Evergreen Health Services
Evergreen Health Services in Shawano, WI — inspection on August 20, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
verified R2 received 990 mls of tube feeding solution but should have received 920 mls per R2's order.
LPN-C verified the order indicated to stop the tube feeding at 4:00 AM and restart it at 8:00 AM after infusing 920 mls.
When Surveyor asked how Certified Nursing Assistants (CNAs) know the head of R2's bed should be elevated, LPN-C indicated the information is contained in the CNA task documentation form.
LPN-C verified there was not a sign in R2's room to alert staff that the head of the bed needed to be elevated and later verified the information was not contained in the CNA task documentation form. LPN-C then added an intervention on the CNA task documemtation form to elevate the head of R2's bed. LPN-C verified R2's Medication Administration Record (MAR) indicated to elevate the head of R2's bed.
On 8/20/25 during the 11:00 AM hour, Surveyor and LPN-C observed R2 in bed with the head of the bed elevated to 10 degrees. LPN-C verified the head of the bed was at 10 degrees but should be elevated to 30 degrees. LPN-c then elevated the head of the bed to 45 degrees.
- On 8/20/25, Surveyor reviewed R1's medical record. R1 was admitted to the facility on [DATE] for respite
care and had diagnoses including Alzheimer's disease, dementia, acute respiratory failure with hypoxia, unspecified severe protein-calorie malnutrition, anxiety, depression, and a gastrostomy. An MDS assessment was completed on 8/7/25; however, a BIMS was not completed because R1 was rarely or never understood. R1 was alert to self per staff assessment and had an activated POAHC who made medical decisions for R1.
R1's MAR indicated to flush R1's feeding tube with 2000 ml of water per day starting after tube feeding at a rate of 390 until gone. (R1's tube feeding was supposed to be completed at 11:00 AM.) The MAR indicated LPN-C started the flush at 12:47 PM on 8/14/25.
On 8/20/25 at 1:46 PM, Surveyor interviewed LPN-C who was not sure if LPN-C started the flush late or charted the flush late. LPN-C indicated the expectation was to chart right after starting the flush.
R1's MAR also indicated tube feed enteral nutrition via pump - tube feeding with carbohydrate stability 1.2 (calories) 1422 ml rate of 90 for 15 continuous hours during hours of 8:00 PM and 11:00 AM daily.
The MAR indicated RN-D started the tube feeding at 9:29 PM on 8/14/25.
On 8/20/25 at 2:23 PM, Surveyor interviewed RN-D who indicated RN-D started R1's tube feeding at approximately 8:10 PM. RN-D indicated RN-D charted late because it was the first chance RN-D had to chart. RN-D indicated the expectation was to chart right away.
On 8/20/25 at 3:10 PM, Surveyor interviewed Director of Nursing (DON)-B who indicated nursing staff should administer tube feeding orders within 30 minutes to 1 hour of what the medical order specifies.
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