EVERGREEN HEALTH SERVICES Nursing Home


EVERGREEN HEALTH SERVICES (CCN: 525343) is a For profit - Limited Liability company facility located in SHAWANO, WI (54166). The facility has an overall rating of 5/5, health inspection rating of 4/5, and a staffing rating of 3/5. It offers 50 certified beds and maintains an average of 41.4 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.22982 total hours per resident per day. It has been certified since December 1, 1983 and the last listed health inspection was on May 10, 2023, The facility is located in Shawano county and provides senior and nursing home care.

EVERGREEN HEALTH SERVICES Summary


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Provider Name: EVERGREEN HEALTH SERVICES

Address: 1250 EVERGREEN ST, SHAWANO, WI 54166

Phone: (715) 526-3107

County: Shawano (570)

Ownership Type: For profit - Limited Liability company

Certified Beds: 50

Average Residents Per Day: 41.4 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: NSH SHAWANO-EVERGREEN LLC

First Approved Date: December 1, 1983

Affiliated Entity: NORTH SHORE HEALTHCARE (377)

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: N

Resident Family Council: Both

Sprinkler System Status: Yes

Overall Rating: 5 ()

Health Inspection Rating: 4 ()

QM Rating: 5 ()

Long Stay QM Rating: 5 ()

Short Stay QM Rating: 5 ()

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 1.85314, LPN Staff Hours Per Day: 0.7410, RN Staff Hours Per Day: 0.6355, Licensed Staff Hours Per Day: 1.3766

Total Nurse Staff Hours Per Day, per resident: 3.22982

Weekend Nurse Staff Hours: 2.85847, Weekend RN Staff Hours: 0.3193

PT Staff Hours Per Day, per resident: 0.0388

Nurse Staff Turnover: 43.2, Nurse Turnover Note:

RN Turnover: 40.0, RN Turnover Note:

Admin Left Number: 0, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.1388, Case Mix LPN Hours Per Day: 0.7164, Case Mix RN Hours Per Day: 0.3571

Adjusted Nurse Aide Hours Per Day, per resident: 1.76513, Adjusted LPN Hours Per Day: 0.7633, Adjusted RN Hours Per Day: 0.6705

Total Adjusted Nurse Hours Per Day, per resident: 3.16908

Adjusted Weekend Nurse Hours Per Day, per resident: 2.80471

Health Survey Dates and Scores: Cycle 1: 2023-05-10 (Score: 28), Cycle 2: 2022-05-12 (Score: 0), Cycle 3: 2021-05-05 (Score: 0)

Total Weighted Health Score: 14.000

Reported Incidents: 0, Substantiated Complaints: 1

Infection Control Citations:

Fines and Penalties: Number of Fines: 0, Total Fines in Dollars: 0.00, Payment Denials Number: 0, Total Penalties Number: 0

Location and GPS: 1250 EVERGREEN ST,SHAWANO,WI,54166 (44.7662, -88.599)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2024-01-29

Type: Health, Deficiency: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-02-29

Citation on 2024-01-29

Type: Health, Deficiency: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2024-02-29

Citation on 2023-05-10

Type: Health, Deficiency: Ensure each resident’s drug regimen must be free from unnecessary drugs.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-08

Citation on 2023-05-10

Type: Health, Deficiency: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-31


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-05-10

Type: Fire Safety, Tag: 0324, Version: New

Description: Provide properly protected cooking facilities.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-25

Citation on 2023-05-10

Type: Fire Safety, Tag: 0345, Version: New

Description: Have approved installation, maintenance and testing program for fire alarm systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-15

Citation on 2023-05-10

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-15

Citation on 2023-05-10

Type: Fire Safety, Tag: 0363, Version: New

Description: Install corridor and hallway doors that block smoke.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-12

Citation on 2023-05-10

Type: Fire Safety, Tag: 0521, Version: New

Description: Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-05-31

Citation on 2023-05-10

Type: Fire Safety, Tag: 0923, Version: New

Description: Have proper medical gas storage and administration areas.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-06-15

Citation on 2022-05-10

Type: Fire Safety, Tag: 0211, Version: New

Description: Keep aisles, corridors, and exits free of obstruction in case of emergency.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2022-06-10

Citation on 2022-05-10

Type: Fire Safety, Tag: 0271, Version: New

Description: Have exits that are accessible at all times.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Waiver has been granted on 2022-09-01

Citation on 2021-05-06

Type: Fire Safety, Tag: 0351, Version: New

Description: Install an approved automatic sprinkler system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2021-05-20