Evergreen Health Services
Evergreen Health Services in Shawano, WI — inspection on September 16, 2025.
Found 3 citations. 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
waited almost 2 hours for staff to answer the call light and stated staff often turn off the call light without meeting R13's needs, including 2 CNAs last night. R13 indicated one CNA stated Surveyors were watching call lights so they needed to turn the call lights off. R13 indicated the CNA turned off R9 and R10's call lights without meeting their needs. R13 indicated when staff turn off the call light without meeting R13's needs, R13 turns the call light back on if staff don't come back after 10 minutes. R13 feels bad for residents whose needs aren't being met and who can't advocate for themselves. R13 stated R13 gets annoyed when staff turn off the call light without providing assistance and has been incontinent due to waiting too long for help. R13 indicated 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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health Services
1250 Evergreen St Shawano, WI 54166
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/16/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Evergreen Health Services
1250 Evergreen St Shawano, WI 54166
SUMMARY STATEMENT OF DEFICIENCIES
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.
Facility ID: