01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-05-29 | 8 | 2025-05-29 | 3 |
| Cycle 2 | 2024-05-22 | 8 | 2024-05-22 | 2 |
| Cycle 3 | 2023-05-10 | 4 | 2023-05-10 | 6 |
CMS CCN 5253432026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Evergreen Health Services
1250 Evergreen St · Shawano, WI 54166 · Shawano County
Certified beds50CMS provider file
Recent citation rows31current CMS citation release
Penalty rows1current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
31 rows in the current release
2 rows carry G–L scope/severity codes; 1 carry J–L. 7 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2025-09-16 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-10-09 · complaint2025-09-16 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-10-09 · complaint2025-09-16 · HEALTHF0880Severity E · pattern; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-10-09 · complaint2025-08-20 · HEALTHF0693Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-09-11 · complaint2025-05-29 · HEALTHF0684Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Correction field: Deficient, Provider has date of correction · 2025-06-19 · complaint2025-05-29 · HEALTHF0695Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide safe and appropriate respiratory care for a resident when needed.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · HEALTHF0809Severity E · pattern; potential for more than minimal harm
Nutrition and Dietary Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-06-192025-05-29 · FIREK0321Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-29 · FIREK0345Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Have approved installation, maintenance and testing program for fire alarm systems.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-05-29 · FIREK0521Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Correction field: Deficient, Provider has date of correction · 2025-06-202025-03-19 · HEALTHF0689Severity G · isolated actual harm
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Deficient, Provider has date of correction · 2025-05-02 · complaint2024-08-07 · HEALTHF0761Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-08-19 · complaint2024-05-22 · HEALTHF0657Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-05-22 · HEALTHF0755Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-05-22 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-05-22 · HEALTHF0849Severity D · isolated; potential for more than minimal harm
Administration Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-05-22 · HEALTHF0883Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Correction field: Deficient, Provider has date of correction · 2024-06-202024-05-22 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-05-22 · FIREK0511Severity D · isolated; potential for more than minimal harm
Services Deficiencies
Have properly installed electrical wiring and gas equipment.
Correction field: Deficient, Provider has date of correction · 2024-06-102024-01-29 · HEALTHF0580Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Correction field: Deficient, Provider has date of correction · 2024-02-29 · complaint2024-01-29 · HEALTHF0686Severity D · isolated; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Correction field: Deficient, Provider has date of correction · 2024-02-29 · complaint2023-05-10 · HEALTHF0757Severity D · isolated; potential for more than minimal harm
Pharmacy Service Deficiencies
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Correction field: Deficient, Provider has date of correction · 2023-06-0803 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-08-20 | Fine | $14,020 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- NSHR OPERATIONS LLCOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 10/01/2019
- ARROWHEAD 123 LLCOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST10% · since 10/01/2019
- THE LANE MORRELL BOWEN TRUSTOrganization · 5% OR GREATER INDIRECT OWNERSHIP INTEREST10% · since 10/01/2019
- MILLS, DAVIDIndividual · 5% OR GREATER INDIRECT OWNERSHIP INTEREST18% · since 10/01/2019
- CIBC BANK USAOrganization · 5% OR GREATER MORTGAGE INTERESTNOT APPLICABLE · since 12/31/2024
- CIBC BANK USAOrganization · 5% OR GREATER SECURITY INTERESTNOT APPLICABLE · since 12/31/2024
- BAUMANN, TROYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2019
- HOEHN, JEFFREYIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 10/01/2019
- CIBC BANK USAOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2019
- CLIFTONLARSONALLEN LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2019
- CONTINUUM THERAPY PARTNERS LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- NORTH SHORE HEALTHCARE LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 12/01/2019
- NSH REHAB LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 03/01/2025
- WIPFLI LLPOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2025
- BAUMANN, TROYIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 10/01/2019
- BELONGIA, CHRISTINAIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2019
- CHERUKULA, MADHAVIIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 02/01/2023
- GEE, DARRENIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/30/2021
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours3.58per resident day
RN hours0.71per resident day
Weekend nurse hours3.24per resident day
Staff turnover52.4%CMS reported field
06 / LOCAL RECORDS
Open the Shawano ledger →