Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
EVANSVILLE MANOR NURSING AND REHAB, LLC
EVANSVILLE, WI · 71 certified beds · Last Life Safety survey February 25, 2026
CMS Certification Number 525418 · first certified September 1988
Ownership
Operated by EDEN SENIOR CARE · For profit - Limited Liability company
- Ownership changed November 1, 2018 (change of ownership)from EVM OPERATIONS LLC
Position within WI
25 citations — more than 73% of the 323 certified nursing homes in WI. Compared within WI rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 9 citations; the earlier surveys in the window averaged 8. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens April 2027 — about 6 months from now. This facility’s last Life Safety survey was February 2026. Facilities in WI are typically surveyed 13–15 months after the last one (median 14), measured over 516 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
1 of the 25 citations on file is Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
7 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 25 Life Safety citations above. The Physical Environment Index
- F-0584 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.
- F-0880 Provide and implement an infection prevention and control program.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
How that compares
Compared with the median facility in WI, and nationally. Surveyors differ markedly between states, so the WI figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 25 |
| Median facility in WI | 17 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| June 29, 2023 | 11 |
| October 3, 2024 | 5 |
| February 25, 2026 | 9 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0912 | Have power receptacles that are properly grounded. | 3 | 2026-02-25 |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | 3 | 2026-02-25 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2026-02-25 |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | 2 | 2026-02-25 |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | 1 | 2026-02-25 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2023-06-29 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 1 | 2026-02-25 |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 1 | 2023-06-29 |
What the citations cover
- Smoke Deficiencies 11
- Gas, Vacuum, and Electrical Systems Deficiencies 6
- Egress Deficiencies 4
- Miscellaneous Deficiencies 2
- Other 2
| Category | Citations |
|---|---|
| Smoke Deficiencies | 11 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 6 |
| Egress Deficiencies | 4 |
| Miscellaneous Deficiencies | 2 |
| Services Deficiencies | 1 |
| Emergency Preparedness Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
February 25, 2026 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0281 | Install proper backup exit lighting. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0341 | Install a fire alarm system that can be heard throughout the facility. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (March 23, 2026) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (March 23, 2026) |
October 3, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0347 | Properly provide smoke detection systems in areas open to corridors. | Deficient, Provider has date of correction (October 31, 2024) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (October 25, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 31, 2024) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (October 31, 2024) |
| K-0920 | Ensure proper usage of power strips and extension cords. | Deficient, Provider has date of correction (October 31, 2024) |
June 29, 2023 — 11 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0223 | Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0291 | Install emergency lighting that can last at least 1 1/2 hours. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0355 | Properly select, install, inspect, or maintain portable fire extinguishes. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Waiver has been granted (August 21, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0912 | Have power receptacles that are properly grounded. | Deficient, Provider has date of correction (July 28, 2023) |
| K-0927 | Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Deficient, Provider has date of correction (July 28, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.