Evansville Manor Nursing and Rehab, LLC
470 Garfield Ave · Evansville, WI · 53536 · 6088825700
71 certified beds For profit - Limited Liability company Chain: Eden Senior Care
Why this verdict
- Carries CMS’s abuse warning icon.
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (3 citations).
- Inspection record is far worse than the national median (deficiency count and severity).
- Federal penalties on record: $190,956 in fines in the last 24 months.
The complete Safety Report — $19
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Red flags
Special Focus Facility candidate
CMS lists this facility as a candidate for its Special Focus program for persistently poor inspection performance.
CMS abuse warning
CMS flags this facility with its abuse icon: cited for abuse that caused harm in the past year, or potential harm in the past two years.
3 immediate-jeopardy citations in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
1 abuse-related citation at the actual-harm level
Inspectors cited failures in the abuse-prevention rules (F600–F610) that resulted in actual harm to a resident.
2 actual-harm citations in the most recent cycle
Inspectors found deficiencies that caused real harm to residents, beyond potential-harm paperwork findings.
$190,956 in federal fines in the last 24 months
4 fines — CMS fines are reserved for verified, serious non-compliance.
66% of nursing staff left within a year
High turnover disrupts continuity of care; the national median is 45%.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 2 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.52 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.79 | 0.55–0.75 |
| Weekend hours / resident-day | 3.09 | ≈ weekday level |
| Nursing turnover / year | 66% | median 45% |
| Fines (3-yr window) | 6 · $214,616 |
Inspection citations (55 in the current record)
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Immediate jeopardy · J March 26, 2026 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected February 28, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Immediate jeopardy · L February 25, 2026
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected March 23, 2026 · Nutrition and Dietary
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Immediate jeopardy · L February 25, 2026
Provide and implement an infection prevention and control program.
Corrected March 23, 2026 · Infection Control
-
Actual harm · G February 25, 2026 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected March 23, 2026 · Quality of Life and Care
-
Potential for harm · D February 25, 2026
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.
Corrected March 23, 2026 · Resident Rights
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Potential for harm · D February 25, 2026
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected March 23, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D February 25, 2026
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected March 23, 2026 · Quality of Life and Care
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Potential for harm · D February 25, 2026
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected March 23, 2026 · Pharmacy Service
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Potential for harm · F February 25, 2026
Dispose of garbage and refuse properly.
Corrected March 23, 2026 · Nutrition and Dietary
-
Potential for harm · F February 25, 2026
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected March 23, 2026 · Administration
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Potential for harm · E February 25, 2026 · found via complaint
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.
Corrected March 23, 2026 · Resident Rights
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Potential for harm · D February 25, 2026 · found via complaint
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected March 23, 2026 · Quality of Life and Care
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Potential for harm · D February 25, 2026 · found via complaint
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.
Corrected March 23, 2026 · Quality of Life and Care
-
Potential for harm · E February 25, 2026 · found via complaint
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.
Corrected March 23, 2026 · Nursing and Physician Services
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Potential for harm · D February 25, 2026 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected March 23, 2026 · Pharmacy Service
-
Potential for harm · D December 4, 2025 · found via complaint
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected December 5, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 4, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected December 5, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D December 4, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected December 5, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Actual harm · G September 17, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected October 8, 2025 · Quality of Life and Care
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Potential for harm · D September 17, 2025 · found via complaint
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected November 4, 2025 · Pharmacy Service
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Potential for harm · D June 18, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 14, 2025 · Quality of Life and Care
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Actual harm · G May 15, 2025 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected June 9, 2025 · Quality of Life and Care
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Potential for harm · D May 15, 2025 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected June 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 15, 2025 · found via complaint
Respond appropriately to all alleged violations.
Corrected June 9, 2025 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · D May 15, 2025 · found via complaint
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected June 9, 2025 · Pharmacy Service
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| September 17, 2025 | Fine | $93,120 |
| September 17, 2025 | Payment Denial | 20 days |
| 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 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 525418 · certified since September 6, 1988. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.