Evansville Manor Nursing and Rehab, LLC

In the surveyor’s words

From the most serious findings on record at Evansville Manor Nursing and Rehab, LLC, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Feb 25, 2026

  Based 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. […]

• Immediate jeopardy, widespreadF880Feb 25, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF600Mar 26, 2026

  Based 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. […]

• Immediate jeopardy, isolatedF689Oct 3, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF689Feb 5, 2024

  Based 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. […]