Evergreen Health Center
1130 N Westfield St, Oshkosh, WI 54902
Evergreen Health Center is a nursing home in Oshkosh, Wisconsin. This page lists the citations, fines and star ratings that CMS publishes for it. Each one has a date and a link to CMS.
CMS star ratings
- 5 of 5CMS overall star rating
- 4 of 5CMS health inspection star rating
- 4 of 5CMS staffing star rating
- 5 of 5CMS quality measures star rating
Facts from CMS
- Phone
- (920) 233-2340
- Last standard health inspection
- May 27, 2026 (5 months ago)
- Certified beds
- 80
- Residents per day, on average
- 55.9
- Ownership type
- Non profit - Corporation
- Legal business name
- Evergreen Retirement Community INC
- Chain
- Not listed by CMS
- Takes part in
- Medicare and Medicaid
Fewer health citations than the Wisconsin average (7 vs 28).
Inspections, fines and changes
This list shows every citation and fine in CMS's current data, which covers about the last three years. It also shows changes CMS made to this home's ratings and records.
CMS update of October 28, 2026
Star rating
The CMS overall star rating changed from 4 of 5 to 5 of 5.
Star rating
The CMS quality measures star rating changed from 4 of 5 to 5 of 5.
CMS update of July 29, 2026
Star rating
The CMS quality measures star rating changed from 3 of 5 to 4 of 5.
2 citations
Health inspection on May 27, 2026
CMS lists this as a standard inspection.
Citation F0686. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
CMS lists it as corrected on June 15, 2026.
Citation F0880. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide and implement an infection prevention and control program.
CMS lists it as corrected on June 15, 2026.
5 citations
Fire safety inspection on May 27, 2026
CMS lists this as a standard inspection.
Citation K0511. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0511 2 times since 2025.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0712 2 times since 2024.
Citation K0761. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
CMS lists it as corrected on June 19, 2026.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0918 2 times since 2024.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on June 19, 2026.
CMS has cited this home for K0211 2 times since 2024.
CMS update of April 29, 2026
Star rating
The CMS overall star rating changed from 5 of 5 to 4 of 5.
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
CMS update of November 20, 2025
Star rating
The CMS quality measures star rating changed from 4 of 5 to 3 of 5.
CMS update of April 30, 2025
Star rating
The CMS quality measures star rating changed from 5 of 5 to 4 of 5.
3 citations
Health inspection on March 12, 2025
CMS lists this as a standard inspection.
Citation F0812. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
CMS lists it as corrected on April 7, 2025.
Citation F0623. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
CMS lists it as corrected on April 7, 2025.
Citation F0692. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide enough food/fluids to maintain a resident's health.
CMS lists it as corrected on April 7, 2025.
10 citations
Fire safety inspection on March 12, 2025
CMS lists this as a standard inspection.
Citation E0004. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Develop and maintain an Emergency Preparedness Program (EP).
CMS lists it as corrected on March 27, 2025.
Citation E0041. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Implement emergency and standby power systems.
CMS lists it as corrected on April 10, 2025.
Citation K0293. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have properly located and lighted "Exit" signs.
CMS lists it as corrected on April 10, 2025.
Citation K0345. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on April 24, 2025.
CMS has cited this home for K0345 2 times since 2024.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on March 28, 2025.
CMS has cited this home for K0353 2 times since 2024.
Citation K0291. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install emergency lighting that can last at least 1 1/2 hours.
CMS lists it as corrected on April 7, 2025.
Citation K0321. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
CMS lists it as corrected on March 28, 2025.
Citation K0374. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on March 28, 2025.
CMS has cited this home for K0374 2 times since 2024.
Citation K0521. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on March 18, 2025.
CMS has cited this home for K0521 2 times since 2024.
Citation K0511. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have properly installed electrical wiring and gas equipment.
CMS lists it as corrected on March 15, 2025.
CMS update of July 31, 2024
Star rating
The CMS staffing star rating changed from 4 of 5 to 5 of 5. CMS changed how it scores this rating for many homes at once.
CMS update of April 25, 2024
Star rating
The CMS staffing star rating changed from 5 of 5 to 4 of 5.
2 citations
Health inspection on January 11, 2024
CMS lists this as a standard inspection.
Citation F0582. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
CMS lists it as corrected on February 1, 2024.
Citation F0607. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
CMS lists it as corrected on February 1, 2024.
14 citations
Fire safety inspection on January 11, 2024
CMS lists this as a standard inspection.
Citation K0353. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Inspect, test, and maintain automatic sprinkler systems.
CMS lists it as corrected on April 2, 2024.
Citation K0712. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have simulated fire drills held at unexpected times.
CMS lists it as corrected on February 1, 2024.
Citation K0918. Severity F: potential for more than minimal harm, widespread.
The rule CMS cited:
Have generator or other power source capable of supplying service within 10 seconds.
CMS lists it as corrected on February 1, 2024.
Citation K0211. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Keep aisles, corridors, and exits free of obstruction in case of emergency.
CMS lists it as corrected on January 31, 2024.
Citation K0345. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Have approved installation, maintenance and testing program for fire alarm systems.
CMS lists it as corrected on February 13, 2024.
Citation K0911. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Meet requirements for the installation and maintenance of electrical systems.
CMS lists it as corrected on February 2, 2024.
Citation K0920. Severity E: potential for more than minimal harm, pattern.
The rule CMS cited:
Ensure proper usage of power strips and extension cords.
CMS lists it as corrected on February 1, 2024.
Citation K0223. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
CMS lists it as corrected on January 31, 2024.
Citation K0372. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
CMS lists it as corrected on February 1, 2024.
Citation K0374. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Install smoke barrier doors that can resist smoke for at least 20 minutes.
CMS lists it as corrected on February 1, 2024.
Citation K0521. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
CMS lists it as corrected on February 1, 2024.
Citation K0753. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have restrictions on the use of highly flammable decorations.
CMS lists it as corrected on February 1, 2024.
Citation K0912. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have power receptacles that are properly grounded.
CMS lists it as corrected on February 1, 2024.
Citation K0923. Severity D: potential for more than minimal harm, isolated.
The rule CMS cited:
Have proper medical gas storage and administration areas.
CMS lists it as corrected on February 1, 2024.
Owners and managers
CMS lists these owners and managers for this home. Names are as CMS writes them.
- EVERGREEN RETIREMENT COMMUNITY INC5% or greater direct ownership interest · 100% · since 02/26/1968
- EVERGREEN COMMUNITIES, INC5% or greater indirect ownership interest · 100% · since 06/01/2022
- AURORA MEDICAL GROUP, INC.Operational/managerial control · not applicable · since 01/15/2025
- EVERGREEN COMMUNITIES, INCOperational/managerial control · not applicable · since 01/15/2025
- EVERGREEN RETIREMENT COMMUNITY INCOperational/managerial control · not applicable · since 01/15/2025
- ARNESON, KENNETHOperational/managerial control · not applicable · since 03/01/2006
- BELLIN, PEGGYOperational/managerial control · not applicable · since 08/03/1992
- CHITWOOD, JAMESOperational/managerial control · not applicable · since 01/15/2025
- CHUNG, SEON YOONOperational/managerial control · not applicable · since 01/21/2025
- DAVIS, DAWNOperational/managerial control · not applicable · since 01/21/2025
- DEARMOND, SARAHOperational/managerial control · not applicable · since 01/15/2025
- DEWITT, DEIRDREOperational/managerial control · not applicable · since 01/21/2025
- FUNCKE, VERNAOperational/managerial control · not applicable · since 01/17/2025
- GREY, MICHAELOperational/managerial control · not applicable · since 01/15/2025
- HIGGINS, BILLIE JOOperational/managerial control · not applicable · since 04/01/2020
- KRUCK, DAVIDOperational/managerial control · not applicable · since 01/15/2025
- LEE, PHYLLISOperational/managerial control · not applicable · since 01/01/2024
- LYNCH, SHERRYOperational/managerial control · not applicable · since 01/21/2025
- MATHES, ANDREWOperational/managerial control · not applicable · since 01/21/2025
- MILLER, CHADOperational/managerial control · not applicable · since 01/15/2025
- PETERS, JANEOperational/managerial control · not applicable · since 09/11/1995
- RAMSEY, THOMASOperational/managerial control · not applicable · since 01/17/2025
- RICHESON, EMILYOperational/managerial control · not applicable · since 01/17/2025
- ROMMELFANGER, ALANOperational/managerial control · not applicable · since 01/17/2025
- STUBBS, JOHNOperational/managerial control · not applicable · since 01/17/2025
- SULLIVAN, GAILOperational/managerial control · not applicable · since 01/21/2025
- WEIGNAD, CATHYOperational/managerial control · not applicable · since 01/17/2025
- WILKES, ANNOperational/managerial control · not applicable · since 01/21/2025
Questions
When was Evergreen Health Center last inspected?
CMS lists May 27, 2026 as the date of its most recent standard health inspection.
How many citations (violations) does Evergreen Health Center have?
CMS lists 7 health citations since January 11, 2024. CMS also calls these deficiencies.
Has Evergreen Health Center been fined?
CMS lists no fines for this home in the past three years.
What is the CMS star rating of Evergreen Health Center?
Its CMS overall star rating is 5 of 5.
Is Evergreen Health Center a Special Focus Facility?
No. CMS does not list it as a Special Focus Facility or a candidate.