Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Manor Senior Care Center during CMS and state inspections, most recent first.
Failure to maintain an active water management program for OPPP control. The facility had multiple removed or unused plumbing fixtures, including mop sinks, hoppers, and a bathroom sink/commode, with stagnant water lines left intact and not flushed. The POD stated only some minimal-use fixtures and eye wash stations were flushed weekly, while other disconnected lines were not. The facility also used chlorine test strips that only read in 0.5 ppm increments, despite the WMP requiring a test kit accurate to 0.1 ppm.
Failure to Provide Dignified Toileting Assistance: A cognitively intact resident with UTI, HTN, difficulty walking, and muscle weakness reported that an aide told her to urinate in her brief because there was no time to take her to the bathroom, and her daughter gave the same account. The DON stated that this was not acceptable and that the resident should have been assisted to the bathroom or provided a bed pan or bedside commode.
Failure to report an allegation of neglect: A cognitively intact resident with UTI-related urinary urgency said an aide told her to urinate in her brief because staff did not have time to take her to the bathroom, and the resident’s daughter reported the same concern. The NHA said he was aware of the allegation but did not report it because he could not substantiate it, despite staff acknowledging the event should have been treated as an allegation of abuse or neglect and reported to the state survey agency.
Failure to adequately investigate and report an allegation of neglect. A cognitively intact resident with UTI and weakness reported that an aide told her to urinate in her brief because there was no time to take her to the bathroom, and the resident’s daughter reported the same concern and said the resident felt she was not treated with dignity and respect. The NHA said he was aware of the allegation but had no documentation of an investigation and initially did not report it to the state because he could not substantiate it, while the DON and an LPN identified the event as potential abuse or neglect.
A resident admitted with stroke, AFib, respiratory failure, DM2, aphasia, right-sided paralysis, dysphagia, and insomnia did not receive a written summary of the baseline care plan, and the resident’s daughter said neither she nor the resident had been given a copy. The DON stated the expectation was to provide the baseline care plan to the resident or representative within 48 hours, but the record lacked documentation that this occurred.
A resident who underwent spinal surgery did not receive consistent post-surgical wound care as ordered, including daily cleaning of the incision and regular wound assessments. Documentation showed lapses in keeping the wound clean and dry, and the wound nurse did not follow up as required, resulting in the resident developing signs of infection and wound complications.
A resident reported missing a blue pair of pants to a CNA, but the grievance was not documented or resolved as per facility policy. The resident was not offered a Resident Assistance Form, and the issue was not logged in the concern log. The DON and NHA were unaware of the grievance, indicating a failure to follow the established grievance resolution process.
A resident with functional urinary incontinence had an indwelling urinary catheter inserted due to severe illness, including dehydration and sepsis. Although the resident's condition improved and treatments were completed, the catheter remained without clear justification. Facility staff acknowledged the catheter was for monitoring during IV fluids but failed to remove it timely, with no clear instructions from the physician on its duration.
The facility failed to ensure that staff members performing CPR on a resident were appropriately certified for healthcare provider-level CPR. One LPN had a lay responder CPR certification, and a CNA who assisted with chest compressions did not have a CPR certification on file. The resident, who was a full code, was pronounced dead after EMTs continued CPR and administered emergency medications.
Failure to Maintain Water Management Controls for Stagnant Plumbing Lines
Penalty
Summary
The facility failed to have an active and ongoing infection prevention and control program for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP). During observation of the mop sink closet in the kitchen, a hot water storage tank was found where the old mop sink had been located, with the hot water line connected to the storage tank and the cold-water line connected to nothing, indicating a stagnant water line. In the 300 hall Soiled Utility room, the hopper fixture had been removed and the remaining water lines were not on a flushing schedule; the Plant Operations Director stated the facility only flushed eye wash stations and some minimal use fixtures every Friday. The POD also stated that the removed hopper lines ran through the ceiling. Additional observations showed similar conditions in other areas of the facility. In the housekeeping closet between the 300 and 400 halls, the cold-water valve had been removed from the mop sink faucet, and the POD stated the cold side was not currently flushed on Fridays. The 400 hall Soiled Utility room had a removed hopper with water lines left intact, the housekeeping closet between the 100 and 200 halls had the cold valve removed from the mop sink faucet, and the 100 hall Soiled Utility room had a removed hopper with water lines still present. In the shared bathroom at the end of the 100 hall, the commode and sink had been removed since 2020, but the water fixtures were left intact and were not on a flushing schedule. During discussion of the Water Management Plan, the POD stated the facility used monthly test strips for free chlorine, and the provided strips only showed total chlorine in 0.5 ppm increments. The facility’s Water Management Plan, dated July 1, 2025, listed a control measure requiring a free and total chlorine test kit that can accurately read to 0.1 ppm.
Failure to Provide Dignified Toileting Assistance
Penalty
Summary
The facility failed to ensure that one resident was treated with dignity and care in a manner that promotes maintenance or enhancement of quality of life. The resident was admitted with diagnoses including metabolic encephalopathy, urinary tract infection, hypertension, difficulty walking, and muscle weakness, and had a BIMS score of 15, indicating she was cognitively intact. During an observation and interview, the resident stated that sometime in the middle of the night an aide told her to urinate in her brief because the aide did not have time to take her to the bathroom, and the resident said she urinated in her brief before the aide later provided continent care. The resident’s daughter reported a similar account, stating that around 04:00 a.m. the resident had used her call light because she needed to go to the bathroom, but an aide told her to go in her brief because there was not time to take her. The daughter stated the resident urinated in her brief and that the resident was being treated for a urinary infection and could not hold her urine. The daughter also stated that she believed her mother had not been treated with dignity and respect. The DON stated that residents should receive urinary care based on their needs and plan of care, and that it would not be acceptable for staff to tell a resident to urinate in a brief; she said staff should have taken the resident to the bathroom, provided a bed pan, or provided a bedside commode.
Failure to Report Allegation of Neglect
Penalty
Summary
The facility failed to report an allegation of neglect/abuse to the appropriate state survey agency for a resident who was cognitively intact with a BIMS score of 15 out of 15 and had diagnoses including metabolic encephalopathy, urinary tract infection, hypertension, difficulty walking, and muscle weakness. During an observation and interview, the resident stated that during the middle of the night an aide told her to urinate in her brief because the aide did not have time to take her to the bathroom, and that she did so before the aide later provided continent care. The resident’s daughter reported the same concern, stating that her mother had called for help to use the bathroom around 4:00 a.m. and was told to urinate in her brief because staff were too busy. The daughter also stated that she had already raised the concern with the Nursing Home Administrator and was told the aide was new and the issue had been addressed with the employee. Review of the facility concern logs did not show any concern for the resident. When interviewed, the NHA stated he was aware of the allegation and had investigated it, but could not substantiate that it occurred. He also stated he had no documentation showing the incident had been investigated at that time and that he did not report the allegation because he could not substantiate it. The DON stated that residents were expected to receive urinary care based on their needs and plan of care, and that telling a resident to urinate in a brief would not be acceptable. She stated the incident would have been an allegation of potential abuse or neglect and should have been reported to the NHA. An LPN stated that the resident’s daughter had voiced the concern to her and that she immediately reported it to the NHA because it was an allegation of abuse or neglect. Facility policy required allegations involving abuse or neglect to be reported immediately, but the NHA did not report the allegation to the state agency until later, after the issue had already been brought forward.
Failure to adequately investigate and report an allegation of neglect
Penalty
Summary
The facility failed to adequately investigate an allegation of neglect/abuse involving a resident who was admitted with metabolic encephalopathy, urinary tract infection, hypertension, difficulty walking, and muscle weakness. The resident had a BIMS score of 15, indicating she was cognitively intact. During observation and interview, the resident stated that during the middle of the night an aide told her to urinate in her brief because the aide did not have time to take her to the bathroom, and that she did so before the aide later returned to provide incontinent care. The resident’s daughter reported that her mother had described the same incident as occurring around 4:00 a.m. after she had used her call light to request assistance to the bathroom. The daughter stated that her mother was being treated for a urinary infection and could not hold her urine, and that she felt her mother had not been treated with dignity and respect. She also stated that she had already told the Nursing Home Administrator about the incident and was told only that the aide involved was new and that the issue had been addressed with the employee. Review of the facility concern logs did not reveal any concern for the resident. The Nursing Home Administrator stated he was aware of the allegation and had investigated it, but he could not substantiate that it occurred and had no documentation showing that the incident was investigated. He also stated that because he could not substantiate the allegation, he did not report it to the state agency. The Director of Nursing stated that residents should be provided urinary care based on their needs and plan of care, and that telling a resident to urinate in a brief would not be acceptable and would be an allegation of potential abuse or neglect. A licensed practical nurse stated that the daughter had voiced the concern to her and that she immediately reported it to the NHA because it was an allegation of abuse or neglect. The facility policy required immediate initiation of an investigation after the administrator had knowledge of the incident and required reporting of alleged abuse or neglect within the required time frame.
Failure to Provide Baseline Care Plan Copy
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to one resident or the resident’s representative within 48 hours of admission. Resident #98 was admitted with diagnoses including stroke, atrial fibrillation, hyperlipidemia, respiratory failure, type 2 diabetes, aphasia, right-sided paralysis, dysphagia, and insomnia. The resident’s BIMS was not assessed due to the resident’s medical condition, and on 03/31/2026 the resident was observed lying in bed and did not respond to verbal questions. Record review showed that an interim plan of care was initiated upon admission, but during interview the resident’s daughter stated that neither she nor the resident had received a copy of the baseline plan of care. The DON stated it was her expectation that each resident or resident representative would receive a copy of the baseline plan of care within 48 hours and that documentation should show the copy was provided. Review of the resident’s baseline care plan confirmed that documentation was not present showing that the resident or representative had received a copy.
Failure to Provide Adequate Post-Surgical Wound Care
Penalty
Summary
The facility failed to provide adequate post-surgical wound care for one resident following spinal surgery. Upon admission, the resident had clear aftercare instructions from the hospital to clean the incision daily with mild soap and water, and to keep the area dry. Physician orders were in place to monitor the surgical site for signs of infection and to keep the incision clean and dry, with wound nurse follow-up. However, documentation revealed that these orders were not consistently followed. The treatment administration record did not show evidence that the wound was routinely kept clean and dry from admission through a significant period, and the wound nurse did not assess the incision regularly as ordered. Progress notes indicated that the resident experienced increasing redness, pain, and eventually drainage and malodor at the surgical site, with concerns for infection and dehiscence. Despite these symptoms and multiple provider consultations, there was a lack of consistent documentation of wound care and hygiene. The resident required assistance with hygiene and was only provided bed baths on a few occasions, with limited evidence of showers or proper incision cleaning as per discharge instructions. The wound nurse confirmed that the incision should have been cleaned daily and acknowledged gaps in wound assessment and care.
Failure to Resolve Resident Grievance for Missing Clothing
Penalty
Summary
The facility failed to provide and document evidence of prompt resolution to a grievance regarding missing personal clothing for a resident. The resident, who was cognitively intact, reported missing a blue pair of pants to a Certified Nurse Aide (CNA) but was not offered a Resident Assistance Form to document the grievance. The CNA did not report the missing item to other staff members, and the grievance was not logged in the facility's concern log. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both confirmed that the facility's policy requires staff to assist residents in completing a Resident Assistance Form when grievances are reported. However, neither the DON nor the NHA were aware of the resident's missing clothing, and no form had been completed for this grievance. The facility's policy outlines a process for addressing grievances, but this process was not followed in this instance, resulting in an unresolved grievance for the resident.
Failure to Justify Continued Use of Indwelling Urinary Catheter
Penalty
Summary
The facility failed to justify the ongoing use of an indwelling urinary catheter for a resident who was admitted with functional urinary incontinence. The resident, who was cognitively intact, reported discomfort from the catheter, which was initially inserted due to severe illness, including dehydration and sepsis. The medical records indicated that the catheter was inserted to monitor urine output while the resident was on IV fluids, but there was no documented indication for its continued use after the resident's condition improved. Despite the resident's improvement and the completion of antibiotic and IV fluid treatments, the catheter remained in place without clear justification. The facility's staff, including the Unit Manager and Director of Nursing, acknowledged the catheter was intended for monitoring purposes during IV fluid administration but failed to remove it in a timely manner. The physician involved did not provide clear instructions on the duration of catheter use, leading to an oversight in its removal, which was only addressed after the surveyor's observation.
Failure to Ensure Proper CPR Certification Among Staff
Penalty
Summary
The facility failed to ensure that two of seven staff members who performed CPR on Resident #2 maintained current CPR certification for healthcare providers. Resident #2, who was admitted with diagnoses including atrial fibrillation, diabetes, and lymphedema, was a full code and wished to have CPR performed. On the day of the incident, Resident #2 became unresponsive, and CPR was initiated by two LPNs. However, one of the LPNs had a CPR certification that was not for healthcare providers, and a CNA who assisted with chest compressions did not have a CPR certification on file. The CNA later reported that they were informed by the Nursing Home Administrator that CNAs were not supposed to perform CPR at the facility. The facility's personnel files confirmed the lack of appropriate CPR certification for the involved staff members. Interviews with staff and representatives from the American Red Cross revealed that the CPR certification held by one of the LPNs was for lay responders and not for healthcare providers. The Director of Nursing confirmed that CNAs were not allowed to perform CPR and that only staff certified in CPR could initiate it. Despite the efforts to resuscitate Resident #2, the resident was pronounced dead after EMTs continued CPR and administered emergency medications. The deficiency highlights the facility's failure to ensure that staff members performing CPR were appropriately certified for healthcare provider-level CPR.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Battle Creek
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Laurels Of Bedford | 2.7 mi | ★★★★★ | 14 | 0 |
| Majestic Care Of Battle Creek | 4.3 mi | ★★★★★ | 12 | 0 |
| The Oaks At Battle Creek | 4.5 mi | ★★★★★ | 0 | 0 |
| Pinnacle Care Of Battle Creek | 5.7 mi | ★★★★★ | 15 | 0 |
| Calhoun County Medical Care Facility | 7.1 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.