Evansville Manor Nursing And Rehab, Llc

F 0684 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

yes and that she instructed staff to reach out to Resident R2's psychiatric team with any changes in mentation and vital signs. Surveyor asked NP C if she would expect facility staff to update the provider when Resident R2 had a change in condition on 8/26/25 including increased blood pressure and heart rate, decreased oxygen level, and was hard to wake, NP C stated that she had no idea that situation had occurred and she would have expected facility staff to report it, and that she would have sent her to the ER.Resident R2 had a change of condition

after receiving the incorrect dose of Clozapine. NP C requested close monitoring the facility failed to do complete ongoing comprehensive assessments of Resident R2 despite changes in level of alertness and vital signs. Resident R2 was sent to the hospital due to accidental overdose of Clozapine.

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Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/17/2025

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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on observation, interview, and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident R5) reviewed for medications.Resident R5 has medications that should not be crushed prior to administration. Resident R5 received those medications crushed. Resident R5 received an enteric coated medication when the medication should have been in

a chewable form. This is evidenced by: The facility's policy Medication Error, dated 5/14/21, includes: All medication errors and drug reactions will be reported promptly to the licensed nurse, the attending physician, and will be documented according to established procedures. Medication error is defined as the preparation or administration of medications or biological that is not in accordance with the prescriber's orders, manufacturer specifications regarding the preparation and administration of the medication or biological and/or accepted professional standards for medication or biological administration. A detailed account of the error will be recorded on an incident report. Such documentation must include, but is not limited to: a. Time and date of the incident b. Name, strength, and dosage of medication administrated c.

Resident's reaction to the medication d. Condition of the resident e. Any treatment administered f. Date and time the physician was notified and what instructions were given. The facility's Medications Not To Be Crushed form, dated 2002, includes: Aspirin enteric coated, Guaifenesin extended release, Bupropion extended release, Finasteride, Tamsulosin, and Omeprazole.Example 1On 10/30/25 at 8:30 AM, Surveyor observed LPN D (Licensed Practical Nurse) prepare Resident R5's medications. Surveyor observed LPN D take an Aspirin enteric coated 81 mg tab out of the stock container and place it in the medication cup. LPN D placed Bupropion HCL ER (XL) 300 mg tablet, Finasteride 5 mg tablet, and Guaifenesin ER 600 mg tablet into the medication cup. LPN D proceeded to crush these medications. LPN D placed Omeprazole 20 mg capsule and Tamsulosin 0.4 mg capsule into another medication cup. LPN D opened both capsules and placed the medication inside the capsules into the medication cup with the other crushed medications. LPN D administered these medications to Resident R5. Surveyor interviewed LPN D regarding the crushed medications.

LPN D indicated she can crush and administer these medications because Resident R5 has an order for crushed medications.Of note, Resident R5 does not have a physician order to crush medications. Resident R5's physician orders, printed 10/30/25, include:Aspirin Low Dose Oral Tablet Chewable 81 mg (milligrams) Bupropion HCL ER (extended release) (XL) Oral tablet extended release 24 hour 300 mg. DO NOT CRUSHFinasteride oral tablet 5 mg.DO NOT CRUSHGuaifenesin ER oral tablet extended release 12 hour 600 MGOmeprazole oral capsule delayed release 20 mg.DO NOT CRUSHTamsulosin GCL (Glyceryl trinitrate ) oral capsule 0.4 mg.CAPSULES SHOULD BE SWALLOWED WHOLE-DO NOT CRUSH, CHEW OR OPENOn 10/30/25 at 9:56 AM, Surveyor interviewed LPN E regarding medication errors. LPN E indicated crushing a medication that should not be crushed is a medication error. LPN E indicated given a medication that is enteric coated when the order is for a chewable is a medication error.On 10/30/25 at 10:03 AM, Surveyor interviewed RN F (Registered Nurse) regarding medication errors. RN F indicated crushing extended-release medications is a medication error. RN F indicated opening capsules that should not be opened and dispensing the medication from inside is considered a medication error.On 10/30/25 at 11:39 AM, Surveyor interviewed DON B (Director of Nursing) regarding medication errors. DON B indicated crushing medications that are extended release is a medication error. DON B indicated extended-release medications should not be crushed. DON B indicated capsules should not be opened unless there is an order to open them.

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