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
Staffing
Hours and turnover
RN hours / resident day
1.35
Registered nurse staffing
LPN hours / resident day
0.13
Licensed practical nurse staffing
Aide hours / resident day
3.31
Nurse aide staffing
Weekend hours
4.32
Weekend nurse staffing
RN turnover
28%
Annual RN turnover
Total nurse turnover
46%
Annual nurse turnover
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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
| 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 |
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
Jump out