Evergreen Manor Senior Care Center

In the surveyor’s words

From the most serious findings on record at Evergreen Manor Senior Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689May 22, 2023

  Based on observation, interview, and record review the facility failed to prevent implement effective interventions to prevent falls for two (Resident #3 and Resident #5) of five reviewed for falls, resulting in a fall with major injury and repeated hospital transfers (Resident #3) and repeated falls and the potential for major injury (Resident #5). Findings include: Resident #3 (R3) Review of an Admission Record revealed Resident #3 (R3) admitted to the facility on [DATE] and readmitted on [DATE] with pertinent diagnoses which included nondisplaced intertrochanteric fracture of left femur, difficulty in walking, multiple fractures of pelvis, dementia, history of falling, unspecified fracture of the lower end of right radius, traumatic hemorrhage of cerebrum, and major depressive disorder. […]

• No harm, potential for more than minimal, widespreadF880Apr 2, 2026

  Based on observation, interview, and record review, the facility failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP), resulting in the potential for increased risk of respiratory infection among all residents in the facility.Findings include: On 3/31/26 at 10:02 AM, observation of the mop sink closet in the kitchen found that a hot water storage tank was placed where the old mop sink was located. At this time, it was observed that the hot water line from the old mop sink was connected to the storage tank and the cold-water line was observed connected to nothing, indicating a stagnant water line. […]

• No harm, potential for more than minimal, widespreadF725Dec 13, 2022

  This Citation includes intakes: MI00131916, MI00130299, and MI00130624 Based on observation, interview, and record review the facility failed to provide sufficient staff to meet resident's needs, as voiced during a confidential Resident Council meeting (15 residents in attendance) and 4 residents (#11, #17, #63 and #67) out of a sample of 18 residents and a facility census of 78, resulting in the potential of unmet needs and frustration. Findings Included: Resident Council Minutes dated 09/14/2022 revealed that residents present at the meeting explained that call light response time continued to depend on the time of day that assistance was requested. […]

• No harm, potential for more than minimal, patternF725Oct 11, 2023

  This citation pertains to MI00139275. Based on observation, interview and record review, the facility failed to ensure call lights were answered in a timely manner for four (Resident #2, #6, #7 and #8) of six reviewed for call light response time, resulting in call lights not being answered for extended periods of time and resident needs not being met in a timely manner. Findings include: Resident #2 (R2): Review of the medical record reflected R2 admitted to the facility on [DATE] and readmitted on [DATE], with diagnoses that included aftercare following joint replacement surgery, presence of artificial left knee joint, difficulty walking, diabetes, atrial fibrillation, congestive heart failure and chronic kidney disease. […]

• No harm, potential for more than minimal, patternF641Sep 23, 2021

  Based on observation, interview, and record review, the facility failed to accurately complete a Minimum Data Set (MDS) assessment for 8 (Resident #17, #40, #46, #54, #57, #60, #62, #69) of 19 reviewed for MDS assessments, resulting in the increased likelihood for inaccurate care plans and unmet care needs. Findings include: Review of the Face Sheet and Minimum Data Set (MDS) dated [DATE](most recent), reflected Resident #17 was a [AGE] year old female admitted to the facility on [DATE], with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]