Evergreen Health Services: Elopement Immediate Jeopardy - WI
Federal inspectors who arrived at Evergreen Health Services on September 16, 2025, left with one of the most serious citations available under Medicare and Medicaid law: an immediate jeopardy finding, meaning the failures they documented created a situation likely to cause serious injury or death.
The citation was for elopement, the term the nursing home industry uses when a resident walks away from a facility without staff knowing. For residents with dementia or other conditions that impair judgment, an unsupervised exit can be fatal.
Inspectors found that Evergreen had failed on multiple fronts at once. Staff were not following the facility's own procedures for monitoring and managing residents identified as elopement risks. Wander risk assessments, the evaluations that determine how closely a resident needs to be watched and what safeguards should be in place, were not being completed when a resident attempted to elope. And the alarmed doors that serve as a last line of defense against an unsupervised exit were not being verified as functioning properly.
The number of residents affected was listed as few, but at the immediate jeopardy level, even one resident reaching an unsecured exit undetected is enough to draw the citation.
What the inspectors also found was a management problem. When an elopement-related incident occurred, the investigation that followed was not thorough. Managers had not been completing the kind of inquiry that would identify what went wrong, who knew what, and what needed to change.
In its plan of correction, the facility acknowledged each of those failures directly. Management staff were educated on completing thorough investigations. Staff were retrained on elopement and wandering procedures, including how to monitor at-risk residents and how to use door alarms. The facility committed to auditing whether wander risk assessments are being completed, whether alarmed doors are functioning, and whether incidents are being investigated properly. Those audits, the plan states, will be reviewed by the facility's Quality Assurance and Performance Improvement committee.
Plans of correction are required under federal law whenever a deficiency is cited. They describe what a facility intends to do. Whether the problems that generated the immediate jeopardy finding were corrected to the satisfaction of inspectors is not reflected in the portion of the inspection report available.
What the record does reflect is the sequence of breakdowns inspectors documented: the risk assessments not done, the alarms not checked, the investigations not completed. Each one, on its own, represents a gap. Together, they describe a system in which a resident at risk of wandering could have reached a door, found it unalarmed or unmonitored, and walked out, while staff remained unaware.
In Wisconsin, as elsewhere, nursing home elopements have ended in deaths. Residents with dementia have been found in ditches, in traffic, in freezing temperatures. The distance between an unlocked door and a tragedy can be measured in minutes.
The inspection report does not describe a specific elopement incident. It does not name a resident who walked out, or a resident who nearly did. What it describes is the infrastructure that was supposed to prevent that from happening, and the ways that infrastructure had stopped working before anyone with authority had noticed, or acted.
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 immediate jeopardy violations during a health inspection on September 16, 2025.
The citation was for elopement, the term the nursing home industry uses when a resident walks away from a facility without staff knowing.
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.