evergreen Health and Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF684Apr 8, 2025

  This citation pertains to Intake Number(s): MI00150988. Based on interview and record review, the facility failed to thoroughly evaluate and timely address a foot injury for one (R802) of one resident reviewed for a change in condition, resulting in a delay in diagnosing and treating a moderately comminuted avulsion fracture (bone broken in multiple places) to the resident's heel (calcaneus), increased pain, and the inability to fully participate in physical rehabilitation. Findings include: A review of a complaint submitted to the State Agency revealed an allegation that the resident sustained an injury to her foot in the facility. On 4/8/25, an unannounced onsite investigation was conducted. […]

• Actual harm, isolatedF684Mar 14, 2024

  This citation pertains to intake: MI00142846. Based on interview and record review the facility failed to ensure staff timely identified a worsening of condition and communicated a change of condition with the nursing staff and physician staff for one (R801) of three residents reviewed for a change of condition. Findings include: Review of a complaint submitted to the State Agency (SA) documented concerns of the facility to have failed to assess a change of condition with R801 in a timely manner. Review of the medical record revealed R801 was admitted to the facility on [DATE] with diagnoses that included: malignant neoplasm of cervix, abscess of vulva and acute kidney failure. […]

• Actual harm, isolatedF686Mar 14, 2024

  This citation pertains to Intake(s): MI0014286, MI00143149, MI00142861 & MI00143213. Based on observation, interview, and record review the facility failed to ensure pressure wounds were identified (R801), assessed and monitored by physicians/wound clinicians consistently if at all (R's 801 & 804) , implement effective treatment for identified wounds timely (R803), implement preventive interventions (R802) for four (R's 801, 802, 803 & 804) of four residents reviewed for wounds, resulting in R801 to have developed an unstageable (full-thickness skin and tissue loss in which the extent of tissue damage within the ulcer cannot be confirmed because the wound bed is obscured by slough or eschar) coccyx/sacrum wound, R802 to have developed a Deep Tissue Injury (DTI- Intact skin with localized… […]

• Actual harm, isolatedF686Jun 29, 2023

  This citation pertains to Intake #MI00135548 Based on interview and record review the facility failed to initiate necessary treatments for one (R155) of seven resident's reviewed for pressure ulcers, resulting in the worsening of a pressure wound to the spine. Findings include: A complaint was filed with the State Agency (SA) that alleged R155 did not receive proper wound treatment for their pressure sores. The complainant reported that the resident was discharge from the facility on or about 2/16/23 and ended up in the hospital on 2/21/23 with unstageable wounds. […]

• Actual harm, isolatedF690Jun 29, 2023

  This citation pertains to Intake #MI00134725 Based on observation, interview and record review the facility failed to timely review abnormal lab results for one (R58) out of four residents reviewed for Urinary Tract Infection (UTI) resulting in a delay in treatment for a UTI and hospitilization. Findings include: A complaint was filed with the State Agency (SA) that alleged R58 had a UTI (urinary tract infection) that was left untreated resulting in R58 being sent to the hospital on 1/29/23 after they were observed with a change in mental status. On 6/27/23 at approximately 10:45 AM, R58 was observed lying in bed. The resident was alert but not able to answer most questions asked including a history of UTI(s) or hospitalization . […]