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38/100EVANSVILLE MANOR NURSING AND REHAB, LLC Inspection Report, Violations & Safety Grade (EVANSVILLE, Wisconsin)
470 GARFIELD AVE, EVANSVILLE, Wisconsin 53536
Phone: 6088825700
CMS Overall:1/5
Overview & Bed Count
Certified Beds
71
Avg Residents/Day
54.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Rock
Sprinkler Systems
Yes
Special Focus
SFF Candidate
Abuse Citation
Yes
CMS Star Ratings
Overall1/5
Health1/5
Staffing3/5
Quality4/5
Nurse Staffing Check
| Metric | This Facility | Wisconsin Avg | Difference |
|---|---|---|---|
| RN Hours per Resident per Day | 0.82 | 0.98 | -0.16 |
| Total Nurse Hours per Resident per Day | 3.97 | 4.25 | -0.28 |
| CMS Staffing Rating | 3/5 | 3.7/5 | - |
| Nursing Staff Turnover | 60.8% | 46.7% | - |
Health Citation History
55 health citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-03-26 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | J – Immediate Jeopardy |
| 2026-02-25 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | L – Immediate Jeopardy |
| 2026-02-25 | Infection Control Deficiencies | Provide and implement an infection prevention and control program. | L – Immediate Jeopardy |
| 2026-02-25 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2026-02-25 | Nutrition and Dietary Deficiencies | Dispose of garbage and refuse properly. | F – Moderate Harm Potential |
| 2026-02-25 | Administration Deficiencies | Have a plan that describes the process for conducting QAPI and QAA activities. | F – Moderate Harm Potential |
| 2026-02-25 | Resident Rights Deficiencies | 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. | E – Moderate Harm Potential |
| 2026-02-25 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2026-02-25 | Resident Rights Deficiencies | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | D – Moderate Harm Potential |
| 2026-02-25 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Develop and implement policies and procedures to prevent abuse, neglect, and theft. | D – Moderate Harm Potential |
| 2026-02-25 | Quality of Life and Care Deficiencies | Provide care and assistance to perform activities of daily living for any resident who is unable. | D – Moderate Harm Potential |
| 2026-02-25 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | D – Moderate Harm Potential |
| 2026-02-25 | Quality of Life and Care Deficiencies | 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. | D – Moderate Harm Potential |
| 2026-02-25 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2026-02-25 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2025-12-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2025-12-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-12-04 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-09-17 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2025-09-17 | Pharmacy Service Deficiencies | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D – Moderate Harm Potential |
| 2025-06-18 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2025-05-15 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | G – Actual Harm |
| 2025-05-15 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2025-05-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2025-05-15 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2025-05-15 | Pharmacy Service Deficiencies | Ensure each resident’s drug regimen must be free from unnecessary drugs. | D – Moderate Harm Potential |
| 2024-10-03 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-10-03 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | G – Actual Harm |
| 2024-10-03 | Nutrition and Dietary Deficiencies | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | F – Moderate Harm Potential |
| 2024-10-03 | Nursing and Physician Services Deficiencies | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | E – Moderate Harm Potential |
| 2024-10-03 | Pharmacy Service Deficiencies | 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. | E – Moderate Harm Potential |
| 2024-10-03 | Nutrition and Dietary Deficiencies | Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | E – Moderate Harm Potential |
| 2024-10-03 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
| 2024-10-03 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | D – Moderate Harm Potential |
| 2024-10-03 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-10-03 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-10-03 | Resident Assessment and Care Planning Deficiencies | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D – Moderate Harm Potential |
| 2024-10-03 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D – Moderate Harm Potential |
| 2024-10-03 | Quality of Life and Care Deficiencies | Provide enough food/fluids to maintain a resident's health. | D – Moderate Harm Potential |
| 2024-10-03 | Quality of Life and Care Deficiencies | Provide safe, appropriate pain management for a resident who requires such services. | D – Moderate Harm Potential |
| 2024-10-03 | Pharmacy Service Deficiencies | Ensure medication error rates are not 5 percent or greater. | D – Moderate Harm Potential |
| 2024-10-03 | Pharmacy Service Deficiencies | Ensure that residents are free from significant medication errors. | D – Moderate Harm Potential |
| 2024-02-05 | Quality of Life and Care Deficiencies | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J – Immediate Jeopardy |
| 2024-02-05 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | G – Actual Harm |
| 2024-02-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | D – Moderate Harm Potential |
| 2024-02-05 | Freedom from Abuse, Neglect, and Exploitation Deficiencies | Respond appropriately to all alleged violations. | D – Moderate Harm Potential |
| 2024-02-05 | Nursing and Physician Services Deficiencies | Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | D – Moderate Harm Potential |
| 2023-06-29 | Quality of Life and Care Deficiencies | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | E – Moderate Harm Potential |
| 2023-06-29 | Quality of Life and Care Deficiencies | Provide appropriate pressure ulcer care and prevent new ulcers from developing. | E – Moderate Harm Potential |
| 2023-06-29 | Resident Rights Deficiencies | 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. | D – Moderate Harm Potential |
Showing 50 of 55 citations.
Fire Safety Citation History
25 fire safety citations on record
| Date | Category | Description | Severity |
|---|---|---|---|
| 2026-02-25 | Egress Deficiencies | Install proper backup exit lighting. | F – Moderate Harm Potential |
| 2026-02-25 | Smoke Deficiencies | Install a fire alarm system that can be heard throughout the facility. | F – Moderate Harm Potential |
| 2026-02-25 | Smoke Deficiencies | Inspect, test, and maintain automatic sprinkler systems. | E – Moderate Harm Potential |
| 2026-02-25 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2026-02-25 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | E – Moderate Harm Potential |
| 2026-02-25 | Smoke Deficiencies | Install smoke barrier doors that can resist smoke for at least 20 minutes. | E – Moderate Harm Potential |
| 2026-02-25 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | E – Moderate Harm Potential |
| 2026-02-25 | Miscellaneous Deficiencies | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | D – Moderate Harm Potential |
| 2026-02-25 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | D – Moderate Harm Potential |
| 2024-10-03 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2024-10-03 | Smoke Deficiencies | Properly provide smoke detection systems in areas open to corridors. | D – Moderate Harm Potential |
| 2024-10-03 | Smoke Deficiencies | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | D – Moderate Harm Potential |
| 2024-10-03 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | D – Moderate Harm Potential |
| 2024-10-03 | Gas, Vacuum, and Electrical Systems Deficiencies | Ensure proper usage of power strips and extension cords. | D – Moderate Harm Potential |
| 2023-06-29 | Emergency Preparedness Deficiencies | Conduct risk assessment and an All-Hazards approach. | F – Moderate Harm Potential |
| 2023-06-29 | Egress Deficiencies | Install emergency lighting that can last at least 1 1/2 hours. | E – Moderate Harm Potential |
| 2023-06-29 | Smoke Deficiencies | Properly select, install, inspect, or maintain portable fire extinguishes. | E – Moderate Harm Potential |
| 2023-06-29 | Smoke Deficiencies | Install corridor and hallway doors that block smoke. | E – Moderate Harm Potential |
| 2023-06-29 | Miscellaneous Deficiencies | Have simulated fire drills held at unexpected times. | E – Moderate Harm Potential |
| 2023-06-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have power receptacles that are properly grounded. | E – Moderate Harm Potential |
| 2023-06-29 | Egress Deficiencies | Keep aisles, corridors, and exits free of obstruction in case of emergency. | D – Moderate Harm Potential |
| 2023-06-29 | Egress Deficiencies | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | D – Moderate Harm Potential |
| 2023-06-29 | Smoke Deficiencies | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | D – Moderate Harm Potential |
| 2023-06-29 | Services Deficiencies | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | D – Moderate Harm Potential |
| 2023-06-29 | Gas, Vacuum, and Electrical Systems Deficiencies | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | D – Moderate Harm Potential |
Total Penalties & Fines
$185,212
Total Fine Amount (CMS)
7
Number of Fines
8
Total Penalties
| Date | Type | Fine Amount | Payment Denial |
|---|---|---|---|
| 2026-03-26 | Fine | $26,685 | - |
| 2025-09-17 | Fine | $61,433 | - |
| 2025-09-17 | Payment Denial | - | 20 days starting 2025-10-15 |
| 2025-05-15 | Fine | $45,318 | - |
| 2024-10-03 | Fine | $12,048 | - |
| 2024-10-03 | Fine | $16,068 | - |
| 2024-02-05 | Fine | $8,018 | - |
| 2024-02-05 | Fine | $15,642 | - |
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Verified Helpline
Care & Coverage Review
Researching facilities in EVANSVILLE, Wisconsin? Speak with a licensed specialist to review your Medicare or health insurance benefits at no cost.
📞 Call (866) 227-7595
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Medicare & Benefits Review
(Ages 64.5+)📞 Call (866) 228-4856
Health Insurance Helpline
(Ages 26–64)
Free, confidential consultation. We may receive referral compensation.