Evansville Manor Nursing And Rehab, Llc
EVANSVILLE MANOR NURSING AND REHAB, LLC in EVANSVILLE, WI — inspection on February 25, 2026.
Found 6 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.
Inspection Findings
were the same and still not cleaned. R21's room was observed. R21's granola wrapper that was under
Assistant) and CNA O.
Both CNAs indicated resident rooms are not clean. CNA H indicated the
indicated the floors are dirty and should be mopped more often.On 2/24/26 at 8:31 AM, Surveyor observed a cleaning cart down the hallway where R3, R21, and R34 reside.
Surveyor observed R3's room had been cleaned. R21 and R34's rooms and shared bathroom were still not cleaned.On 2/24/26 at 1:57 PM, Surveyor interviewed HS F (Housekeeping Supervisor) regarding resident room cleaning.
HS F stated resident rooms should be cleaned daily. HS F stated housekeeping staff does not move resident belongings, so if residents have personal belongings on the sink counter, that area does not get cleaned by housekeeping. HS F stated there is a Daily Cleaning Checklist that gets completed daily and she keeps 3 months of logs in her binder.On 2/24/26, Surveyor requested the Daily Cleaning Checklist for the past 2 weeks for the hall R3, R21, and R34 reside on.
The facility provided five days of Daily Cleaning Checklist, 2/10/26, 2/11/26, 2/12/26, 2/18/26, and 2/22/26.2/10/26 Daily Cleaning Checklist has blanks for the following: R3 did not receive sweep/vacuum floor or change curtain (if dirty). R21 did not receive any cleaning. R34 did not receive any cleaning.2/11/26 Daily Cleaning Checklist has blanks for the following: R3 did not have disinfect high touch points or change curtain (if dirty). R21 did not receive cleaning. R34 did not receive disinfect high touch points, clean & sanitize bathroom, and change curtain (if dirty).2/12/26 Daily Cleaning Checklist has blanks for the following: R3 did not receive cleaning. R21 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty). R34 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty).2/18/26 Daily Cleaning Checklist has blanks for the following: R3 did not receive mop floor and change curtain (if dirty). R21 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty). R34 did not receive sweep/vacuum floor, restock paper products, change curtain (if dirty).2/22/26 Daily Cleaning Checklist only has check hand sanitizer marked for R3, R21, and R34.
The rest is blank. On 2/24/26 at 3:16 PM, Surveyor interviewed MT P (Maintenance) regarding the cleanliness of resident rooms. MT P indicated he oversees housekeeping, but HS F is the housekeeping supervisor. MT P indicated he was not aware resident rooms were not being cleaned. MT P indicated he was unaware the wall heater units in R21 and R34's room were falling off the walls. MT P indicated rooms are audited when a resident is discharged from the room.
MT P indicated staff should put in a work order if there is maintenance required for a resident's room.
MT P indicated staff should have reported the wall heater units were falling off the walls.
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Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536
Nursing) if there were any assessments or monitoring of R1's condition on 1/9/26 and 1/10/26. DON
AM, DON B stated that no, she couldn't find anything in R1's medical record that she was further
monitoring and nurse assessments. DON B stated yes that she would have expected the nurse on duty to have taken vital signs and completed an assessment at least every shift, and to enter a progress note into the electronic medical record.
Staff noted R1 was crying and endorsed 10/10 abdominal and lower back pain on 1/9/26.
Despite R1's refusal to be sent to the ER on [DATE], staff completed no assessments and did no further monitoring of R1's change of condition.
The following day, 1/10/26, R1 was confused, lethargic, and unable to sit up. R1 was transferred to the ER and spent 5 days in the ICU with a life-threatening condition.
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Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536
was located, R8 reported that it was on their foot and that staff has them wear boots during the day
determined the root cause to be for R8's pressure injury, DON B stated that it was due to the blankets causing pressure.
Surveyor asked DON B what interventions were implemented, DON B stated they initiated a foot cradle to off- load the blankets.
Surveyor shared the observation of R8 not wearing the pressure relieving boots and asked DON B if R8 should be wearing the boots when in bed, DON B stated yes.
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Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536
Based on the assessments, a personalized care plan is created. ADLs will be individualized. ADL cares will be provided based on the resident preferences.
Resident ADL care needs will be communicated to staff via the care plan and Kardex (a care plan for the CNAs (Certified Nursing Assistants)).R21 admitted to the facility on [DATE] with diagnoses including quadriplegia C5-C7 incomplete (partial paralysis of limbs affecting cervical vertebrae 5 thru 7).R21's BIMS (Brief Interview for Mental Status), dated 2/4/26, has a score of 15, indicating R21 is cognitively intact.R21's physician order, dated 1/27/26, includes Physical Therapy Eval (Evaluation) and treat for ROM (Range of Motion) and pain/spasticity to BLE (Bilateral Lower Extremities).R21's Physical Therapy Treatment Encounter Note(s), dated 2/17/26, states: ROM to BLE targeting hip, knee and ankle. Pt (patient) (R21) tolerates well reporting improve comfort following. Pt (R21) d/c (discharged ) this visit.
Hung up ROM program in room.
Staff given updated recommendation for ROM program. Pt (R21) d/c due to reaching max level of independence.R21's comprehensive care plan, last reviewed 2/12/26, includes: Focus: The resident has limited physical mobility.Interventions: Active Assisted Range of Motion Program daily to BLE (see signs hanging in room).R21's CNA (Certified Nursing Assistant) Kardex, printed 2/24/26, includes: Active Assisted Range of Motion Program daily to BLE (see signs hanging in room) and Active Assisted Range of motion to BLE (see signs hanging in room). R21's Passive Rage of Movement Exercise signs for the Leg and Foot include: Perform the exercises a minimum of 5 repetitions, once daily.
Hip Bending Movement.
Leg Movement In and Out.
Hip Turning Movement.
Hamstring Stretch.
Bending Foot Down Movement.
Bending Foot Up Stretch.
Moving Foot In and Out.
Toe Bending Movement.On 2/22/26 at 2:30 PM, Surveyor interviewed R21. R21 stated she does not receive the ROM exercises to her legs daily as she is supposed to. R21 indicated the ROM exercises decreases her edema and pain.On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O (Certified Nursing Assistant) regarding R21's ROM program. CNA O indicated staff use the CNA Kardex to know what assistance a resident needs. CNA O stated R21 has a ROM program with exercises to be done while R21 is in bed. CNA O indicated she assisted CNA H with R21's cares today (2/23/26). CNA O stated they did not perform R21's ROM exercises.On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding R21's ROM program. CNA H indicated she and CNA O provided cares for R21. CNA H indicated the CNAs assist R21 with her ROM exercises. CNA H stated they did not assist R21 with her ROM exercises today (2/23/26). On 2/23/26 at 4:13 PM, Surveyor interviewed DON B (Director of Nursing) regarding care plans. DON B indicated staff should follow residents' care plans.
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Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536
At 10:49 AM, room [ROOM NUMBER]'s call light was turned off.
Total wait time was 32 minutes.
Example 5: R1 was admitted to the facility on [DATE]. R1's most recent MDS (Minimum Data Set) dated 2/2/26, indicates, in part: a BIMS (Brief Interview of Mental Status) score of 15 out of 15, indicating R1 is cognitively intact.
R1's Care Plan, dated 12/15/23, states, in part: Focus: The resident has an ADL (Activities of Daily Living) self-care performance deficit r/t (related to) lymphedema, fibromyalgia, chronic pain and morbid obesity.
Interventions: 2 staff in room for all cares for staff safety d/t (due to) allegations when able. bathing/shower assist – one. dressing assist – one. personal hygiene/oral care assist – one. toilet use: Hoyer to/from commode with mesh Hoyer sling with commode cut out.
On 2/22/26 at 11:48 AM, Surveyor interviewed R1 in her room.
Surveyor observed R1 sitting in her recliner with her feet up and the Hoyer sling under her in her chair. R1 stated that the facility does not have enough staff, especially on the PM and overnight shifts. R1 indicated that she had to wait up to an hour for staff to answer her call light or to assist her in getting off the commode. R1 stated that the staff have to use a Hoyer lift to assist her, which requires 2 staff members to get her in and out of bed and on and off the commode. R1 stated that when she has to wait that long on the commode, her right hip and leg go numb, and the back of her legs turn purple. R1 indicated that sitting on the Hoyer sling all day causes her to get indentations on her bottom which hurt like hell. R1 stated she had told staff that she shouldn't be sitting on the Hoyer sling all day, but the more she complains, the more sarcastic staff become, so she stopped saying anything. R1 stated that it makes her very angry and that her concerns are not being taken seriously by staff.
On 2/23/26 at 1:55 PM, Surveyor interviewed CNA O regarding staffing. CNA O indicated there are not enough staff to complete everything the residents need. CNA O indicated things like repositioning, range of motion, and oral care does not get done because there is just too much to do. CNA O indicated she was unable to take lunch or break because she was too busy trying to meet the needs of the residents.
On 2/23/26 at 2:33 PM, Surveyor interviewed CNA H regarding staffing. CNA H indicated things would be better and she would be able to complete her task if there was more help. CNA H stated she did not get a break today because there is too much to do. CNA H stated she is not able to get everything done. CNA H stated she has to tell residents that she does not have time to complete things or will tell the residents she will have to do things later, but it doesn't get done. CNA H stated she gets the residents clean, changed, and fed and doesn't have time to do much else.
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Evansville Manor Nursing and Rehab, LLC 470 Garfield Ave Evansville, WI 53536
services of a licensed pharmacist.
interview and record review, the facility did not provide pharmaceutical services (including
and biologicals) to meet the needs of each resident for 1 of 1 residents (R34) reviewed for medications.R34 had a medication error due to not receiving her medications timely.
This is evidenced by:The facility's policy Administering Medications, dated 1/22/24, includes: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. 4.
Medications shall be administered per provider's (MD (Medical Doctor), NP (Nurse Practitioner), PA (Physician Assistant)) written/verbal orders upon verification of the right medication, dose, route, time and positive verification of the resident's identity when no contraindications are identified, and the medication is labeled according to accepted standards. 7.
Medications should be administered within one (1) hour of the prescribed times. 10.
The individual administering the medication shall sign the resident's Medication Administration Record (MAR) for the specific time and day the medication was administered.The facility's policy Medication Error and Drug Interactions, dated 2/12/24, includes: Definition: Medication Error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with: 1.
The prescriber's order.R34 admitted to the facility on [DATE] with diagnoses including neuromuscular dysfunction of bladder (loss of normal bladder control due to nerve damage), central pain syndrome (chronic neurological condition leading to constant, moderate-to-severe pain), and calculus of kidney (hard mineral and salt deposits forming inside the kidneys, kidney stones).R34's physician orders for February 2026 include: Potassium Citrate-Citric Acid Oral Solution 1100-334 MG/5ML Give 5 ml via G-Tube (Gastrostomy tube, a medical device inserted through the abdomen into the stomach to deliver nutrition, fluids, and medications directly bypassing the mouth) four times a day for kidney stones.
Oxybutynin Chloride Oral Solution 5 MG/5ML Give 5 ml via G-Tube three times a day for urinary leakage.Gabapentin Oral Solution 250 MG/5ML Give 2 ml via G-Tube three times a day for pain.R34's Medication Admin Audit Report includes:Potassium Citrate-Citric Acid Oral Solution 1100-334 MG/5ML Give 5 ml via G-Tube four times a day for kidney stones.
Schedule Date 02/23/2026 8:00 AM.
Administration Time 02/23/26 9:18 AM.
Oxybutynin Chloride Oral Solution 5 MG/5ML Give 5 ml via G-Tube three times a day for urinary leakage.
Schedule Date 02/23/2026 8:00 AM.
Administration Time 02/23/26 9:18 AM.
Gabapentin Oral Solution 250 MG/5ML Give 2 ml via G-Tube three times a day for pain.
Schedule Date 02/23/2026 8:00 AM.
Administration Time 02/23/26 9:18 AM.On 2/23/26 at 4:28 PM, Surveyor interviewed LPN N (Licensed Practical Nurse). LPN N indicated if a medication is scheduled at 8:00, the medication can be given between 7:00 AM and 9:00 AM. LPN N indicated if the medication is not given in that time frame, it would be a medication error.On 2/23/26 at 4:13 PM, Surveyor interviewed DON B (Director of Nursing. DON B indicated if a medication is scheduled at 8:00 AM, then the nurse can administer the medications between 7:00 AM and 9:00 AM. DON B indicated giving medications outside of the scheduled times would be considered a medication error.