Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Evergreen Health Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a current stage 3 sacral pressure injury had an air mattress in place for pressure injury prevention, but the setting was not documented in the chart and was observed at the firmest level despite the resident weighing far less than the setting indicated. Staff gave conflicting accounts about who was responsible for checking and adjusting the mattress, and the DON confirmed the care card and plan of care did not contain an air mattress setting.
Infection prevention and control was not maintained for three residents with wounds or an indwelling catheter. Staff performed wound care, toileting, and transfers without the required gowns and gloves for residents on EBP, and one resident’s catheter bag was observed on the floor and leaking. The record also showed one resident with an unstageable sacral pressure injury was not placed on EBP when staff later verified it should have been in effect.
Staff failed to document food cooling temperatures, follow safe reheating protocols, and ensure proper labeling and dating of food items. Food was observed being held and served at improper temperatures, and staff did not consistently monitor dishwasher sanitization. These deficiencies in food safety practices had the potential to affect all residents.
Three residents experienced significant unplanned weight changes without consistent monitoring or timely physician notification, and there were delays in implementing recommended nutritional supplements. The facility did not follow its own policies for weight monitoring, documentation, and physician communication, resulting in lapses in care for residents with complex medical needs.
Air Mattress Setting Not Documented or Set Correctly for Resident With Stage 3 Pressure Injury
Penalty
Summary
The facility did not ensure one resident with impaired cognition and a current stage 3 sacral pressure injury received appropriate care related to an air mattress that had been implemented for pressure injury prevention. The resident had diagnoses including Alzheimer’s disease, weight loss, and osteoporosis, and the Minimum Data Set showed a BIMS score of 5 out of 15, indicating severely impaired cognition. The care plan identified impaired skin integrity and wounds related to decreased mobility, bladder incontinence, a history of pressure injuries, and inability to consistently reposition in bed and chair. The resident also had a history of moisture-associated skin damage on the coccyx and a stage 3 pressure injury on the sacral region. Surveyors reviewed the resident’s record and found the air mattress had been provided for wound prevention, but the medical record did not contain an order to check the mattress setting or ensure it was set appropriately. The resident’s weights were documented between 130.6 and 138 pounds, yet the mattress was observed set at 10, which was the most firm setting and corresponded to a weight of 400 pounds or greater. Staff interviews confirmed the setting was not documented in the care sheet, TAR, or physician orders, and the mattress remained at 10 during multiple observations before later being found set at 5. Interviews showed conflicting understanding among staff about who was responsible for adjusting the mattress. A CNA stated CNAs do not adjust air mattress settings and that nurses are responsible, while the DON stated the care card should contain the setting and that the mattress should be set according to the resident’s weight. The DON also stated a bath aide weighed residents and set air mattresses, but the bath aide stated she weighed residents and did not check mattress settings. The resident’s wound history showed the coccyx wound had healed and reopened multiple times, and the current stage 3 pressure injury was present during the survey.
Infection control and EBP not followed during wound care, toileting, and transfers
Penalty
Summary
The facility did not establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable disease and infection for three sampled residents. The facility’s Infection Control Program stated that enhanced barrier precautions (EBP) are used in addition to standard precautions for residents with wounds or indwelling medical devices, and that PPE includes gloves and gowns during high-contact resident care activities. The facility’s indwelling urinary catheter policy stated the drainage bag should be below the level of the bladder and should never touch the floor. R1 had diagnoses including malignant neoplasm of the prostate and a pressure ulcer of the sacral region, and had a BIMS score of 14 out of 15. Surveyors observed RN-D and CNA-F complete a dressing change for R1’s unstageable pressure injury without wearing gowns. There was no EBP sign on or near R1’s door to alert staff to the need for PPE during high-contact care. DON-B and ADON-C later verified that R1 should have been on EBP related to the unstageable pressure injury and that staff should have followed EBP after the wound was noted. R5 had diagnoses including dementia, retention of urine, and chronic kidney disease, and had a BIMS score of 10 out of 15. A surveyor observed CNA-E toilet R5 and transfer R5 from a wheelchair to a recliner without PPE, even though a sign outside the room indicated R5 was on EBP and PPE was required for personal care and transfers. R5 reported a urine odor in the room related to the nighttime catheter bag being placed on the floor and leaking. Surveyors also observed R10, who had Alzheimer’s disease, osteoporosis, a BIMS score of 5 out of 15, and a current stage 3 sacral pressure injury, being transferred and toileted by CNA-G and CNA-H without gowns or gloves while R10 was on EBP. CNA-G acknowledged the EBP sign and PPE cart outside the room and stated staff should have worn gowns and gloves during transfers and toileting.
Failure to Maintain Safe and Sanitary Food Storage and Preparation Practices
Penalty
Summary
The facility failed to ensure that food was stored, prepared, and served in a safe and sanitary manner, as required by professional standards and the FDA Food Code. Staff did not document food cooling temperatures, and there was no policy provided for food cooling practices. During kitchen inspections, surveyors observed that staff regularly pre-cooked and cooled food for future meals, but cooling logs could not be located by either the Dietary and Nutritional Coordinator or the Lead staff member. This lack of documentation meant there was no verification that critical food safety limits were being met. Staff also did not follow safe reheating protocols for food intended for resident consumption. During meal service observations, food items were found to be below the required hot holding temperatures, and reheating procedures did not ensure that food reached the necessary 165°F. Staff members were observed reheating food in microwaves without covering, stirring, or allowing the food to stand as required, and did not check the temperature of reheated food before serving it to residents. Additionally, staff were unclear about the correct temperature requirements and procedures for reheating and holding food. Food items in freezers, coolers, and dry storage areas were not consistently labeled or dated, with several open and undated items found during inspections. The facility lacked a specific policy for labeling and dating food, and staff relied on various charts and guidelines, but these were not consistently followed. Furthermore, staff did not consistently monitor and document dishwasher surface temperatures, and there was a period when the facility ran out of temperature strips needed to verify sanitization. These combined actions and inactions had the potential to affect all residents in the facility.
Failure to Monitor and Report Significant Weight Changes and Delays in Nutritional Interventions
Penalty
Summary
The facility failed to ensure appropriate care and treatment related to weight monitoring and nutritional management for three residents. For one resident with neurocognitive disorder, dementia, and malnutrition, the facility did not consistently monitor weights as ordered by the physician and failed to notify the physician when a significant weight loss occurred. The resident's care plan indicated increased nutritional needs and assistance with meals, but weekly weights were not completed, and the physician was not updated regarding a 10.14% weight loss over a short period. Another resident with aphasia and dysphagia experienced an 8.92% weight loss, but there was no documentation of a physician order for weight monitoring or evidence that the physician was notified of the significant weight loss. The resident had a poor appetite and required a modified diet and nutritional supplements, but the facility did not document physician notification or follow-up regarding the weight change. A third resident with multiple chronic conditions, including diabetes and heart failure, experienced significant and rapid fluctuations in weight, including both losses and gains exceeding 5 lbs. The facility did not document timely physician notification of these changes, nor did it promptly follow up on a supplement order recommended by the dietitian. Staff interviews confirmed that notifications to the physician and documentation of such notifications were inconsistent or absent, and the facility's own policies regarding weight monitoring and physician notification were not followed.
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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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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Home | 0.8 mi | ★★★★★ | 0 | 0 |
| Eden Rehab Suites And Green House Homes | 2.2 mi | ★★★★★ | 5 | 0 |
| Edenbrook Of Oshkosh | 2.4 mi | ★★★★★ | 12 | 0 |
| Park View Health Center | 3.9 mi | ★★★★★ | 0 | 0 |
| Edenbrook Omro | 8.8 mi | ★★★★★ | 2 | 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 August 2026) and official state health department websites.