Evergreen Health Services: Tube Feeding Failures Found - WI
The inspection at Evergreen Health Services, conducted August 20, 2025, was triggered by a complaint. What inspectors found was a cluster of failures around two residents who depended on tube feeding to survive, and a staff record that was corrected on the spot only after an inspector started asking questions.
The resident identified in the report as R2 received 990 milliliters of tube feeding solution on a night when the order said to stop at 920. The nurse, identified as LPN-C, confirmed the overage. She also told the inspector that nursing assistants knew to keep the head of R2's bed elevated because the information was on the CNA task documentation form. When the inspector asked her to show it, she looked. It wasn't there. LPN-C then added the intervention to the form during the inspection.
That same morning, the inspector and LPN-C stood together in R2's room and looked at the bed. The head was elevated to 10 degrees. The order required 30 degrees. LPN-C confirmed it was wrong and raised the bed to 45 degrees. The medication administration record had contained the instruction to elevate the bed all along. There was no sign posted in the room. The CNA form had contained nothing until LPN-C typed it in.
Elevating the head of the bed during tube feeding is a standard precaution against aspiration, the process by which formula or stomach contents can be inhaled into the lungs. R2's records did not explain the underlying reason for the elevation requirement, but the order was explicit, and the angle at which R2 was lying that morning fell well short of it.
The second resident, R1, came to the facility for respite care with a list of diagnoses that included Alzheimer's disease, dementia, acute respiratory failure with hypoxia, and severe protein-calorie malnutrition. R1 rarely or never understood verbal communication, according to staff assessments, and a healthcare proxy had been activated to make medical decisions. R1 received nutrition and hydration entirely through a gastrostomy tube.
R1's orders called for a 2,000-milliliter water flush each day, to begin after tube feeding concluded at 11:00 AM. The medication record showed LPN-C started the flush at 12:47 PM on August 14. When the inspector asked about it six days later, LPN-C said she wasn't sure whether she had started it late or simply charted it late. She said the expectation was to document immediately after starting.
The tube feeding itself told a similar story. R1's orders called for 1,422 milliliters of formula at a rate of 90 milliliters per hour across 15 continuous hours, running from 8:00 PM to 11:00 AM. The record showed RN-D started the feeding at 9:29 PM on August 14, an hour and a half after it was supposed to begin. RN-D told the inspector she had actually started the feeding around 8:10 PM and had charted late because it was the first chance she'd had. She said the expectation was to chart right away.
The Director of Nursing, identified as DON-B, told the inspector that nursing staff should administer tube feeding orders within 30 minutes to one hour of what the medical order specifies.
The gap between 8:00 PM and 9:29 PM is 89 minutes. Whether the feeding started late or the documentation did, the record that exists shows a start time outside the window DON-B described as acceptable.
R1 could not speak for herself. Her proxy made her medical decisions. The flush that was supposed to begin after her feeding ended at 11:00 AM started, according to the only record available, one hour and 47 minutes later. No one who reviewed that record before the inspector arrived appears to have flagged it.
CMS assigned the deficiency a harm level of minimal harm or potential for actual harm, affecting a few residents. The facility was cited under F0693, which covers the administration of enteral nutrition.
R2 was still lying at 10 degrees when the inspector arrived that morning.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Health Services from 2025-08-20 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
Evergreen Health Services in Shawano, WI was cited for violations during a health inspection on August 20, 2025.
The inspection at Evergreen Health Services, conducted August 20, 2025, was triggered by a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.