EVANSVILLE MANOR NURSING AND REHAB, LLC
470 GARFIELD AVE, EVANSVILLE, WI 53536
At or above the 2024 benchmark — review inspection history before visiting.
Quality Breakdown
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RN Staffing
Registered nurse time each resident receives daily. 2024 federal benchmark: 0.55 hrs. Repealed February 2026.
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0.89 — At or above the repealed 0.55 hr benchmark |
The 0.55 hour RN standard was repealed effective February 2, 2026 and is not currently enforced. We still grade against it. Why |
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Health Deficiencies (last 3 survey cycles)
Violations found during federal inspections, with how many remain open and how many involved actual harm.
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Total
61
Outstanding
6
Actual harm or worse (G–L)
8
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CMS Ratings
Overall and Staffing quality ratings from CMS (1-5 stars).
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Quality: ★★★☆☆ (3/5)
Staffing: ★★☆☆☆ (2/5)
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NursingHomeGrade Score
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8/100 |
Loaded into NursingHomeGrade on April 12, 2026. This is the load date, not the date CMS published the underlying survey data — see release dates.
Inspection Deficiencies
Health inspections identify violations of federal standards. Severity ranges from no actual harm (A–F) to immediate jeopardy (J–L).
2 immediate jeopardy, 6 actual harm issues found among 61 total deficiencies. 55 corrected. — 6 still outstanding
Most recent inspection (December 4, 2025)
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has plan of correction, corrected March 23, 2026
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has plan of correction, corrected March 23, 2026
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has plan of correction, corrected March 23, 2026
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has plan of correction, corrected March 23, 2026
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Quality of Life and Care Deficiencies — Deficient, Provider has plan of correction, corrected March 23, 2026
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has plan of correction, corrected March 23, 2026
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected December 5, 2025
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 9, 2025
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 9, 2025
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected June 9, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Nutrition and Dietary Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected November 4, 2025
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 9, 2025
Ensure medication error rates are not 5 percent or greater.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 8, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 14, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 9, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Provide enough food/fluids to maintain a resident's health.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Provide safe, appropriate pain management for a resident who requires such services.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected October 28, 2024
Inspection cycle 2 (June 29, 2023)
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Ensure that residents are free from significant medication errors.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected July 28, 2023
Inspection cycle 3 (February 5, 2024)
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2024
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2024
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Respond appropriately to all alleged violations.
Freedom from Abuse, Neglect, and Exploitation Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Provide and implement an infection prevention and control program.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Implement a program that monitors antibiotic use.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 21, 2022
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 21, 2022
Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 21, 2022
Ensure staff are vaccinated for COVID-19
Infection Control Deficiencies — Deficient, Provider has date of correction, corrected May 21, 2022
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2024
Post nurse staffing information every day.
Nursing and Physician Services Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2024
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected February 28, 2024
Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies — Deficient, Provider has date of correction, corrected May 21, 2022
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected June 5, 2023
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Rights Deficiencies — Deficient, Provider has date of correction, corrected May 21, 2022
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