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Complaint Investigation

Evansville Manor Nursing And Rehab, Llc

May 15, 2025 · Evansville, WI · 470 Garfield Ave
Citations 2
CMS Rating 1/5
Beds 71
Provider ID 525418
Healthcare Facility
Evansville Manor Nursing And Rehab, Llc
Evansville, WI  ·  View full profile →
Inspection Summary

EVANSVILLE MANOR NURSING AND REHAB, LLC in EVANSVILLE, WI — inspection on May 15, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF804
Minimal harm or R16's Minimum Data Set (MDS) dated [DATE] indicates R16 has a Brief Interview of Mental Status (BIMS) of Some On 5/13/25 at 4:10 PM, Surveyor interviewed R16. R16 reported her only concern was about cold food. R16 affected

F-F804: Each resident receives, and the facility provides food that is palatable and at the proper temperature .

Procedure: .

2. TCF (Time/Temperature Control for Safety Food) foods such as meat, poultry, fish and eggs should be cooked to the minimum internal temperature specified below:

Pork, Beef, or Veal

(Steaks or Chops)- 145* F for 15 seconds

(Roasts)- 145* F for 4 minutes

Poultry- 165* F for 15 seconds

Fish- 145* F for 15 seconds

Ground meats (except poultry)- 160* F for 15 seconds

Ground chicken or turkey- 165* F for 15 seconds

Casseroles- 165* F for 15 seconds

Egg dishes- 160* F for 15 seconds

3.

Foods not listed above must be cooked to a minimum of 135* F and transferred to holding equipment.

4.

Hot foods must be held at a minimum of 135* F .

525418

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 525418 B.

Wing 05/15/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536

Procedure: .

  • TCF (Time/Temperature Control for Safety Food) foods such as meat, poultry, fish and eggs should be
  • cooked to the minimum internal temperature specified below: Pork, Beef, or Veal (Steaks or Chops)- 145* F for 15 seconds (Roasts)- 145* F for 4 minutes Poultry- 165* F for 15 seconds Ground meats (except poultry)- 160* F for 15 seconds Ground chicken or turkey- 165* F for 15 seconds Casseroles- 165* F for 15 seconds Egg dishes- 160* F for 15 seconds

  • Foods not listed above must be cooked to a minimum of 135* F and transferred to holding equipment.
  • Hot foods must be held at a minimum of 135* F .

08/27/2025

N o. 0938-0391

IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED

05/15/2025 Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536

potential for actual harm

Example 1: R16's Minimum Data Set (MDS) dated [DATE] indicates R16 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating R16 is cognitively intact.

On 5/13/25 at 4:10 PM, Surveyor interviewed R16. R16 reported her only concern was about cold food. R16 stated that the food would be good if it wasn't always cold.

Surveyor asked R16 how often she gets cold food. R16 replied it is pretty much always cold.

Example 2: On 5/13/25 at 8:15 AM, Surveyor received a test tray and recorded the following temperatures: Scrambled eggs- 88.3* F Bacon- 77.5 * F Toast with butter not melted- 74.8* F Oatmeal- 124* F Milk- 34.5 * F Surveyor found the scrambled eggs were cold and tasteless, the bacon was cold and chewy, the toast was cold, and the butter was not melted, and the oatmeal was lukewarm.

On 5/13/25 at 8:19 AM, Surveyor interviewed RN C (Registered Nurse) and asked if it is the expectation the residents are served hot, palatable food and RN C indicated yes. RN C looked at the toast on the test tray with unmelted butter and indicated that does not look good.

On 5/13/25 at 12:23 PM, Surveyor interviewed DM D (Dietary Manager) and asked what his expectation is for food temperatures for hot food being served. DM D indicated meats should be 165* F, vegetables- 149* are not at the temperature they should be. DM D indicated there are no warmers in the carts and the food is served on heated plates with insulated bottoms and tops. DM D indicated he is aware of the issue with cold food. DM D indicated the facility got new carts in December that are insulated. DM D indicated he feels the problem is the nursing staff need to pass the trays out faster. DM D indicated it is expected residents receive hot food and has offered to the residents who have voiced concerns with cold food that they can eat in dining room so the meals reach them faster or they can send the trays back to the kitchen for a new tray.

08/27/2025

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EVANSVILLE, WI, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from EVANSVILLE MANOR NURSING AND REHAB, LLC or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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