Cycle 1
Health 2025-03-12 · Fire 2025-03-12
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Oshkosh, WI
Evergreen Health Center
5-star overall rating with 4-star inspections with 3 recent health deficiencies with 10 fire-safety deficiencies in the latest cycle
1130 N Westfield St, Oshkosh, WI
(920) 233-2340
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
5 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
80
Certified beds
Average residents
58
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1999-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.35
Registered nurse staffing · state 0.97 · national 0.68
LPN hours / resident day
0.13
Licensed practical nurse staffing · state 0.64 · national 0.87
Aide hours / resident day
3.31
Nurse aide staffing · state 2.59 · national 2.35
Total nurse hours
4.79
All reported nurse hours · state 4.20 · national 3.89
Licensed hours
1.48
RN + LPN hours · state 1.60 · national 1.54
Weekend hours
4.32
Weekend nurse staffing · state 3.72 · national 3.43
Weekend RN hours
1.06
Weekend registered nurse coverage · state 0.66 · national 0.47
Physical therapist
0.10
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
1.48
CMS adjusted RN staffing hours
Adjusted total hours
5.25
CMS adjusted total nurse staffing hours
Case-mix index
1.25
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
46%
Annual nurse turnover · state 48% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,011
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
34.29
Composite VBP score used to determine payment impact.
Payment multiplier
0.9883
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.66
Baseline 18.05% · Performance 21.12% · Measure score 0.66 · Achievement 0.66 · Improvement 0
Healthcare-associated infections
3.95
Baseline 5.63% · Performance 6.65% · Measure score 3.95 · Achievement 3.95 · Improvement 0
Total nurse turnover
2.04
Performance 55.34% · Measure score 2.04 · Achievement 2.04 · This facility did not have sufficient data to calculate a baseline period measure result.
Adjusted total nurse staffing
7.06
Baseline 4.91 hours · Performance 5.09 hours · Measure score 7.06 · Achievement 7.06 · Improvement 1.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.71% |
10.72%
1 pts worse
|
No Different than the National Rate · Eligible stays 109 · Observed rate 11.93% · Lower 95% interval 8.12% |
| Discharge to community | 50.91% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 105 · Observed rate 50.48% · Lower 95% interval 42.07% |
| Medicare spending per beneficiary | 0.8 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 98.51% |
95.27%
3.2 pts better
|
Numerator 66 · Denominator 67 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 67 |
| Discharge self-care score | 82.46% |
53.69%
28.8 pts better
|
Numerator 47 · Denominator 57 |
| Discharge mobility score | 54.39% |
50.94%
3.5 pts better
|
Numerator 31 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 1.49% |
2.29%
0.8 pts better
|
Numerator 1 · Denominator 67 · Adjusted rate 1.68% |
| Healthcare-associated infections requiring hospitalization | 6.65% |
7.12%
0.5 pts better
|
No Different than the National Rate · Eligible stays 65 · Observed rate 4.62% · Lower 95% interval 3.57% |
| Staff COVID-19 vaccination coverage | 5.56% |
8.2%
2.6 pts worse
|
Numerator 13 · Denominator 234 |
| Staff flu vaccination coverage | 91.74% |
42%
49.7 pts better
|
Numerator 333 · Denominator 363 |
| Discharge function score | 68.42% |
56.45%
12 pts better
|
Numerator 39 · Denominator 57 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | 97.78% |
96.28%
1.5 pts better
|
Numerator 44 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 34.29% |
25.2%
9.1 pts better
|
Numerator 12 · Denominator 35 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
95.7%
4.3 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
95.0%
5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.2%
2 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 5.1% · Q3 5.7% · Q4 5.3% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.5% |
5.0%
3.5 pts better
|
11.4%
9.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 5.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.5% |
| Percentage of long-stay residents who lose too much weight | 7.3% |
4.9%
2.4 pts worse
|
5.4%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 11.8% · Q2 6.7% · Q3 3.7% · Q4 6.2% · 4Q avg 7.3% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 21.8% |
16.6%
5.2 pts worse
|
19.6%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.6% · Q2 23.3% · Q3 22.2% · Q4 21.2% · 4Q avg 21.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.7% |
16.7%
7 pts better
|
16.7%
7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 11.1% · Q3 8.0% · Q4 6.9% · 4Q avg 9.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 32.0% |
21.1%
10.9 pts worse
|
16.3%
15.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 32.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 15.1% |
17.3%
2.2 pts better
|
14.9%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 20.7% · Q3 11.5% · Q4 16.1% · 4Q avg 15.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
2.3%
2.3 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 3.2% |
3.0%
0.2 pts worse
|
1.7%
1.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 5.1% · Q3 2.9% · Q4 2.6% · 4Q avg 3.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.9% |
25.5%
6.4 pts worse
|
19.8%
12.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 29.8% · Q2 38.0% · Q3 34.0% · Q4 25.9% · 4Q avg 31.9% |
| Percentage of long-stay residents with pressure ulcers | 8.2% |
5.5%
2.7 pts worse
|
5.1%
3.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.9% · Q2 11.4% · Q3 8.8% · Q4 5.9% · 4Q avg 8.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.5% |
86.8%
11.7 pts better
|
81.7%
16.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 98.4% · Q2 98.6% · Q3 98.5% · Q4 98.6% · 4Q avg 98.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 22.3% |
15.0%
7.3 pts worse
|
12.0%
10.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 20.0% · Expected 10.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.3%
0.7 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
82.2%
16.4 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
22.7%
5 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 22.9% · Expected 19.7% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-11 · Fire 2024-01-11
2 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
14 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (5 deficiencies)
Cycle 3
Health 2022-11-23 · Fire 2022-11-23
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
8 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-03-12
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2025-03-27
F · Potential for more than minimal harm
2025-03-12
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-12
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2025-04-10
F · Potential for more than minimal harm
2025-03-12
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-04-24
F · Potential for more than minimal harm
2025-03-12
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-03-12
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-12
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-03-12
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-03-12
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-18
D · Potential for more than minimal harm
2025-03-12
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2025-03-15
F · Potential for more than minimal harm
2024-01-11
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2024-04-02
F · Potential for more than minimal harm
2024-01-11
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2024-02-01
F · Potential for more than minimal harm
2024-01-11
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-02-01
E · Potential for more than minimal harm
2024-01-11
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2024-01-31
E · Potential for more than minimal harm
2024-01-11
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-02-13
E · Potential for more than minimal harm
2024-01-11
K911 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the installation and maintenance of electrical systems.
Corrected 2024-02-02
E · Potential for more than minimal harm
2024-01-11
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2024-01-31
D · Potential for more than minimal harm
2024-01-11
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
K753 · Miscellaneous Deficiencies
Fire Safety
Have restrictions on the use of highly flammable decorations.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
K912 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have power receptacles that are properly grounded.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-02-01
F · Potential for more than minimal harm
2022-11-23
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-02-13
F · Potential for more than minimal harm
2022-11-23
K346 · Smoke Deficiencies
Fire Safety
Follow proper procedures when the fire alarm was out of service for more than 4 hours.
Corrected 2022-12-13
F · Potential for more than minimal harm
2022-11-23
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2022-12-20
F · Potential for more than minimal harm
2022-11-23
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2022-12-13
F · Potential for more than minimal harm
2022-11-23
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-02-13
D · Potential for more than minimal harm
2022-11-23
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-23
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-12-02
D · Potential for more than minimal harm
2022-11-23
K919 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Meet requirements for the use of electrical equipment.
Corrected 2022-12-12
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-03-12
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-04-07
E · Potential for more than minimal harm
2025-03-12
F623 · Resident Rights Deficiencies
Health
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
Corrected 2025-04-07
D · Potential for more than minimal harm
2025-03-12
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-04-07
D · Potential for more than minimal harm
2024-01-11
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2024-02-01
D · Potential for more than minimal harm
2024-01-11
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-02-01
E · Potential for more than minimal harm
2022-11-23
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-11-23
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2022-12-19
D · Potential for more than minimal harm
2022-11-23
F729 · Nursing and Physician Services Deficiencies
Health
Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.
Corrected 2022-12-12
Penalties and ownership
What sits behind the stars
Ownership
Evergreen Communities, Inc
5% Or Greater Indirect Ownership Interest · Organization
Evergreen Retirement Community Inc
5% Or Greater Direct Ownership Interest · Organization
Arneson, Kenneth
Operational/Managerial Control · Individual
Arneson, Kenneth
Corporate Director · Individual
Arneson, Kenneth
Corporate Officer · Individual
Aurora Medical Group, Inc.
Operational/Managerial Control · Organization
Bellin, Peggy
Operational/Managerial Control · Individual
Chitwood, James
Operational/Managerial Control · Individual
Chitwood, James
Corporate Director · Individual
Chung, Seon Yoon
Operational/Managerial Control · Individual
Chung, Seon Yoon
Corporate Director · Individual
Davis, Dawn
Operational/Managerial Control · Individual
Davis, Dawn
Corporate Director · Individual
Dearmond, Sarah
Operational/Managerial Control · Individual
Dearmond, Sarah
Corporate Director · Individual
Dewitt, Deirdre
Operational/Managerial Control · Individual
Dewitt, Deirdre
Corporate Director · Individual
Evergreen Communities, Inc
Operational/Managerial Control · Organization
Evergreen Retirement Community Inc
Operational/Managerial Control · Organization
Funcke, Verna
Operational/Managerial Control · Individual
Funcke, Verna
Corporate Director · Individual
Grey, Michael
Operational/Managerial Control · Individual
Grey, Michael
Corporate Director · Individual
Higgins, Billie Jo
Operational/Managerial Control · Individual
Higgins, Billie Jo
Corporate Director · Individual
Higgins, Billie Jo
Corporate Officer · Individual
Kruck, David
Operational/Managerial Control · Individual
Kruck, David
Corporate Director · Individual
Lee, Phyllis
Operational/Managerial Control · Individual
Lynch, Sherry
Operational/Managerial Control · Individual
Lynch, Sherry
Corporate Director · Individual
Mathes, Andrew
Operational/Managerial Control · Individual
Mathes, Andrew
Corporate Director · Individual
Miller, Chad
Operational/Managerial Control · Individual
Miller, Chad
Corporate Director · Individual
Peters, Jane
Operational/Managerial Control · Individual
Ramsey, Thomas
Operational/Managerial Control · Individual
Ramsey, Thomas
Corporate Director · Individual
Richeson, Emily
Operational/Managerial Control · Individual
Richeson, Emily
Corporate Director · Individual
Rommelfanger, Alan
Operational/Managerial Control · Individual
Rommelfanger, Alan
Corporate Director · Individual
Stubbs, John
Operational/Managerial Control · Individual
Stubbs, John
Corporate Director · Individual
Sullivan, Gail
Operational/Managerial Control · Individual
Sullivan, Gail
Corporate Director · Individual
Weignad, Cathy
Operational/Managerial Control · Individual
Weignad, Cathy
Corporate Director · Individual
Wilkes, Ann
Operational/Managerial Control · Individual
Wilkes, Ann
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Bethel Home
Oshkosh, WI
4-star overall rating with 4-star inspections with 3 recent health deficiencies with 17 fire-safety deficiencies in the latest cycle
#2
Eden Rehab Suites And Green House Homes
Oshkosh, WI
3-star overall rating with 3-star inspections with $13,886 in total fines with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#3
Edenbrook Of Oshkosh
Oshkosh, WI
2-star overall rating with 2-star inspections with 14 recent health deficiencies with 19 fire-safety deficiencies in the latest cycle
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