Evergreen Health Services
Inspection Findings
F-Tag F0677
F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
waited almost 2 hours for staff to answer the call light and stated staff often turn off the call light without meeting Resident R13's needs, including 2 CNAs last night. Resident R13 indicated one CNA stated Surveyors were watching call lights so they needed to turn the call lights off. Resident R13 indicated the CNA turned off Resident R9 and Resident R10's call lights without meeting their needs. Resident R13 indicated when staff turn off the call light without meeting Resident R13's needs, Resident R13 turns the call light back on if staff don't come back after 10 minutes. Resident R13 feels bad for residents whose needs aren't being met and who can't advocate for themselves. Resident R13 stated Resident R13 gets annoyed when staff turn off the call light without providing assistance and has been incontinent due to waiting too long for help. Resident R13 indicated Resident R13 has to wait even longer after the call light is turned off and staff leave because staff don't come back for a longer time. Surveyor reviewed the facility's grievance log from the last survey (8/20/25) to the present and noted a grievance related to long call light response times that was dated 8/25/25. On 9/8/25 Surveyor requested call light audits for seven rooms on seven dates on a specified shift picked at random and noted the following call light times (rounded to the nearest minute) that were 15 minutes or longer: ~ On 8/3/25: 18 minutes and 19 minutes ~ On 8/9/25: 29 minutes, 32 minutes, and 44 minutes ~ On 8/14/25: 17 minutes and 26 minutes ~ On 8/15/25: 25 minutes and 57 minutes ~ On 8/26/25: 21 minutes and 25 minutes ~ On 8/30/25: 19 minutes and 26 minutes ~ On 9/1/25: 15 minutes, 20 minutes, 26 minutes, and 26 minutes On 9/8/25 at 1:54 PM, Surveyor observed the call light screen with Registered Nurse (RN)-P and noted call lights at 19 minutes, 25 minutes, and 41 minutes. RN-P indicated that was not unusual.On 9/8/25 at 5:10 PM, Surveyor interviewed CNA-I who indicated the facility is short staffed. CNA-I stated call light response times should be 1 to 2 minutes. CNA-I indicated CNA-I tries to respond to call lights within 2 to 3 minutes unless CNA-I is giving a shower or doing something that takes longer.On 9/8/25 at 5:48 PM, Surveyor interviewed Licensed Practical Nurse (LPN)-N who indicated call lights should be answered as soon as they are turned on. LPN-N stated the average call light response time is approximately 7 minutes. LPN-N indicated the longest call lights LPN-N has seen have been 15 to 20 minutes.On 9/8/25 at 5:51 PM, Surveyor interviewed CNA-O who indicated staffing is not consistent and call light response times would be better if there were more staff. CNA-O indicated the worst times for call lights are in the morning, between 3:00 and 4:00 PM, and between 7:00 and 8:00 PM. CNA-O indicated residents' needs are likely not met at times.On 9/8/25 at 5:54 PM, Surveyor interviewed LPN-D who indicated there is room for improvement with call lights. LPN-D indicated the average call light response time is approximately 20 minutes but should be less than 5 minutes. LPN-D indicated if there were more staff, call light response times would be less. LPN-D verified residents complain about long call response times.On 9/9/25 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated call lights should be answered in the order they are turned on. NHA-A indicated if several lights are on at the same time, staff should check with residents, see what they need, and let them know they'll be back to assist them shortly. NHA-A indicated staff should not turn the call light off if the resident's needs have not been addressed since the call light serves as a reminder that the resident still needs services. NHA-A indicated it's not okay for staff to tell residents they can't go to bed. NHA-A indicated if staff assigned to a hall are busy elsewhere, they should use their walkie talkie to communicate with other staff and ask for help. NHA-A indicated staff can help residents on any hall as needed. NHA-A indicated the facility is staffed appropriately for the census and management should be on the floor helping as needed. NHA-A indicated NHA-A doesn't like to specify call light response times and indicated a 15 minute call light response time is acceptable at a busy time like shift change. NHA-A indicated on average call lights should be answered within 7 to 10 minutes.
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health Services
1250 Evergreen St Shawano, WI 54166
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety
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.4. Educated management staff on completing a thorough investigation. 4. Implemented audits to ensure wander risk assessments are completed, alarmed doors are functioning properly, and incidents are thoroughly investigated. Audits will be reviewed with Quality Assurance and Performance Improvement (QAPI) members.
Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/16/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health Services
1250 Evergreen St Shawano, WI 54166
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0880
F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
container of individually packaged hand sanitizing wipes that were near the sink. On 9/8/25 at 5:18 PM, Surveyor interviewed CNA-I who indicated residents should be offered hand hygiene before and after meals and was unsure why that didn't occur. CNA-I then offered a wipe to 3 residents in the dining room.
On 9/9/25 at 1:46 PM, Surveyor interviewed Nursing Home Administrator (NHA)-A who indicated staff were trained and should follow the facility's infection control and hand hygiene policies and procedures. NHA-A indicated residents should be offered hand hygiene in the dining room and should be provided hand sanitizing wipes on room trays for every meal.
Event ID:
Facility ID:
If continuation sheet
EVERGREEN HEALTH SERVICES in SHAWANO, WI inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SHAWANO, WI, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVERGREEN HEALTH SERVICES or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.