Cycle 1
Health 2025-01-15 · Fire 2025-01-15
3 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Battle Creek, MI
Evergreen Manor Senior Care Center
4-star overall rating with 4-star inspections with 3 recent health deficiencies
111 Evergreen, Battle Creek, MI
(269) 969-6110
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
91
Certified beds
Average residents
87
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Nexcare Health Systems
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 4 overall / 3 health / 4 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.65
Registered nurse staffing · state 0.77 · national 0.68
LPN hours / resident day
0.62
Licensed practical nurse staffing · state 0.88 · national 0.87
Aide hours / resident day
2.31
Nurse aide staffing · state 2.38 · national 2.35
Total nurse hours
3.58
All reported nurse hours · state 4.03 · national 3.89
Licensed hours
1.27
RN + LPN hours · state 1.65 · national 1.54
Weekend hours
3.10
Weekend nurse staffing · state 3.52 · national 3.43
Weekend RN hours
0.42
Weekend registered nurse coverage · state 0.49 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.74
CMS adjusted RN staffing hours
Adjusted total hours
4.06
CMS adjusted total nurse staffing hours
Case-mix index
1.21
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 41% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 44% · national 46%
SNF VBP
Value-based purchasing
Program rank
5,655
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
35.42
Composite VBP score used to determine payment impact.
Payment multiplier
0.9891
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
2.17
Baseline 20.52% · Performance 20.43% · Measure score 2.17 · Achievement 2.17 · Improvement 0
Healthcare-associated infections
5.17
Baseline 5.67% · Performance 6.29% · Measure score 5.17 · Achievement 5.17 · Improvement 0
Total nurse turnover
4.35
Baseline 59.61% · Performance 45.92% · Measure score 4.35 · Achievement 4.35 · Improvement 3.44
Adjusted total nurse staffing
2.48
Baseline 3.88 hours · Performance 3.78 hours · Measure score 2.48 · Achievement 2.48 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.27% |
10.72%
0.5 pts better
|
No Different than the National Rate · Eligible stays 138 · Observed rate 9.42% · Lower 95% interval 7.48% |
| Discharge to community | 54.46% |
50.57%
3.9 pts better
|
No Different than the National Rate · Eligible stays 136 · Observed rate 50.74% · Lower 95% interval 46.23% |
| Medicare spending per beneficiary | 0.82 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 97.67% |
95.27%
2.4 pts better
|
Numerator 84 · Denominator 86 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 86 |
| Discharge self-care score | 21.43% |
53.69%
32.3 pts worse
|
Numerator 15 · Denominator 70 |
| Discharge mobility score | 64.29% |
50.94%
13.4 pts better
|
Numerator 45 · Denominator 70 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 86 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 6.29% |
7.12%
0.8 pts better
|
No Different than the National Rate · Eligible stays 91 · Observed rate 4.4% · Lower 95% interval 3.43% |
| Staff COVID-19 vaccination coverage | 5.88% |
8.2%
2.3 pts worse
|
Numerator 12 · Denominator 204 |
| Staff flu vaccination coverage | 32.08% |
42%
9.9 pts worse
|
Numerator 68 · Denominator 212 |
| Discharge function score | 61.43% |
56.45%
5 pts better
|
Numerator 43 · Denominator 70 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 45 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 36.54% |
25.2%
11.3 pts better
|
Numerator 19 · Denominator 52 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.8 |
1.7
0.1 pts worse
|
1.9
0.1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.8 · Observed 2.0 · Expected 2.1 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.1 |
1.5
0.6 pts worse
|
1.8
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 2.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.3% |
95.0%
4.3 pts better
|
93.4%
5.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.4% · Q4 98.6% · 4Q avg 99.3% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.8% |
3.1%
1.3 pts better
|
3.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 2.9% · Q3 1.6% · Q4 1.4% · 4Q avg 1.8% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 7.1% |
4.1%
3 pts worse
|
11.4%
4.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 7.5% · Q3 7.0% · Q4 5.0% · 4Q avg 7.1% |
| Percentage of long-stay residents who lose too much weight | 5.3% |
5.5%
0.2 pts better
|
5.4%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.0% · Q2 3.3% · Q3 1.8% · Q4 10.0% · 4Q avg 5.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 19.8% |
19.6%
0.2 pts worse
|
19.6%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 21.4% · Q2 20.0% · Q3 20.3% · Q4 17.2% · 4Q avg 19.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 21.1% |
16.5%
4.6 pts worse
|
16.7%
4.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.4% · Q2 20.3% · Q3 19.6% · Q4 24.1% · 4Q avg 21.1% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.2% |
13.9%
4.7 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 6.1% · Q3 3.2% · Q4 10.7% · 4Q avg 9.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.9% |
11.7%
0.8 pts better
|
14.9%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.7% · Q2 4.8% · Q3 7.3% · Q4 16.4% · 4Q avg 10.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.9% |
0.9%
About the same
|
1.0%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.3% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.9% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
1.7%
0.9 pts better
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 4.3% |
20.4%
16.1 pts better
|
19.8%
15.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.0% · Q2 4.3% · Q3 4.7% · Q4 1.3% · 4Q avg 4.3% |
| Percentage of long-stay residents with pressure ulcers | 4.1% |
5.6%
1.5 pts better
|
5.1%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.9% · Q2 2.2% · Q3 3.8% · Q4 0.0% · 4Q avg 4.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 82.1% |
82.8%
0.7 pts worse
|
81.7%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 72.7% · Q2 82.6% · Q3 90.4% · Q4 81.4% · 4Q avg 82.1% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
11.5%
About the same
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 11.0% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.3%
1.3 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.3% |
79.5%
7.8 pts better
|
79.7%
7.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.0% |
24.2%
0.8 pts worse
|
23.9%
1.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.0% · Observed 23.0% · Expected 21.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-07 · Fire 2024-03-07
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (1 deficiency)
Cycle 3
Health 2022-12-13 · Fire 2022-12-13
11 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-03-07
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-03-25
F · Potential for more than minimal harm
2024-03-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-03-25
E · Potential for more than minimal harm
2024-03-07
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2024-03-25
F · Potential for more than minimal harm
2022-12-13
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-13
K761 · Miscellaneous Deficiencies
Fire Safety
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Corrected 2023-01-11
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-16
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-12-31
D · Potential for more than minimal harm
2025-01-15
F585 · Resident Rights Deficiencies
Health
Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.
Corrected 2025-01-24
D · Potential for more than minimal harm
2025-01-15
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-01-24
D · Potential for more than minimal harm
2024-05-09
F678 · Quality of Life and Care Deficiencies
Health
Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
Corrected 2024-05-20
D · Potential for more than minimal harm
2024-03-07
F602 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from the wrongful use of the resident's belongings or money.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-07
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-07
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-07
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-07
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2024-03-25
D · Potential for more than minimal harm
2024-03-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-03-25
E · Potential for more than minimal harm
2023-10-11
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-10-24
G · Actual harm
2023-05-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-22
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-22
F610 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Respond appropriately to all alleged violations.
Corrected 2023-06-01
D · Potential for more than minimal harm
2023-05-22
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-06-01
F · Potential for more than minimal harm
2022-12-13
F725 · Nursing and Physician Services Deficiencies
Health
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected 2023-01-11
D · Potential for more than minimal harm
2022-12-13
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-10
D · Potential for more than minimal harm
2022-12-13
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-01-10
Penalties and ownership
What sits behind the stars
Ownership
Nexcare Holdings, LLC
5% Or Greater Direct Ownership Interest · Organization
Branscum, James
5% Or Greater Indirect Ownership Interest · Individual
Eisenberg, Leo
5% Or Greater Indirect Ownership Interest · Individual
Nexcare Health Systems, LLC
Operational/Managerial Control · Organization
Perry, Michael
Operational/Managerial Control · Individual
Robin Eisenberg 2014 Family Trust
5% Or Greater Indirect Ownership Interest · Organization
Sangster, Todd
Corporate Officer · Individual
Smith, Cheryl
W-2 Managing Employee · Individual
Wronski, Frank
5% Or Greater Indirect Ownership Interest · Individual
Nearby options
Other facilities in reach
#1
The Laurels of Bedford
Battle Creek, MI
3-star overall rating with 3-star inspections with 10 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Majestic Care of Battle Creek
Battle Creek, MI
2-star overall rating with 2-star inspections with $76,538 in total fines with 15 recent health deficiencies
#3
The Oaks at Battle Creek
Battle Creek, MI
4-star overall rating with 3-star inspections with 9 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
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