Evergreen Manor Senior Care Center

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident (#100) was treated with dignity and care in manner that promotes maintenance or enhancement of her quality of life out of one resident reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to report an allegation of neglect/abuse to the appropriate state survey agency for one resident (#100) of one resident reviewed for neglect/abuse. Findings Included:Resident #100 (R100)Review of the medical record revealed R100 was admitted [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalance, urinary tract infection, hypertension, difficulty walking, and muscle weakness. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/30/2026, revealed a BIMS score of 15 (cognitively intact) out of 15. On 03/31/2026 at 09:31 a.m. during observation and interview R100 was observed lying down in bed. R100's daughter V was observed sitting in a chair at her bedside. R100 explained that she had a concern regarding her care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to adequately investigate an allegation of neglect/abuse for one resident (#100) of one resident review of neglect/abuse. Findings Included: Resident #100 (R100)Review of the medical record revealed R100 was admitted [DATE] with diagnoses that included metabolic encephalopathy (brain dysfunction caused by chemical imbalance, urinary tract infection, hypertension, difficulty walking, and muscle weakness. Review of R98's document entitled Brief Interview of Mental Status (3.0 BIMS), completed 03/30/2026, revealed a BIMS score of 15 (cognitively intact) out of 15. On 03/31/2026 at 09:31 a.m. during observation and interview R100 was observed lying down in bed. R100's daughter V was observed sitting in a chair at her bedside. R100 explained that she had a concern regarding her care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a written summary of the baseline care plan to one resident (#98) or residents representative out of 18 residents reviewed for baseline care plan.

Inspectors wroteThis citation pertains to intake 2648236. Based on observation, interview, and record review, the facility failed to provide adequate post-surgical wound care for one (R201) of one resident reviewed. Review of the clinical record revealed R201 was admitted into the facility on 9/25/25 with diagnoses that included: encounter for surgical aftercare following surgery on the nervous system, depression, anxiety, and difficulty walking. According to the Minimum Data Set (MDS) assessment dated [DATE], R201 required substantial/maximal assistance for shower/bathing and scored 15/15 on the Brief Interview for Mental Status exam (which indicated intact cognition). A review of R201's After Visit Summary (instructions provided to resident at discharge from the hospital) dated 9/25/25 revealed resident underwent spinal surgery. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide and document evidence of prompt resolution to a grievance for missing personal clothing of one (resident #48) out of one resident reviewed resulting in unresolved grievance. Findings Included: Resident #48 (R48) Review of the medical record revealed R48 was admitted to the facility 12/06/24 with diagnoses that included sepsis (complicated infection), cellulitis (bacterial skin infection) of left lower limb, chronic pain syndrome, depression, gastro-esophageal reflux, hypertension, neuropathy (pain from nerve damage), osteoarthritis (degenerative joint disease), rheumatoid arthritis (chronic inflammation of joints), spinal stenosis(spinal narrowing), obesity, lymphedema (swelling of extremities cause by lymphatic system blockage), and difficulty walking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to justify the ongoing use of an indwelling urinary catheter for one (R11) of three reviewed.

Inspectors wroteBased on interview and record review, the facility failed to ensure two of seven staff reviewed who performed cardiopulmonary resuscitation (CPR) on Resident #2 maintained current CPR certification for healthcare providers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure two out of two residents (Resident #46 & 190) were free from misappropriation of property when $70 and a purse were identified to be missing. Findings Included: In an interview on 3/06/2024 at 9:38 AM, Resident # 46 (R46) stated that she had $70 stolen, and said it was on her windowsill under a small bag (resembled a makeup bag). R46 said about one week ago was when her $70 was found to be missing. R46 said a Certified Nurse Aid (CNA), who's name she could not recall, was in her room cleaning off her windowsill approximately one week ago from this interview, and said she told the CNA not to lift the bag up off the windowsill, but the CNA did anyhow and saw the money. R46 said that no staff had interviewed her nor got a statement from her regarding her missing $70. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately report an allegation of misappropriation of $70 that was fund to be missing for one of one residents (Resident #46). Findings Included: In an interview on 3/06/2024 at 9:38 AM, Resident # 46 (R46) stated that she had $70 stolen, and said it was on her windowsill under a small bag (resembled a makeup bag). R46 said about one week ago was when her $70 was found to be missing. R46 said a Certified Nurse Aid (CNA), who's name she could not recall, was in her room cleaning off her windowsill approximately one week ago from this interview, and said she told the CNA not to lift the bag up off the windowsill, but the CNA did anyhow and saw the money. R46 said that no staff had interviewed her nor got a statement from her regarding her missing $70. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to thoroughly investigate for one out of one resident (Resident #46) an incident of $70 coming up missing that kept in Resident #46's room. Findings Included: In an interview on 3/06/2024 at 9:38 AM, Resident # 46 (R46) stated that she had $70 stolen, and said it was on her windowsill under a small bag (resembled a makeup bag). R46 said about one week ago was when her $70 was found to be missing. R46 said a Certified Nurse Aid (CNA), who's name she could not recall, was in her room cleaning off her windowsill approximately one week ago from this interview, and said she told the CNA not to lift the bag up off the windowsill, but the CNA did anyhow and saw the money. R46 said that no staff had interviewed her nor got a statement from her regarding her missing $70. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care with activities of daily living (ADL) to one (Resident #339) of two residents reviewed for ADL care. Resident # 339 (R339) Review of the medical record revealed Resident #339 (R339) was admitted to the facility on [DATE] with diagnoses that included unspecified fracture of the right forearm, Congestive Heart Failure, muscle weakness and history of a CVA. According to Resident #339 (R339)'s Minimum Data Set (MDS) dated [DATE], revealed R339 scored 10 out of 15 (moderate cognitive impairment) on the Brief Interview for Mental Status (BIMS- a cognitive screening tool) and had no behaviors. R339 required partial to moderate assistance due to impairment on one side and use of a walker and wheelchair. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent the administration of an unnecessary dose of a pneumococcal immunization for one (Resident #2) of five reviewed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to effectively clean and maintain the physical plant effecting 87 residents, resulting in the increased likelihood for cross-contamination, bacterial harborage, and decreased illumination.

Inspectors wroteThis 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.