470 Garfield Ave, Evansville, WI 53536 · Rock County · (608) 882-5700
71 certified beds, about 58 residents a day · For profit - Limited Liability company · Medicare and Medicaid since 1988
CMS Care Compare ratings, data as of September 1, 2026 · CCN 525418 · See it on Medicare.gov · Compare with other homes
At its most recent standard inspection, on February 25, 2026, inspectors cited 14 health deficiencies (the Wisconsin average is 9.5, the national average 9.2).
Of 55 health citations since June 2023, 10 were rated as actual harm or immediate jeopardy to residents (5 immediate jeopardy).
CMS lists 7 fines totaling $208,709 in the last three years; the largest was $69,720, and the latest is dated March 26, 2026.
Nurses and nurse aides worked 3.65 hours per resident per day, against 4.21 across Wisconsin and 3.86 nationally. Registered nurses accounted for 0.72 of those hours.
60.3% of nursing staff left within the year CMS measured (Wisconsin average 46.9%).
CMS links it to Eden Senior Care, an affiliated group of 21 nursing homes.
Federal rules call for a standard inspection at least every 15 months, plus a visit whenever a complaint is filed. Each mark below is one citation, colored by how serious inspectors rated it. How to read a citation.
Under each citation, the quoted text is the inspector's own summary from the federal statement of deficiencies (CMS form 2567), word for word apart from a privacy scrub; CMS removes residents' and staff names before it publishes the text. The full notes are on Medicare.gov.
CMS rates every citation by how much harm it caused (rows) and how many residents it touched (columns). The count in each box is this home's, across all 55 health citations on file.
Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from sexual abuse for 1 of 5 residents reviewed (R1). R2 has a history of making inappropriate comments and inappropriately touching female residents and staff. R2 is care planned to be kept out of arms reach of female residents and to be monitored when out in common areas. On 2/27/26, R2 was left unsupervised and inappropriately touched R1. The facility's failure to provide adequate supervision and protect residents from sexual abuse created a reasonable likelihood for serious psychosocial harm, thus resulting in a finding of immediate jeopardy (IJ) that began on 2/27/26. Surveyor notified NHA A (Nursing Home Administrator) of the immediate jeopardy on 3/12/26 at 12:00 PM. The immediacy was removed and corrected on 2/28/26. The deficient practice is being cited as past noncompliance. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This has the potential to affect all 61 residents. Kitchen staff were not testing the parts per million (PPM) of the chemical sanitizing solution in the low temperature dishwasher during a Norovirus (a contagious virus which causes nausea, vomiting and diarrhea) outbreak. In addition, on 2/4/26 DA I (Dietary Aide) was out with GI (gastrointestinal) illness symptoms. According to CDC (Center for Disease Control and Prevention) DA I should have been removed from work until 48 hours after DA I's last symptom/episode. DA I was allowed to return to work too early after the onset of GI symptoms and prepare food. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable disease and infections. This has the potential to affect all 61 residents. The facility failed to follow infection control standards of practice and procedures. The facility failed to maintain accurate and up to date outbreak line listings for staff and residents. Staff were allowed to return to work early after the onset of GI (Gastrointestinal Illness) symptoms. The facility failed to ensure residents experiencing GI symptoms were put into precautions timely. Observations were made of staff inappropriately handling soiled linens. Observation were made of staff failing to wear PPE (Personal Protective Equipment) as required. [...]
Inspectors wroteBased on interview, and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice (N6, Wisconsin Nurse Practice Act) for 1 of 3 sampled residents (R1). On 1/9/26, R1 voiced having increased abdomen and low back pain and was crying while voicing pain rated 10 out of 10. There is no documentation of a RN (Registered Nurse) assessment being completed. There is no documentation of nursing staff continuing to monitor R1's change in condition. [...]
Inspectors wroteBased on observation and interview, the facility did not ensure that garbage and refuse were properly disposed of in outside garbage storage receptacles. This practice has the potential to affect all 61 residents. Surveyor observed the facility's outside garbage receptacle to be full to the top and the lid wide open. Evidenced by:On 2/22/26 at approximately 9:30 AM, during the initial kitchen tour with LC AA (Lead Cook), Surveyor observed the outside garbage storage receptables. One of the receptacles had the cover wide open and there were garbage bags up to and over the top of the sides. Surveyor asked LC AA about the lid. LC AA stated, that shouldn't be open, it could cause problems. On 2/24/26 at 2:53 PM, Surveyor interviewed DM BB (Dietary Manager) who stated the lid should be closed for pest control.
Inspectors wrote:Based on interview and record review, the facility's Quality Assessment and Assurance committee failed to develop and implement appropriate plans of action to correct deficient practices related to food safety requirements and infection control. This has the potential to affect all 61 residents. The facility failed to follow infection control standards of practice and proper sanitation of dishware during a Gastrointestinal illness outbreak. Evidenced by: The facility's Quality Assurance/Assessment and Performance Improvement (QAPI) Plan policy, dated 9/4/24, states, in part: Purpose: The QAPI Program is to utilize an on-going, data driven, pro-active approach to advance to the quality of life and quality of care for all residents at the facility. QAPI principles will drive our facilities decision making to promote excellence in all resident and staff related areas. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that each resident has a safe, clean, comfortable and homelike environment for daily living for 3 of 61 Residents (R3, R21, and R34). R3's room was not clean. R21's room was not clean. R34's room was not clean. R21 and R34 share a bathroom. The shared bathroom was not clean. This is evidenced by:The facility's Cleaning Checklist for Elderly Home, undated, includes: Introduction Maintaining a clean and sanitary environment is essential in elderly care facilities to ensure the health and well-being of residents, staff, and visitors. This checklist provides guidance for cleaning areas where residents are present. Resident Rooms (Occupied) *Dust surfaces gently, avoiding disturbance to residents *Disinfect frequently touched surfaces: [...]
Inspectors wroteNumber of residents sampled: 61Number of residents cited: 5Based on observation, interview and record review, the facility did not ensure that sufficient nursing staff was provided to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident (R) for 5 of 61 residents reviewed (R1, R3, R19, R21, R34). R3 stated she has to wait up to 45 minutes for her call light to be answered and staff leave her room without meeting her needs. R21 states she does not get the care she is supposed to get per her care plan because the staff do not have enough time to complete the task because of lack of staffing. R21 states staff will turn off her call light and leave the room without meeting her needs. R34 did not get repositioned per her care plan because the CNAs stated they were too busy and do not have enough staff. [...]
Inspectors wroteNumber of residents sampled: 4Number of residents cited: 2Based on interview and record review, the facility did not make prompt efforts to document, investigate, and resolve grievances a resident may have for 2 of 4 residents reviewed for grievances (R2 and R40). R2 voiced a grievance to the facility. Staff did not write their concerns up as a grievance, complete an investigation, or follow-up with the complainant. R40's APOA (Activated Power of Attorney) voiced a grievance to the facility. Staff did not write their concerns up as a grievance, complete an investigation, or follow-up with the complainant. Evidenced by: The facility's policy titled Grievance/Concerns last revised on 10/29/24 states in part .Procedure: 1. Facility will make prompt efforts to resolve all grievances.4. Residents have the right to file grievances orally or in writing; [...]
Inspectors wroteBased on interview and record review, the facility did not ensure to develop and implement written policies and procedures that: S483.12(b)(1) Prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 3 of 8 staff reviewed for background checks. RN LL (Registered Nurse) did not have a background check completed every 4 years. LPN MM (Licensed Practical Nurse) did not have a background check completed every 4 years. CNA X (Certified Nursing Assistant) did not have a universal background check completed despite indicating that she lived out of state last year. This is evidenced by:The facility policy, Policy and Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 11/17/17 with last revision date of 2/25/25, states, in part: Purpose: To provide residents a safe environment that is free from harm. [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure that a resident who is unable to carry out activities of daily living (ADLs) receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 3 sampled Residents (R40). R40's APOA (Activated Power of Attorney) reported that R40 was not being changed into their pajamas at night,Evidenced by:The facility's policy titled Activities of Daily Living with a revision date of 2/25/25 states in part Policy: Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrates that such diminution was unavoidable. [...]
Inspectors wroteNumber of residents sampled: 2Number of residents cited: 2Based on observation, interview, and record review, the facility did not ensure each resident received care, consistent with professional standards of practice, to prevent pressure injuries (PI) for 2 of 2 Residents (R8 and R34) reviewed for pressure injuries. R34 has a PI and was not repositioned per her care plan. R8 has a stage 4 pressure injury and was observed lying in bed without prevlon boots on. This is evidenced by: The facility's policy Pressure Injury Prevention and Wound Care Management, dated 8/25/25, includes: The purpose of the policy is to provide healthcare staff with the standards of care, and processes to be followed for all residents: [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure residents with limited range of motion, received appropriate treatment and services to increase range of motion/mobility and/or to prevent further decrease in range of motion/mobility for 1 of 2 residents (R21) reviewed for range of motion (ROM). R21 did not receive active assisted range of motion to her bilateral lower extremities (BLE) per R21's provider orders and comprehensive care plan. This is evidenced by:The facility's policy Activities of Daily Living (ADLs), dated 2/25/25, includes: Policy: [...]
Inspectors wroteBased on 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 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. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that a resident's drug regimen was free from unnecessary medications for 1 of 5 residents reviewed for unnecessary medications (R1). R1 takes a medication used for anxiety PRN (as needed). The facility failed to recognize that all PRN psychotropic medications or medications used off-label as psychotropic medications should be limited to 14 days unless deemed appropriate by the provider. Evidenced by:The facility policy, Psychotropic Medication, dated 8/1/15 with a last revision date of 5/1/25, states, in part: . Procedure: . 11. PRN orders for psychotropic drugs are limited to 14 days. [...]
Inspectors wroteBased on interview and record review the facility failed to protect the resident's right to be free from verbal abuse by a CNA (certified nursing assistant) for 1 of 3 Residents (R1) reviewed for abuse. R1 and CNA C (certified nursing assistant) had a verbal altercation. The facility did not implement appropriate actions to protect R1. CNA C continued to provide direct care to residents. The facility did not educate all staff on abuse during the abuse investigation. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment or exploitation. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately to the administrator of the facility and to other officials, including the State Survey Agency, in accordance with State law through established procedures for 1 of 3 residents (R1) reviewed for abuse. Facility became aware of an abuse allegation on 9/26/25 at 10:15 PM and did not report to the State Agency until 9/27/25 at 12:12 PM. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that in response to allegations of abuse, neglect, exploitation, or mistreatment, that all alleged violations are thoroughly investigated, and that steps were taken to prevent further abuse for 1 or 3 residents reviewed (R1). On 9/27/25, the facility became aware of an abuse allegation regarding R1. The facility failed to provide evidence to prevent further abuse to R1 and other residents. The facility allowed the staff member identified in the abuse allegation to continue working with residents. Evidenced by: The facility policy entitled, Policy & Procedure Vulnerable Adult Abuse and Neglect Prevention, dated 3/25/25, states, in part: . Purpose: To provide residents a safe environment that is free from harm. Policy: [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 3 residents (R2) reviewed for medication errors. R2 received the wrong dose of a medication, and the facility failed to increase registered nurse (RN) assessments and update the provider timely when R2 had a change in condition. Evidenced by:The facility's policy titled Change in Condition last revised on 11/13/24, states in part .Procedure: 1. The physician and Durable Power of Attorney/responsible party will be notified when there has been a change that is sudden in onset, change that is a marked difference in usual sign/symptoms and/or the signs/symptoms are unrelieved by measures already prescribed: 2. Specific information that requires prompt notification include, but is not limited to: a. [...]
Inspectors wroteBased 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 (R5) reviewed for medications. R5 has medications that should not be crushed prior to administration. R5 received those medications crushed. 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. [...]
Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents (R) receive treatment and care in accordance with professional standards of practice or the comprehensive person-centered care plan for 1 of 1 residents (R3) reviewed. R3 voiced concern that her bottom was getting sore from sitting on the Hoyer sling. The Registered Nurse (RN) did not complete an assessment and delayed in notifying the provider of R3's potential skin breakdown. R3 has a diagnosis of Congestive Heart Failure (CHF) that was not being adequately monitored. The facility did not follow physician's orders for bi-weekly weights and did not notify the provider when there were weight fluctuations.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure adequate supervision and safety to prevent accidents from occurring for 2 of 3 residents (R6 and R15) reviewed for falls and 4 of 5 residents (R12, R18, R19, and R20) reviewed for Hoyer transfers. R6 is being cited at severity level 3 (actual harm). R15, R12, R18, R19, and R20 are being cited at severity level 2 (potential for more than minimal harm). R6 was left in her bed with the bed in the high position. R6 fell out of bed landing face down resulting in a nasal fracture and lacerations to her forehead and lip that required sutures. R12, R18, R19, and R20 were being transferred with a Hoyer lift and only one staff present, resulting in R12 sustaining a skin tear to his toe. R15's care planned interventions were not being followed, resulting in a possible hand fracture. This is evidenced by: [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents received food that is palatable and at a safe and appetizing temperature for 1 of 1 test tray on the 100 hallway affecting 9 out of 10 residents and 1 of 4 residents (R16) interviewed on food. R16 voiced concerns regarding cold food. Surveyor received a test tray, and the food was cool and not palatable. Evidenced by: The facility policy, entitled Food Temperature Record, dated 6/28/22, states, in part: .Policy: To ensure that foods and beverages are held and served at temperatures which comply with State and Federal Regulations. F804: Each resident receives, and the facility provides food that is palatable and at the proper temperature . Procedure: . 2. [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 9 residents (R8 and R9) reviewed for abuse. A friend of MR O (Medical Records) observed DA P (Dietary Aide) post a photo of R8 and R9 on her personal Snapchat account with text indicating Hanging with my homies. The friend of MR O forwarded the photo to MR O, who is employed at the facility. MR O did not immediately report this allegation of abuse to the facility. This is evidenced by: The Facility's Vulnerable Adult Abuse and Neglect Prevention Policy and Procedure, revised 3/25/25, documents in part: [...]
Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment are reported to the administrator and other officials in accordance with State law through established procedures for 1 of 9 residents (R8 and R9) reviewed for abuse. A friend of MR O (Medical Records) observed DA P (Dietary Aide) post a photo of R8 and R9 on her personal Snapchat account with text indicating Hanging with my homies. The friend of MR O forwarded the photo to MR O, who is employed at the facility. The facility did not interview other residents to determine the scope of the concern or educate staff regarding timely reporting. This is evidenced by: The Facility's Vulnerable Adult Abuse and Neglect Prevention Policy and Procedure, revised 3/25/25, documents in part: [...]
Inspectors wroteBased on interview and record review, the facility did not ensure adequate monitoring for medications for 1 of 4 Residents (R3) reviewed for unnecessary medications. R3 was receiving Metoprolol (blood pressure medication) without evidence of R3's blood pressure being monitored per physician orders. Evidenced by: The facility policy, entitled Administering Medications, dated 1/22/24, states, in part: . Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: . 4. Medications shall be administered per provider's (Medical Doctor, Nurse Practitioner. Physician Assistant) written/verbal orders upon verification of the right medication, dose, route, time . R3 was admitted to the facility on [DATE] and discharged on 4/30/25. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident received adequate supervision to prevent accidents for 1 of 1 resident (R56) reviewed for wandering and elopement potential. R56 has dementia and mild intellectual disabilities and has an Activated Power of Attorney for Health Care (APOAHC). R56 eloped from the facility on 8/5/24. The facility did not have adequate supervision to ensure they were aware of R56's whereabouts and did not have security measures and monitoring in place to ensure R56 could not access various locations in the building. R56 exited a door at the rear of the facility; the door alarm was disengaged allowing R56 to exit a door into a fenced-in courtyard and out through a gate without sounding an alarm and alerting staff R56 had exited the facility. [...]
Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents admitted without a pressure injury (PI) did not develop pressure injuries unless clinically unavoidable and did not ensure residents are provided cares and services consistent with professional standards of practice to prevent the development of PI for 1 of 5 residents (R14) reviewed for pressure injuries. R14 developed a stage 3 PI behind his left ear. The facility failed to implement pressure relieving interventions prior to R14 developing a PI. Evidenced by: The AMDA (American Medical Directors Association) clinical practice guideline entitled, 'Pressure Ulcers and Other Wounds,' dated 2017, states in part: .A pressure ulcer (Injury) is localized damage to the skin or underlying soft tissue, usually over a bony prominence or related to a medical or other device. [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure food was stored or labeled in accordance with professional standards. This has the potential to affect the census of 59 residents. Multiple food and beverage items for resident consumption stored in the facility's kitchen refrigerator and dry storage room were not labeled with open or expiration dates and/or were beyond the labeled discard date. Dish washing was completed without testing the dishwasher temperature and concentration of the sanitizer. Sanitizer buckets were utilized without testing for temperature and concentration of sanitizer.
Inspectors wroteExample 5 R7's shower day is Friday. R7 did not receive a shower three times from August 1, 2024, through September 26, 2024. R7 did not have showers on 8/9/24, 8/30/24, and 9/13/24. R7's shower documentation for the dates of missed showers, documents: 8, 8 NA which indicates 8- Activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity, Not Applicable. Of note, these dates were not noted to be resident refusals. Example 6 R27's shower day is Thursday. R27 did not receive a shower in August at all and had not received a shower in September as of September 26, 2024. R27 did not have showers on 8/1/24, 8/8/24, 8/15/24, 8/22/24, 8/29/24, 9/5/24, 9/12/24, and 9/19/24. R27's shower documentation for the dates of missed showers, documents: [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure drugs and biological's are labeled in accordance with currently accepted professional standards for 2 of 2 Medication carts reviewed for medication storage. The 300 Hall medication cart had an undated open insulin pen for R26, R512, and R33. The 200 Hall medication cart had an undated open insulin pen for R40. RN R (Registered Nurse) repackaged Aspirin 81 milligrams for her residents at the beginning of her shift and stored them in a medication cup in the top drawer of the medication cart. As evidenced by: The facility policy entitled, Medication Storage, dated 2/12/24 states in part, Purpose: To ensure that medications and biologicals [sic] are stored in a safe, secure storage and safe handling. Procedure: General Guidelines . 3. [...]
Inspectors wroteBased on observation and interview, the facility did not ensure that each resident receives food and drink that is palatable and at a safe and appetizing temperature, for 4 of 4 hallways and one of one dining room This has the potential to affect the total census of 59 residents (4 of 4 hallways, 1 of 1 dining room, and 1 of 1 test tray). Residents voiced concerns with receiving hot foods cold. Test tray was observed to have hot foods served cold and beverages served warm. R2 indicated that hot food is not served hot. R38 and R31 indicated hot food is served cold and cold foods are served warm often. R38 and R31 indicated this has been discussed previously at monthly Resident Council meetings. R17 & R9 voiced concerns with receiving cold food.
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure each resident has a safe, clean, comfortable, and homelike environment for 1 (R32) of 28 residents reviewed. Surveyor observed R32's room to smell like urine, a brown substance on floor, garbage can full of garbage, and white debris under R32's bed and on floor on 9/23/24 and 9/24/24. Evidence by The facility policy, Cleaning Resident Room, revision date 5/8/24, states, in part; .To ensure appropriate cleaning procedures using an EPA (Environmental Protection Agency)- approved cleaning agent for disinfection of room surfaces and equipment .10. Thoroughly mop entire floor with approved cleaning solution (under furniture, behind doors, along baseboards. Mop your way out the door and place wet floor sign in doorway. 11. Discard all disposable items . [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that each resident was free from misappropriation for 1 of 8 abuse investigations reviewed (R24). On 9/22/24, R24 filled out a grievance indicating he gave a Norro foot massager to RN L (Registered Nurse) to borrow and did not see it again. R24 further documents, he asked RN L for it back on 9/21/24, and was ignored. R24 threatened to call the police on RN L before RN L provided R24 with his belonging. This is evidenced by: The facility's policy and procedure, Abuse and Neglect Prevention, revised, 10/4/23, documents in part, the following: Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. [...]
Inspectors wroteBased on the interview and record review, the facility did not ensure alleged violations involving misappropriation were reported to the State Agency immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, for 1 of 8 (R24) allegations reviewed. On 9/22/24 R24 filled out a grievance/allegation indicating he gave a Norro foot massager to RN L (Registered Nurse) to borrow and did not see it again. R24's grievance (an allegation of misappropriation) was forwarded to BOM M (Business Officer Manager), who is the Manger on Duty. [...]
Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate an allegation of misappropriation for 1 of 8 abuse allegations (R24). On 9/22/24 R24 filled out a grievance indicating he gave a Norro foot massager to RN L (Registered Nurse) to borrow and did not see it again. DON B (Director of Nursing) and NHA A (Nursing Home Administrator) have not investigated this allegation of misappropriation. This is evidenced by: The facility's policy and procedure, Abuse and Neglect Prevention, revised, 10/4/23, documents in part, the following: Purpose: To provide residents a safe environment that is free from harm. Policy: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, neglect, mistreatment, or exploitation. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not develop and implement a comprehensive person-centered care plan for 1 of 29 sampled residents (R32) to meet a resident's medical, nursing, and psychosocial needs that are identified. R32's Comprehensive Care Plan does not reflect person-centered interventions to best support R32. Evidenced by: The facility policy, Care Plan- Baseline and Comprehensive, dated 6/20/23, states, in part; .Purpose: To ensure that each resident receives care individualized to him or herself and that goals and approaches for care are communicated to all parties including caregivers, the resident, and the resident's representative .Policy: [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 resident reviewed for change of condition (R56). R56 has congestive heart failure and did not have his weight monitored and reported to the physician in accordance with orders and standards of practice.
Inspectors wroteBased on interview and record review, the facility did not ensure that residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 1 resident (R39) reviewed for hydration. R39 had an order for a fluid restriction that was not monitored by staff, as well as a significant weight gain that was not reported to R39's medical provider. Evidenced by: The facility's policy titled Hydration revised on 2/4/24 states in part .3. Fluid breakdown for residents on fluid restrictions will be placed on the MAR (Medication Administration Record), on the POC (Point of Care) task list, and in the resident care plan .14. [...]
Inspectors wroteBased on interview and record review, facility staff did not adequately assess and treat pain and provide necessary care and services to attain or maintain the highest practicable physical well-being for 1 of 3 Residents reviewed for pain (R45). The facility failed to provide R45 with his ordered PRN pain medication when reporting 8 out of 10 pain, in consecutive shift assessments. The facility also failed to reassess the resident's pain after non-pharmacologic interventions had been administered. This is evidenced by: The facility policy entitled, Pain Management and Assessment, dated 4/27/22 states, in part: . Procedure: 1. Nursing staff will identify individuals who have pain or who are at risk for having pain .7. Non-pharmacological interventions (i.e. [...]
Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that it was free of medication error rates of 5% or greater. There were 8 errors out of 27 opportunities that affected 1 of 1 sampled residents (R43) and 2 of 9 supplemental residents (R513 & R15) included in the medication pass task, which resulted in an error rate of 29.63%. The facility's medication error rate was 29.63% with medication errors observed for R513, R43, and R15. This is evidenced by: The facility policy, Administering Medications, dated 8/1/2015, states in part, as follows: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. [...]
Inspectors wroteBased on observation, interview and record review, the facility did not ensure residents are free of significant medication errors for 1 of 1 total sampled residents (R513). Surveyor observed R513's medication pass on 9/23/24. RN R (Registered Nurse) stated, R513's Entresto (combination medication to treat heart failure) is not available. R513's order for Entresto for high blood pressure is dated 8/30/24. R513 has not received Entresto since it was ordered. This is evidenced by: The facility policy, Administering Medications, dated 8/1/2015, states in part, as follows: Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that each staff implemented proper safety interventions as directed by a resident's plan of care and did not ensure residents were free from accidents and hazards for 1 of 3 residents (R1) reviewed for falls. On [DATE], a Certified Nursing Assistant (CNA) attempted to provide care to R1 without maintaining the proper safety interventions as directed in R1's care plan. R1 rolled off the bed, falling approximately 2 feet and hitting his head. Facility staff picked up R1 off the floor and placed him in bed before the Registered Nurse (RN) could arrive on the scene to assess R1 for possible injuries. R1 was sent to the hospital where he was found to have suffered a fractured neck, resulting in his death. This created a finding of immediate jeopardy that began on [DATE]. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure each resident received the necessary care and services in accordance with professional standards of practice to meet each resident's physical needs for 1 of 3 (R3) sampled residents. R3 had a diagnosis of CHF (Congestive Heart Failure). The facility failed to complete comprehensive assessments for R3 including daily weights and monitoring edema, resulting in repeated hospitalizations. Evidenced by: According to an article from The National Library of Medicine titled Congestive Heart Failure (Nursing) last updated 11/5/23, .Monitoring: Patients with HF require frequent monitoring of vital signs, including oxygen saturation .Frequent assessment and monitoring for symptoms is also indicated. All patients with HF require daily weight monitoring . [...]
Inspectors wroteBased on record review and interview, the facility did not ensure that an allegation of abuse, neglect, exploitation or mistreatment was reported immediately, for 1 of 5 sampled residents (R1).
Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an incident and did not take action to prevent further potential abuse for 1 of 5 sampled residents (R1). Incident occurred with a CNA where R1 fell out of bed and sustained an injury. This incident was not investigated and the results of the investigation were not reported.
Inspectors wroteBased on interview and record review, the facility did not ensure 2 Certified Nursing Assistants (CNAs; CNA N and CNA O) of 5 CNA's employed by the facility received 12 hours per year of in-service training. This practice had the potential to affect multiple residents in the facility. CNA N was hired on 9/13/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. CNA O was hired on 12/22/22 and did not have 12 hours of in-service training during the most recent anniversary of hire year. Evidenced by: The Facility Assessment with a date completed/updated of 1/23/24, indicates, in part: .Yearly education requirements are managed by Relias. Annual education includes training in dementia, depression, PTSD (Post-Traumatic Stress Disorder), schizophrenia, adjustment disorder and anxiety. [...]
Inspectors wroteExample 5 R25 was admitted to the facility on [DATE], has diagnoses that include hemiplegia (paralysis of one side of the body) and hemiparesis (weakness on one side of the body due to brain or spinal cord damage), R25 has a BIMS (Brief Interview for Mental Status) of 00 indicating a severe cognitive impairment. R25's Care Plan, revised on 3/16/23, with a target date of 6/22/23, states: Weigh at the same time of day and record: Monthly. Report significant changes to MD (Doctor). On 1/4/23, at 5:18 PM, a progress note was entered into R25's eMAR by Diet. P (Dietician) that states in part: R25 has experienced a significant weight loss of 9.5 lbs./5.8% in less than 90 days. Current weight is 153.5 lbs. Will continue current plan and monitor for further weight loss. On 2/27/23, at 12:27 PM, a progress note was entered into R25's eMAR by Diet. P that states in part: [...]
Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents (R) receive care, consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for 5 of 5 Residents reviewed for Pressure Injuries out of a total sample of 22 Residents (R361, R43, R23, R28, & R25). R361 was admitted to the facility with a pressure injury to her bottom, that was not assessed or measured until several days after her admission. R43 developed a pressure injury (PI) to left heel on 6/13/23 there was no Registered Nurse (RN) assessment, Braden tool was not re-done, and Provider (Physician or Nurse Practitioner) was not updated. The facility did not follow R23's physician orders for wound care treatment. The facility did not follow R28's physician orders for wound care treatment. [...]
Inspectors wroteBased on observation and interview, the facility did not provide a safe, clean, comfortable, and homelike environment for 1 of 19 residents (R35). R35's bed linens were not replaced, nor was her bed made after having been incontinent.
Inspectors wroteBased on interview and record review the facility did not ensure that preadmission screening for individuals with a mental disorder were followed through with for 1 of 5 residents (R26) reviewed for unnecessary medications. R26 did not have a Preadmission Screening and Resident Review (PASRR) II completed. This is evidenced by: R26 admitted to the facility in 2019 with the following diagnoses: major depressive disorder- recurrent severe without psychotic features, chronic PTSD (post-traumatic stress disorder), and personality disorder. At the time of admission, the facility completed a PASRR I with a 30-day exemption (meaning they thought he would be discharged back into the community within 30 days). The facility's Policy and Procedure entitled admission Criteria dated 2/25/22, documents in part: .8. [...]
Inspectors wroteBased on observation, interview, and record review the facility did not ensure that residents who are unable to carry out activities of daily living (ADLs) receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 19 sampled residents (R22 and R25) that were reviewed for ADLs. R22 voiced of not receiving a shower for 22 days. R25 nails were observed to be dirty and extending past fingertips. This is evidenced by: The facility policy, entitled Activities of Daily Living (ADLs), dated 3/15/21, states in part: . 2. The facility will provide care and services for the following activities of daily living: Hygiene- bathing, dressing, grooming, and oral care . Elimination- toileting . 4. Resident's abilities to perform ADLs will be monitored for evidence of any decline and appropriate interventions put in place as applicable . 7. [...]
Inspectors wroteBased on interview and record review the facility did not ensure residents are free of any significant medication errors for 2 out of 18 residents (R22 & R32). R22 did not receive his ordered Carbidopa-Levodopa in the correct time parameters of the medication order 42 times out of 360 opportunities. R32 did not receive her ordered Lantus in the correct time parameters as ordered 9 times out of 59 opportunities. R32 did not receive her ordered Novolog Insulin in the correct time parameters as ordered 24 times out of 177 opportunities. This is evidenced by: The facility policy, entitled Administering Medications, dated 8/15/22, states, in part: . Purpose: To ensure safe and effective administration of medication in accordance with physician orders and state/federal regulations. Procedure: . 3. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that before offering the influenza and/or pneumococcal immunizations, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza and/or pneumococcal immunizations; and that the resident either received the influenza and/or pneumococcal immunizations or did not receive the influenza and/or pneumococcal immunizations due to medical contraindications or refusal. This affected 2 of 5 residents (R26 and R34) reviewed for immunizations. [...]
Inspectors wroteBased on interview and record review, the facility did not ensure that before offering COVID-19 vaccine, each resident or the resident representative receives education regarding the benefits and risks and potential side effects associated with the COVID-19 vaccine, and the resident's medical record includes documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with COVID-19 vaccine; and if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. This affected 1 of 5 residents reviewed for immunizations (R52). R52 was not offered the COVID-19 vaccine(s). This is evidenced by: The facilities Policy and Procedure entitled COVID-19 Vaccine dated 5/3/23 documents in part: .2. [...]
25 fire safety citations on file: 9 on February 25, 2026, 5 on October 3, 2024, 11 on June 29, 2023.
| Date | Penalty | Amount or length |
|---|---|---|
| March 26, 2026 | Fine | $26,685 |
| September 17, 2025 | Fine | $60,528 |
| September 17, 2025 | Payment Denial | 20 days from October 15, 2025 |
| May 15, 2025 | Fine | $69,720 |
| October 3, 2024 | Fine | $12,048 |
| October 3, 2024 | Fine | $16,068 |
| February 5, 2024 | Fine | $8,018 |
| February 5, 2024 | Fine | $15,642 |
A payment denial means Medicare and Medicaid stopped paying for new admissions for that period.
Hours of care per resident per day, from the payroll records every home sends CMS. Higher means more staff time with each resident.
| Measure | This home | Wisconsin | United States |
|---|---|---|---|
| All nursing staff (RN, LPN and aides) | 3.65 | 4.21 | 3.86 |
| Registered nurses | 0.72 | 0.99 | 0.69 |
| All nursing staff on weekends | 3.29 | 3.77 | 3.42 |
| Nurse aides | 2.08 | ||
| Licensed practical nurses | 0.86 | ||
| Nursing staff turnover (share who left in a year) | 60.3% | 46.9% | 45.8% |
| Registered nurse turnover | 60.0% | 39.7% | 42.9% |
| Administrators who left | 0 |
CMS expects 4.11 hours a day for residents as sick as this home's (its case-mix figure). The staffing star compares the two.
Every nursing home sends CMS its staff hours for each day (the Payroll Based Journal). Here they are added up by quarter. The latest quarter is the one behind the figures above. In January to March 2026, nursing staff hours per resident were 3.80 on weekdays and 3.29 on weekends, 13% lower on weekends (nationally, weekends ran 15% lower). Contract or agency staff worked 10.4% of nursing hours, against 5.3% nationally. Total nursing hours per resident went from 3.60 in April to June 2025 to 3.65 in January to March 2026.
| Quarter | All nursing staff | Registered nurses | Weekdays | Weekends | Contract staff share | Days with no RN hours | Residents a day |
|---|---|---|---|---|---|---|---|
| Jan to Mar 2026 | 3.65 | 0.72 | 3.80 | 3.29 | 10.4% | 1 of 90 | 58 |
| Oct to Dec 2025 | 3.52 | 0.79 | 3.68 | 3.09 | 6.1% | 0 of 92 | 56 |
| Jul to Sep 2025 | 3.65 | 0.89 | 3.84 | 3.15 | 5.4% | 0 of 92 | 56 |
| Apr to Jun 2025 | 3.60 | 0.77 | 3.76 | 3.19 | 4.4% | 0 of 91 | 59 |
| United States, Jan to Mar 2026 | 3.75 | 0.62 | 3.92 | 3.33 | 5.3% | 0.5% of days | |
| Wisconsin, Jan to Mar 2026 | 4.19 | 0.95 | 4.36 | 3.74 | 8.8% | 0.3% of days |
Hours per resident per day: staff hours in the quarter divided by resident days (the daily census CMS derives from resident assessments). Registered nurses include the director of nursing and RNs with administrative duties; aides include nurse aides in training and medication aides, as in CMS's own staffing measure. How these are calculated.
Staff pay reports
No staff pay figure for this home has passed review yet. A figure appears only after at least 5 reports from at least 3 different people, sent over at least 60 days, have passed review. If you work here, your report helps start one.
| Job | Median | Middle half | Employed |
|---|---|---|---|
| Wisconsin, all employers | |||
| CNAs (nursing assistants) | $21.70 | $19.03 to $22.75 | 28,370 |
| LPNs and LVNs | $30.65 | $28.67 to $36.06 | 7,390 |
| Registered nurses | $45.93 | $39.39 to $49.33 | 68,060 |
| United States, nursing care facilities | |||
| CNAs (nursing assistants) | $20.67 | $17.91 to $22.55 | 534,270 |
| LPNs and LVNs | $33.86 | $30.05 to $37.40 | 188,210 |
| Registered nurses | $41.11 | $37.85 to $47.68 | 142,270 |
Hourly wages; the middle half runs from the 25th to the 75th percentile. Source: U.S. Bureau of Labor Statistics, Occupational Employment and Wage Statistics, May 2025. BLS has no separate estimate for medication aides. These are survey estimates for whole occupations, not figures for any one home.
The measures CMS uses for the quality star. Lower is better for every one of them.
| Measure | This home | Wisconsin | US |
|---|---|---|---|
| Percentage of long-stay residents whose need for help with daily activities has increased Long Stay residents, 2025Q2-2026Q1 | 4.9 | 16.1 | 13.9 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder Long Stay residents, 2025Q2-2026Q1 | 0.5 | 2.1 | 0.8 |
| Percentage of long-stay residents with a urinary tract infection Long Stay residents, 2025Q2-2026Q1 | 0.0 | 2.6 | 1.6 |
| Percentage of long-stay residents experiencing one or more falls with major injury Long Stay residents, 2025Q2-2026Q1 | 1.6 | 3.3 | 3.2 |
| Percentage of short-stay residents who newly received an antipsychotic medication Short Stay residents, 2025Q2-2026Q1 | 0.0 | 1.2 | 1.6 |
| Percentage of long-stay residents whose ability to walk independently worsened Long Stay residents, 2025Q2-2026Q1 | 5.2 | 18.4 | 14.1 |
| Percentage of long-stay residents with pressure ulcers Long Stay residents, 2025Q2-2026Q1 | 9.6 | 5.0 | 4.6 |
| Percentage of long-stay residents who received an antipsychotic medication Long Stay residents, 2025Q2-2026Q1 | 10.7 | 15.8 | 15.4 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission Short Stay residents, 20250101-20251231 | 23.0 | 23.1 | 23.8 |
| Percentage of short-stay residents who had an outpatient emergency department visit Short Stay residents, 20250101-20251231 | 11.3 | 15.5 | 12.0 |
| Number of hospitalizations per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.0 | 1.7 | 1.9 |
| Number of outpatient emergency department visits per 1000 long-stay resident days Long Stay residents, 20250101-20251231 | 1.3 | 2.3 | 1.8 |
For a stay to recover after a hospital visit, these are the results CMS publishes for Evansville Manor Nursing and Rehab, LLC's Medicare short-stay residents. On returning residents home or to the community, CMS rates it worse than the national rate (37.3% of residents, after adjusting for how sick they were). How to read these, and what Medicare pays for.
37.3% this home
Worse than the national rate
US median of homes 51.5% · Wisconsin: 52 better, 26 worse
Rate of successful return to home or community from a SNF (risk-standardized discharge to community rate). Higher is better. October 2022 to September 2024. 87 eligible stays.
9.5% this home
No different from the national rate
US median of homes 10.7% · Wisconsin: 0 better, 6 worse
Rate of potentially preventable hospital readmissions 30 days after discharge from a SNF (risk-standardized rate). Lower is better. October 2022 to September 2024. 86 eligible stays.
7.3% this home
No different from the national rate
US median of homes 7.1% · Wisconsin: 0 better, 0 worse
Percentage of infections residents got during their SNF stay that resulted in hospitalization (risk-standardized rate). Lower is better. October 2023 to September 2024. 59 eligible stays.
51.9% this home
Median of homes: Wisconsin54.2% · US 56.6%
Percentage of residents who are at or above an expected ability to care for themselves and move around at discharge. Higher is better. October 2024 to September 2025. 52 residents counted.
0.0% this home
Median of homes: Wisconsin0.0% · US 0.0%
Percentage of SNF residents who experience one or more falls with major injury during their SNF stay. Lower is better. October 2024 to September 2025. 94 residents counted.
5.8% this home
Median of homes: Wisconsin2.2% · US 1.7%
Percentage of residents with pressure ulcers or pressure injuries that are new or worsened (adjusted rate). Lower is better. October 2024 to September 2025. 94 residents counted.
97.5% this home
Median of homes: Wisconsin100.0% · US 98.7%
Percentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge. Higher is better. October 2024 to September 2025. 40 residents counted.
Source: CMS Skilled Nursing Facility Quality Reporting Program - Provider Data, released 2026-09-30. Better, no different and worse are CMS's own comparisons with the national rate, after adjusting for how sick residents were. Medians of homes and the state counts are worked out by us from the same file.
Legal business name: EVANSVILLE MANOR NURSING AND REHAB, LLC. CMS links this home to Eden Senior Care, a group of 21 nursing homes averaging 2.6 stars overall.
| Name | Role | Type | Share | Since |
|---|---|---|---|---|
| Lifsics, Channie | 5% or greater direct ownership interest | Individual | 9% | 10/01/2018 |
| Polstein, Mordechai | 5% or greater direct ownership interest | Individual | 19% | 10/01/2018 |
| Stesel, Maxim | 5% or greater direct ownership interest | Individual | 53% | 10/01/2018 |
| Plymale, Monica | W-2 managing employee | Individual | 10/01/2018 | |
| Rice, Pamela | W-2 managing employee | Individual | 10/01/2018 | |
| Mauer, Dovie | Operational/managerial control | Individual | 10/01/2018 | |
| Polstein, Mordechai | Operational/managerial control | Individual | 10/01/2018 | |
| Rice, Pamela | Operational/managerial control | Individual | 10/01/2018 |
As listed in the CMS ownership file, which names owners with a 5% or greater stake and the people and companies with operational or managerial control.
Chosen from this home's own inspection record.
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