Evansville Manor Nursing And Rehab, Llc

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 .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 20 525418 Department of Health & Human Services Printed: 08/27/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0804 Example 1:

Level of Harm - Minimal harm or Resident R16's Minimum Data Set (MDS) dated [DATE REDACTED] indicates Resident R16 has a Brief Interview of Mental Status (BIMS) of potential for actual harm 15 out of 15, indicating Resident R16 is cognitively intact.

Residents Affected - Some On 5/13/25 at 4:10 PM, Surveyor interviewed Resident R16. Resident R16 reported her only concern was about cold food. Resident R16 stated that the food would be good if it wasn't always cold. Surveyor asked Resident R16 how often she gets cold food. Resident 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* F, and eggs -150*-160* F. Surveyor informed DM D of the test tray temperatures. DM D indicated the foods 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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 20 525418

Procedure: .

1. 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 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

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

08/27/2025 Department of Health & Human Services Centers for Medicare & Medicaid ServicesPrinted: N o. 0938-0391 STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION NAME OF PROVIDER OR SUPPLIER(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:(X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY COMPLETED (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIESSTREET ADDRESS, CITY, STATE, ZIP CODE B. Wing (Each deficiency must be preceded by full regulatory or LSC identifying information) 05/15/2025 Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Example 1: Resident R16's Minimum Data Set (MDS) dated [DATE REDACTED] indicates Resident R16 has a Brief Interview of Mental Status (BIMS) of 15 out of 15, indicating Resident R16 is cognitively intact.

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