Evansville Manor: Cold Food Violations Found - WI
The scrambled eggs came in at 88.3 degrees. The bacon was 77.5 degrees. The toast was 74.8 degrees, with butter that hadn't melted. The oatmeal, the warmest item on the tray, reached only 124 degrees, well below the 135-degree minimum required for hot foods in holding. The inspector recorded each temperature and described what she tasted: eggs that were cold and flavorless, bacon that was cold and chewy, toast that was simply cold.
The resident, identified in inspection records as R16, is cognitively intact, scoring a perfect 15 out of 15 on a standardized mental status assessment. She told the inspector her only complaint about the facility was the food temperature. "The food would be good if it wasn't always cold," she said. Asked how often she gets cold food, she answered: pretty much always.
A registered nurse who spoke with the inspector that same morning looked at the test tray, saw the unmelted butter on the toast, and said it didn't look good. She confirmed that serving residents hot, palatable food was the expectation.
The dietary manager, interviewed later that afternoon, had his own set of expectations. He told the inspector that meats should reach 165 degrees, vegetables 149 degrees, and eggs somewhere between 150 and 160 degrees. None of those benchmarks were met that morning. When the inspector told him what the test tray temperatures actually were, he acknowledged the food was not where it should be.
He also acknowledged he already knew there was a problem.
The facility had purchased new insulated carts in December, he said. The food goes out on heated plates with insulated tops and bottoms. Despite that, the temperatures are still falling short. His explanation: nursing staff need to pass the trays out faster.
His offered solution for residents who have complained was to invite them to eat in the dining room, where meals reach them sooner, or to send their trays back to the kitchen for a replacement.
That offer puts the burden of a kitchen and delivery problem onto residents, some of whom may not be able to advocate for themselves the way R16 can. She is among the residents the inspection report identifies as affected, and she is, by the facility's own assessment, fully capable of understanding and articulating her experience. She has been doing exactly that. The food is pretty much always cold, she said, and the inspection record suggests she has been saying so for some time.
Inspectors cited the facility under F804, which covers the requirement that residents receive food that is both palatable and served at a proper temperature. The deficiency was tagged at a level of minimal harm or potential for actual harm, affecting some residents.
The inspection was complaint-driven, conducted on May 15, 2025, with the test tray observations recorded two days earlier on May 13. The dietary manager had no answer for why the new insulated carts, purchased five months before the inspection, had not solved the problem he said he was already aware of. He had no timeline for fixing it. What he had was a workaround: eat in the dining room, or send it back.
R16 said the food would be good if it were hot.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Evansville Manor Nursing and Rehab, LLC from 2025-05-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: July 5, 2026 · Our methodology
EVANSVILLE MANOR NURSING AND REHAB, LLC in EVANSVILLE, WI was cited for violations during a health inspection on May 15, 2025.
The scrambled eggs came in at 88.3 degrees.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.