Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Health Services during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of wandering exited the facility unsupervised due to a malfunctioning exit alarm system and inadequate supervision. Staff failed to consistently monitor and respond to alarms, and temporary backup alarms were found to be turned off or nonfunctional. The facility did not determine the root cause of the alarm failure or ensure staff were properly educated on alarm use, resulting in immediate jeopardy.
Eight residents experienced prolonged call light response times, with some waiting up to nearly an hour for assistance with ADLs such as toileting and transfers. These delays led to incontinence, embarrassment, and stress, and in several cases, staff turned off call lights without meeting residents' needs. Staff and resident interviews, as well as facility records, confirmed that staffing shortages and staff routines contributed to these delays, despite facility policies requiring prompt response and assistance.
Staff did not consistently offer or assist residents with hand hygiene before or after meals, despite facility policy and CDC guidelines requiring this practice, especially during COVID-19 precautions. Hand sanitizing wipes or sanitizer were not made available on dining tables, and staff interviews revealed lapses in following infection control procedures.
Several residents experienced significant delays in receiving room tray meals, with breakfast and lunch often served 30 minutes to an hour past posted times. Residents expressed frustration over the wait, especially when compared to those eating in the dining room, and reported that concerns had been raised repeatedly in resident council meetings. Staff interviews revealed a lack of awareness about the extent of the issue, and observations confirmed that meal trays were left on carts for extended periods before delivery.
A resident with multiple cardiac and neurological conditions was returned to the facility with a cardiac monitor, but staff failed to assess the resident's ability to use the device, did not document monitoring or device checks, and did not obtain or follow up on necessary orders or instructions. Interviews confirmed a lack of documentation and follow-up regarding the cardiac monitor, resulting in a deficiency related to appropriate care and treatment.
Three residents with respiratory conditions used CPAP machines without timely physician orders for use, cleaning, or maintenance, as required by facility policy. Observations showed that some residents' CPAP equipment was visibly dirty, and residents reported not receiving needed staff assistance with cleaning. Staff acknowledged that orders and cleaning should have been completed upon admission, but these actions were not taken.
A resident was found with hydrocortisone cream at their bedside without a physician's order or authorization for self-administration. Facility policy requires an order and assessment for bedside medication, but neither was present in the medical record. Staff confirmed the absence of an order and that the medication was not on the MAR, resulting in a failure to ensure safe and accurate drug administration.
Surveyors observed multiple failures in infection prevention and control, including staff not performing hand hygiene between glove changes, not using required PPE during high-contact care for a resident on enhanced barrier precautions, and leaving a catheter drainage bag uncovered and on the floor. These lapses occurred during care for residents with significant medical needs, including wounds and catheters, and were confirmed by staff interviews and record review.
Three residents experienced falls due to inadequate supervision and care planning. One resident fell while smoking unsupervised, lacking a smoking care plan despite needing assistance with locomotion. Another resident fell from a lift chair without reassessment or implemented interventions. A third resident's care plan was not updated promptly after a fall, delaying necessary interventions.
The facility failed to properly store and administer medications for two residents. An RN misplaced a resident's eye drops, leading to a nine-day lapse in administration. Additionally, an LPN left medication unattended on a cart. Both actions violated facility policies requiring secure storage and supervision of medications.
A resident with chronic gout and frequent flare-ups did not have an updated care plan to reflect their current care needs. Despite multiple documented episodes of pain and swelling, the care plan lacked measures to monitor or manage these issues, which was confirmed by the Nurse Practitioner and Director of Nursing.
Medication was not administered according to the facility's policy for a resident with diabetes mellitus. An LPN failed to recap the needle after drawing up insulin, as observed by a surveyor. Both the LPN and the DON confirmed that the policy requires recapping the needle after withdrawing medication.
The facility failed to monitor adverse reactions to gabapentin for two residents prescribed the medication for pain management. Despite the facility's policy requiring ongoing monitoring for medication efficacy and adverse consequences, the plans of care for both residents did not include such monitoring. The DON acknowledged the oversight, attributing it to a misunderstanding of the policy requirements.
The facility failed to coordinate hospice services for two residents, resulting in inadequate documentation and communication. Hospice visit notes were not properly maintained in the medical records or hospice binders, and there was a lack of designated staff to coordinate care with hospice representatives.
A resident with chronic health conditions did not receive the full pneumococcal vaccine series as recommended by the CDC. Despite consent for the PCV13 vaccine, the resident only received the PPSV23 vaccine, and the facility failed to administer the required PCV15 or PCV20 dose.
Failure to Provide Adequate Supervision and Maintain Functional Exit Alarms for Resident at Risk of Elopement
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple medical conditions, including toxic encephalopathy, chronic kidney disease, and a BIMS score of 0, exited the facility unsupervised. The resident was at risk for wandering and elopement, as documented in their care plan, and required increased supervision. Despite being equipped with a WanderGuard bracelet and having interventions in place, the resident was able to leave the facility without staff knowledge and was later found lying on the side of a road, confused and unable to answer questions, approximately 0.3 miles from the facility. The facility failed to ensure that all exit doors were properly alarmed and did not have a reliable system in place to verify that door alarms were functioning. The Director of Maintenance had been checking door alarms by visually observing keypads rather than actually testing the alarms, and it was discovered after the incident that at least one exit door alarm did not sound when opened, despite appearing to be armed. Staff interviews revealed that alarms were not consistently heard or responded to, and some staff were unsure how to operate or reset the alarms. Additionally, temporary magnetic strip alarms installed as a backup were found to be turned off or nonfunctional on several doors during the surveyor's inspection. The facility's investigation into the incident did not include interviews with staff or residents regarding the alarms, nor did it determine the root cause of the alarm malfunction. There was a lack of documentation and education regarding the proper functioning and monitoring of both the permanent and temporary alarm systems. The failure to provide adequate supervision and to maintain a reliable alarm system for residents at risk for elopement resulted in a finding of immediate jeopardy.
Removal Plan
- Ensure temporary alarms are in place and functioning and implement a process that includes increased frequency of door alarm monitoring.
- Review residents at risk for wandering.
- Educate all staff on the facility's elopement/wandering procedure and alarms, including monitoring and managing residents at risk for elopement or unsafe wandering and completing a wander risk assessment when a resident attempts to elope.
- Educate management staff on completing a thorough investigation.
- Implement audits to ensure wander risk assessments are completed, alarmed doors are functioning properly, and incidents are thoroughly investigated. Review audits with Quality Assurance and Performance Improvement (QAPI) members.
Delayed Call Light Response and Inadequate ADL Assistance
Penalty
Summary
Surveyors identified that the facility failed to provide timely assistance for activities of daily living (ADLs) to eight out of sixteen sampled residents. Multiple residents experienced prolonged call light response times, with documented waits ranging from 15 to 57 minutes. These delays resulted in residents waiting to be assisted to bed, experiencing incontinence, and feeling embarrassment or stress. In several cases, staff turned off call lights without addressing the residents' needs, requiring residents to reactivate their call lights or wait even longer for assistance. Residents and their roommates confirmed these occurrences during interviews, and staff interviews corroborated that call light response times were often lengthy, especially during busy periods or when the facility was short-staffed. The facility's own policies require that all staff respond to activated call lights and that residents receive necessary services to maintain their abilities in ADLs. Despite these policies, staff interviews revealed that call lights were sometimes turned off without providing the requested assistance, and residents were told they could not go to bed at their preferred times. Staff described having routines for putting residents to bed and sometimes delaying assistance based on their own schedules rather than residents' needs. Several staff members acknowledged that staffing shortages contributed to the delays, and that response times could be as long as 20 minutes or more, particularly during shift changes or peak times. Medical records and Minimum Data Set (MDS) assessments indicated that the affected residents had significant physical and cognitive needs, including total dependence on staff for bathing, toileting, and transfers. The delays in responding to call lights led to increased incontinence, embarrassment, and stress for these residents. The facility's grievance log and call light audits further substantiated the pattern of delayed responses, with multiple instances of call lights remaining unanswered for extended periods. Facility leadership acknowledged that staff should not turn off call lights without meeting residents' needs and that communication among staff should be used to ensure timely assistance, but also indicated that a 15-minute response time was considered acceptable during busy times.
Failure to Provide Hand Hygiene During Meals Under Infection Control Precautions
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, specifically regarding hand hygiene practices during meal times. Despite being under COVID-19 precautions due to staff exposure, staff did not offer or assist residents with hand hygiene before or after meals in the dining room. Observations showed that hand sanitizing wipes or hand sanitizer were not made available on dining tables, and staff did not consistently provide or remind residents to perform hand hygiene prior to eating. Interviews with dietary and nursing staff revealed a lack of adherence to the facility's hand hygiene policy, with some staff forgetting to offer hand hygiene and others being unsure of the procedures. While some staff eventually offered wipes after being prompted, this was not done consistently or in accordance with policy requirements. The deficiency was observed during both lunch and supper, affecting multiple residents in the dining room. Staff interviews confirmed that hand hygiene should have been offered before and after meals, but this was not routinely practiced. The facility's own policy, as well as CDC guidelines, require hand hygiene before and after eating to prevent the spread of infection, especially during a COVID-19 outbreak. The Nursing Home Administrator confirmed that staff were trained and expected to follow these procedures, but the observed practices did not align with policy or regulatory expectations.
Delayed Meal Service for Room Trays
Penalty
Summary
The facility failed to ensure that meals and snacks were served at regular times and according to resident preferences for seven sampled residents. Multiple observations over several days revealed that room trays for breakfast and lunch were consistently delivered 30 minutes to an hour after the posted meal times. Residents reported frequent delays, with some indicating that breakfast was sometimes not served until nearly two hours after the scheduled time. Residents who received room trays expressed frustration at having to wait significantly longer than those who ate in the dining room, and several noted that the issue was ongoing and had been discussed in resident council meetings. Surveyors observed that room trays were plated first but then left on carts for extended periods before being delivered to residents' rooms. The delivery process involved multiple stops across different units, further delaying meal service. Residents interviewed described feeling upset and dissatisfied with the wait times, particularly for breakfast and lunch. Some residents noted that meal delivery was more timely when a hospitality aide was scheduled, but this only occurred twice per week. The dietary manager and nursing home administrator were unaware of the extent of resident concerns, and the dietary manager stated that kitchen staff typically did not assist with tray delivery except during staffing shortages. The deficiency was further substantiated by group interviews during a resident council meeting, where multiple residents confirmed that room tray delivery was frequently late, sometimes by over an hour. Residents expressed that the delays were unacceptable and that they should not have to wait so long for meals, especially when the posted meal times were not being honored. The observations and interviews consistently demonstrated a pattern of late meal service for residents receiving room trays, with staff and management unaware or uninformed about the ongoing concerns.
Failure to Assess and Monitor Cardiac Device Use
Penalty
Summary
A deficiency occurred when the facility failed to provide appropriate care and treatment for a resident who required cardiac monitoring. The resident, who had a history of hemiplegia, hemiparesis following a stroke, congestive heart failure, COPD, emphysema, and atrial fibrillation, was admitted with moderate cognitive impairment and was responsible for their own healthcare decisions. After a cardiology appointment, the resident returned to the facility with a cardiac monitor in place, but there was no documentation of new orders or instructions regarding the monitor. Staff did not assess the resident's ability to follow cardiac monitoring instructions, nor did they document any monitoring assessments, device checks, or symptom reporting related to the cardiac monitor. Interviews with staff revealed that the folder sent with the resident to the appointment was empty upon return, and no follow-up was conducted to obtain necessary paperwork or orders from the clinic. The LPN acknowledged that there was no documentation regarding the duration of monitor use, frequency of assessments, or device checks. The respiratory therapist who applied the monitor noted that the resident was unable to clearly express understanding of how to use the device. The DON confirmed that there was no documentation of follow-up or monitoring related to the cardiac monitor in the resident's medical record, and that such assessment and monitoring should have been included in the plan of care.
Failure to Provide Physician Orders and Proper Maintenance for CPAP Therapy
Penalty
Summary
The facility failed to provide appropriate respiratory care and services for three residents who required the use of continuous positive airway pressure (CPAP) machines. All three residents had medical conditions such as chronic obstructive pulmonary disease (COPD), pulmonary fibrosis, obstructive sleep apnea, mesothelioma of the pleura, and respiratory failure, which necessitated the use of CPAP therapy. Despite these needs, the facility did not obtain or document physician's orders for the use, cleaning, or maintenance of the CPAP machines upon the residents' admission, as required by facility policy. Observations and interviews revealed that the residents were using CPAP machines without proper physician orders in place. One resident reported using their CPAP machine at night with settings from home and cleaning it independently, while another required staff assistance for cleaning and mask application but did not receive it. The surveyor observed that the CPAP equipment for two residents was visibly dirty, with masks and tubing containing skin particles, hair, dirt, and oil, and residents confirmed that staff had not cleaned the machines since admission. The facility's policy required verification of physician orders and regular cleaning and maintenance of CPAP equipment, including mask, tubing, and filters. However, the lack of timely physician orders and failure to assist residents with cleaning and maintaining their CPAP machines resulted in noncompliance with these requirements. Staff and leadership acknowledged during interviews that orders should have been obtained and cleaning performed as per policy, but these actions were not completed prior to the surveyor's findings.
Unauthorized Medication at Bedside Without Physician Order
Penalty
Summary
A deficiency occurred when a resident was found with a tube of 1% hydrocortisone cream at their bedside without a physician's order or authorization to keep medication at the bedside. The facility's policy requires a prescriber's order and an interdisciplinary team assessment to determine if a resident can safely self-administer medication and store it at the bedside. The resident's medical record did not contain an order for hydrocortisone cream, nor was there documentation of an assessment or care plan permitting self-administration or bedside storage of medication. Observations by the surveyor confirmed the presence of the cream at the bedside on multiple occasions, including once with the cap off. Interviews with the resident, an LPN, and the DON confirmed that the resident did not have an order for the cream or for self-administration, and the medication was not listed on the Medication Administration Record. The resident had intact cognition and was their own medical decision maker, but previous assessments indicated they did not wish to self-administer medication. The facility failed to follow its own policy and regulatory requirements for safe and accurate administration of drugs and biologicals.
Failure to Maintain Infection Prevention and Control Program
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in hand hygiene and use of personal protective equipment (PPE) during resident care. For one resident on enhanced barrier precautions (EBP) due to a urinary catheter, a CNA did not perform appropriate hand hygiene or don clean gloves while providing care, and an LPN did not wear a gown during high-contact care. Additionally, the resident's uncovered catheter drainage bag was observed on the floor, contrary to facility policy requiring catheter bags to be covered or shielded. During wound care for another resident with a right heel wound, an LPN failed to perform hand hygiene between glove changes while completing the dressing change procedure. The resident had severe cognitive impairment and required regular wound care as ordered in the medical record. The LPN acknowledged that hand hygiene should have been performed between glove changes, as confirmed by the Director of Nursing (DON). In a separate incident, a CNA providing perineal care to a resident with severe cognitive impairment and an open wound on the right lower leg removed soiled gloves and donned clean gloves without washing or sanitizing hands in between. The DON confirmed that hand hygiene should be completed between glove changes, especially after pericare. These observed failures to follow established infection control policies contributed to the deficiency cited by surveyors.
Inadequate Supervision and Care Planning Leads to Resident Falls
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for three residents. One resident, who had a history of acute pulmonary edema, COPD, emphysema, and weakness, fell while smoking outside without supervision. Although the resident was assessed as being able to smoke independently, they required assistance with locomotion and did not have a smoking care plan at the time of the fall. The resident attempted to move their wheelchair with their feet, resulting in a fall and a head laceration that required emergency room treatment. Another resident, diagnosed with Parkinson's disease, chronic respiratory failure, and asthma, fell from a lift chair. Despite a physician's order for physical therapy and a care plan indicating the need for reassessment of lift chair safety, the resident was not reassessed, and the interventions were not implemented. The resident continued to use the lift chair independently, which led to the fall. A third resident, with a history of hemiplegia, hemiparesis, dysphagia, and aphasia, experienced a fall. Although an intervention was planned to add a 'Call don't fall' sign to the resident's care plan, it was not implemented in a timely manner. The resident's care plan was not updated immediately after the fall, delaying the intervention meant to prevent further incidents.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and administration of medications for two residents, leading to deficiencies in medication management. For one resident, an RN administered prescribed eye drops but failed to return them to the locked medication cart, resulting in the eye drops being misplaced. Consequently, the resident did not receive the medication as ordered for nine days. The facility's Director of Nursing confirmed that the RN should have secured the eye drops to prevent them from being misplaced. The resident's medical history included pneumonia, Sjogren's syndrome, and bacteremia, and they had moderate cognitive impairment. In another instance, an LPN prepared medication for a resident and left it unattended on top of the medication cart while filling a pitcher of water. The LPN acknowledged this was not usual practice but felt it was acceptable due to the presence of a surveyor. The Director of Nursing verified that medication should not be left unattended and should be either locked in the cart or carried by the staff member. These actions were contrary to the facility's policies on medication storage and administration, which require medications to be secured and not left unattended.
Failure to Update Care Plan for Resident with Chronic Gout
Penalty
Summary
The facility did not revise a plan of care to reflect the current care needs for a resident (R6) who had chronic gout and frequent gout flare-ups. Despite being admitted with a diagnosis of gout and having multiple documented instances of gout flare-ups, R6's care plan did not include any measures to monitor or manage these flare-ups. The resident's medical record indicated several episodes of pain and swelling in the fingers, with physician notes recommending treatments and referrals to rheumatology, which the resident refused. However, these recurrent issues were not reflected in the care plan, which is a requirement for comprehensive care management. During the survey, the resident reported pain and swelling in the finger, which was observed by the surveyor. The resident mentioned using alcohol wipes for relief but had run out of them. Interviews with the Nurse Practitioner and the Director of Nursing confirmed that the resident had frequent gout flare-ups and that there should have been a care plan in place to address this recurring issue. The lack of a care plan for managing the resident's gout flare-ups constitutes a deficiency in the facility's care planning process.
Failure to Adhere to Medication Administration Policy
Penalty
Summary
Medication was not administered in accordance with the facility's policy for one resident (R31) who was diagnosed with diabetes mellitus. The facility's Medication Administration policy, dated January 2023, specifies that needles should be recapped using an appropriate safety device after withdrawing the medication dose. However, during observations on May 21, 2024, the surveyor noted that the Licensed Practical Nurse (LPN) did not recap the needle after drawing up 40 IU of Lantus and 10 units of Humalog. The LPN was observed walking from the medication cart to the dining room with an uncapped needle on both occasions. Upon interviewing the LPN, it was confirmed that the practice is to recap the needle after drawing up medication. The Director of Nursing (DON) also confirmed that staff should follow the facility's policy of recapping the needle after withdrawing the medication. This failure to adhere to the policy was observed and documented by the surveyor, indicating a deficiency in the administration of medication for resident R31.
Failure to Monitor Adverse Reactions to Gabapentin
Penalty
Summary
The facility did not ensure monitoring for adverse reactions to high-risk medications for two residents who were prescribed gabapentin for pain management. The facility's Medication Monitoring Medication Management Policy requires ongoing monitoring for efficacy and adverse consequences of medications. However, the medical records for both residents did not include monitoring for adverse reactions to gabapentin, despite the known side effects of the medication. The Director of Nursing (DON) acknowledged that staff did not monitor for side effects because gabapentin was used for pain and not seizures, indicating a misunderstanding of the policy requirements. Resident 21 was admitted with a diagnosis of back pain and had an order for gabapentin 300 mg three times daily. The resident's plan of care did not include monitoring for adverse reactions to gabapentin. Similarly, Resident 32, who had diagnoses including low back pain, osteoporosis, and opioid dependence, was prescribed gabapentin 100 mg two capsules three times daily for neuropathic pain. The plan of care for Resident 32 also lacked monitoring for adverse reactions. The surveyor's review and interview with the DON revealed that the facility failed to adhere to its own medication management policy, resulting in a deficiency in monitoring for potential adverse effects of gabapentin.
Failure to Coordinate Hospice Services for Two Residents
Penalty
Summary
The facility did not ensure hospice services were coordinated for two residents, R27 and R15, who were reviewed for hospice services. For R27, hospice visit notes were kept in the resident's room instead of in the medical record or a hospice binder at the nurses' station. Additionally, there was a lack of communication and coordination between the facility staff and hospice staff regarding R27's care, including the administration of a urinalysis and subsequent treatment for a urinary tract infection. The Director of Nursing (DON) was unaware that hospice staff were documenting care notes in a binder in R27's room, which led to confusion and delayed treatment for R27's symptoms of infection and abdominal pain. For R15, hospice visit notes were not kept in the resident's medical record or the hospice binder at the nurses' station. The hospice company faxed the visit notes to the facility only after being contacted by the DON. The Social Worker (SW) indicated that they did not play a significant role in coordinating hospice services, and it was usually the nursing staff who ensured day-to-day care. The DON confirmed that the designated person responsible for coordinating hospice care was the SW, but there was a clear lack of communication and documentation regarding R15's hospice care. The facility's agreements with the hospice companies required regular communication and documentation to ensure the needs of hospice patients were met 24 hours a day. However, the facility failed to designate a member of the interdisciplinary team to coordinate care with hospice representatives, leading to deficiencies in the documentation and communication of hospice services for both R27 and R15.
Failure to Administer Full Pneumococcal Vaccine Series
Penalty
Summary
The facility did not ensure that vaccines were reviewed, offered, and administered for one resident (R20) of five sampled residents. R20, who was admitted to the facility with diagnoses including acute on chronic systolic (congestive) heart failure, COPD, and type 2 diabetes mellitus, did not receive the full pneumococcal vaccine series as recommended by the CDC. Despite a consent form signed by R20's Power of Attorney for Healthcare (POAHC) for the PCV13 vaccine, R20 only received the PPSV23 vaccine and was not administered the PCV13 vaccine as required. The Wisconsin Immunization Registry confirmed that R20 was administered PPSV23 but did not receive any other pneumococcal vaccines, and the CDC guidelines were not followed in this case. The Nursing Home Administrator (NHA) and Assistant Director of Nursing (ADON) were interviewed and confirmed that R20's vaccine history search indicated that R20 was not due for another vaccine. However, upon reviewing the CDC guidelines, it was clear that R20 should have received a dose of PCV15 or PCV20 at least one year after the PPSV23 vaccination. The Director of Nursing (DON) also confirmed that R20's record indicated only the PPSV23 vaccination had been administered, and the consent for PCV13 was not acted upon. R20's POAHC confirmed the desire for R20 to receive the full pneumococcal vaccination series, which was not completed by the facility.
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Illustrative
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Shawano
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shawano Health Services | 0.3 mi | ★★★★★ | 14 | 0 |
| Birch Hill Health Services | 0.5 mi | ★★★★★ | 11 | 0 |
| The Pines Post Acute And Memory Care | 7.4 mi | ★★★★★ | 0 | 0 |
| Greentree Health And Rehabilitation Center | 12 mi | ★★★★★ | 2 | 0 |
| Suring Health And Rehab Center | 19.8 mi | ★★★★★ | 6 | 1 |
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