CCN 525343

Evergreen Health Services

1250 Evergreen St, Shawano, WI 54166 · Shawano County

Phone: (715) 526-3107
Ownership: For profit - Limited Liability company
Certified beds: 50
Residents per day: 37.5
Health citations: 20
Penalties: 1
Fines: 1 · $14,020
Map: Open location

Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Overall

CMS overall star rating in this file.

Health inspection

Compared with other homes in the state.

Staffing

Based on reported PBJ nurse hours.

Quality measures

Long-stay 2 · short-stay 4.

Provider Information star ratings. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Staffing hours

Reported hours per resident per day come from the Payroll-Based Journal figures in the Provider Information file. Case-mix and adjusted hours account for how much care CMS expects given the residents’ needs. State and U.S. figures are averages from the same release.

Measure: This home; State; U.S.
Nurse aide: 2.03; 2.58; 2.32
LPN/LVN: 0.84; 0.64; 0.86
Registered nurse: 0.71; 0.99; 0.69
Total nurse staff: 3.58; 4.21; 3.86
Weekend total: 3.24; 3.77; 3.42
Weekend RN: 0.41; 0.68; 0.48

Adjusted total nurse hours: 3.63. Adjusted RN hours: 0.72. Case-mix total: 3.79. Case-mix index: 1.384.

Total nursing staff turnover: 52.4%. RN turnover: 57.1%. Administrators who left: 0.

How to read staffing hours

Payroll-Based Journal figures in Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Fines and penalties

CMS reports 1 fine totaling $14,020, and 0 payment denials.

Date	Type	Amount or days
August 20, 2025	Fine	$14,020

Cycle 1 standard survey: May 29, 2025. Health deficiencies counted in cycle 1: 7. Cycle 1 total health score: 111.

Cycle 2 standard survey: May 22, 2024. Cycle 2/3 health deficiencies: 11. Total weighted health survey score: 98.25.

Penalties file and Provider Information. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Health inspection citations

The Health Deficiencies file lists 20 citations for this home, including 1 at immediate jeopardy and 1 at actual harm. CMS may display some citations here that are not used in the health inspection rating, including citations under dispute.

September 16, 2025

3 citations

Tag	What CMS cited	Scope and severity	Status
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1	J: isolated, immediate jeopardy to resident health or safety	Deficient, Provider has date of correction · October 9, 2025
F677	Provide care and assistance to perform activities of daily living for any resident who is unable. Quality of Life and Care Deficiencies · Complaint survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 9, 2025
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Complaint survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · October 9, 2025

August 20, 2025

1 citation

Tag	What CMS cited	Scope and severity	Status
F693	Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · September 11, 2025

May 29, 2025

5 citations

Tag	What CMS cited	Scope and severity	Status
F809	Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times. Nutrition and Dietary Deficiencies · Standard survey · Cycle 1	E: pattern, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 19, 2025
F695	Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 19, 2025
F755	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 19, 2025
F880	Provide and implement an infection prevention and control program. Infection Control Deficiencies · Standard survey · Cycle 1	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 19, 2025
F684	Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 19, 2025

March 19, 2025

1 citation

Tag	What CMS cited	Scope and severity	Status
F689	Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · Complaint survey · Cycle 2	G: isolated, actual harm that is not immediate jeopardy	Deficient, Provider has date of correction · May 2, 2025

August 7, 2024

1 citation

Tag	What CMS cited	Scope and severity	Status
F761	Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Pharmacy Service Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · August 19, 2024

May 22, 2024

5 citations

Tag	What CMS cited	Scope and severity	Status
F657	Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 20, 2024
F755	Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 20, 2024
F757	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 20, 2024
F849	Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Administration Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 20, 2024
F883	Develop and implement policies and procedures for flu and pneumonia vaccinations. Infection Control Deficiencies · Standard survey · Cycle 2	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 20, 2024

January 29, 2024

2 citations

Tag	What CMS cited	Scope and severity	Status
F580	Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 29, 2024
F686	Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · Complaint survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · February 29, 2024

May 10, 2023

2 citations

Tag	What CMS cited	Scope and severity	Status
F812	Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · Standard survey · Cycle 3	F: widespread, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · May 31, 2023
F757	Ensure each resident’s drug regimen must be free from unnecessary drugs. Pharmacy Service Deficiencies · Standard survey · Cycle 3	D: isolated, no actual harm, with potential for more than minimal harm	Deficient, Provider has date of correction · June 8, 2023

Health Deficiencies. Data from CMS, updated September 1, 2026. CMS Provider Data Catalog · How we rate · Corrections

Other facts in the provider file

Provider type: Medicare and Medicaid.
Chain name in the file: North Shore Healthcare (59 facilities). Chain average overall rating: 2.7.
Legal business name: NSH Shawano-Evergreen LLC.
First approved for Medicare and Medicaid services: December 1, 1983.
Resident and family council: Resident.
Automatic sprinklers in all required areas: Yes.
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Questions

What is the CMS overall rating for Evergreen Health Services?

Evergreen Health Services has an overall rating of 2 out of 5. The health inspection rating is 2, staffing is 3, and the quality measure rating is 3.

How many health citations does CMS list for Evergreen Health Services?

The Health Deficiencies file lists 20 health citations for this home. 1 are coded immediate jeopardy (J, K, or L) and 1 are coded actual harm that is not immediate jeopardy (G, H, or I).

What nurse staffing does CMS report for Evergreen Health Services?

CMS reports 3.58 total nurse hours per resident per day, including 0.71 registered nurse hours. These are Payroll-Based Journal measures in the Provider Information file.

CMS file

Staffing hours

Fines and penalties

Health inspection citations

September 16, 2025

August 20, 2025

May 29, 2025

March 19, 2025

August 7, 2024

May 22, 2024

January 29, 2024

May 10, 2023

Other facts in the provider file

Other homes in Shawano

Questions

Opening the record…

Staffing hours

Fines and penalties

Health inspection citations

September 16, 2025

August 20, 2025

May 29, 2025

March 19, 2025

August 7, 2024

May 22, 2024

January 29, 2024

May 10, 2023

Other facts in the provider file

Other homes in Shawano

Questions