Evergreen Health Services: Hand Hygiene Skipped at Meals - WI
That's what a federal inspector found at Evergreen Health Services on September 8, 2025, watching residents settle into the dining room for a meal without anyone offering them a way to clean their hands first. The wipes sat in a container beside the sink while residents ate.
When the surveyor spoke with a certified nursing assistant identified in inspection records as CNA-I that evening at 5:18 p.m., the aide acknowledged that residents should be offered hand hygiene before and after meals. Asked why that hadn't happened, CNA-I said she was unsure. Then, with the surveyor present, she walked over and offered wipes to three residents still in the dining room.
The next afternoon, the facility's nursing home administrator, identified as NHA-A, told the inspector that staff had been trained and were expected to follow the facility's infection control and hand hygiene policies. Residents, NHA-A said, should be offered hand sanitizing wipes in the dining room, and wipes should also be placed on room trays for every meal.
Trained. Expected. Should be. None of those words describe what the inspector witnessed.
The violation was cited under F0880, the federal tag covering infection prevention and control. Inspectors classified the level of harm as minimal harm or potential for actual harm, and noted that some residents were affected.
That classification, minimal harm, can obscure what hand hygiene actually prevents. Nursing home residents are among the most medically vulnerable people in any community. Many have compromised immune systems, chronic conditions, or wounds that make infections harder to fight and easier to spread. A dining room is where residents gather in close proximity, touching shared surfaces, eating with their hands. It is one of the more obvious places where an infection control lapse can move from one person to several.
The inspection at Evergreen covered a complaint and took place September 16, 2025, though the observations that produced this citation were made the week before, on September 8 and 9.
What the record shows is a gap between what the administrator described as standard practice and what a surveyor observed during a single mealtime visit. The wipes existed. The policy existed. The training, according to NHA-A, existed. The only thing missing was someone handing a wipe to a resident before they ate.
CNA-I's response, uncertain about why it didn't happen, then correcting course once a surveyor was watching, is the kind of detail that tends to matter more than the violation tag itself. It suggests the lapse wasn't confusion about the policy. It was the policy not being followed.
Whether that reflects a staffing pressure that pushes aides to move faster through meal service, a supervision gap, or simple habit drift is not something the inspection record answers. What it does answer is what happened on the evening of September 8: residents sat down to eat, and no one offered them a way to clean their hands first.
NHA-A told the inspector that wipes should also appear on room trays for every meal, for residents who eat in their rooms. The inspection record does not describe what surveyors found when they looked at room trays, or whether that part of the policy was being followed either.
The facility serves residents who depend on staff to do for them what most people do automatically before they eat. Washing hands, or in a setting where a sink isn't always reachable, using a sanitizing wipe, is not a complex intervention. It does not require equipment, clinical judgment, or significant time. It requires someone to pick up the container that was already sitting near the sink and hand a wipe to the person about to eat.
On the evening of September 8, at Evergreen Health Services in Shawano, that did not happen. Three residents got their wipes only after a federal inspector was already in the room watching.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evergreen Health Services from 2025-09-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 19, 2026 · Our methodology
Evergreen Health Services in Shawano, WI was cited for violations during a health inspection on September 16, 2025.
The wipes sat in a container beside the sink while residents ate.
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.