Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Envive Of Evansville during CMS and state inspections, most recent first.
The facility failed to carry out care plan interventions for residents at risk for falls and for one resident requiring weight monitoring. A resident with Parkinson’s disease and Alzheimer’s disease was observed without non-skid socks and without a bedside mat, another resident with MS and dementia was observed without the ordered toilet mat, and a resident with dementia and hospice services missed ordered monthly weights and reweigh attempts after a refusal. Another resident with hemiplegia and a history of falls was repeatedly observed without the ordered bedside mat. The DON confirmed the missing fall-prevention items and the lack of reweighing.
Improper Medication Storage in Multiple Medication Carts: Loose pills were found in 4 of 4 medication carts, including multiple unidentified tablets and capsules in the Short Hall, Pavillion, Pathways, and North East Hall carts. RN and LPN staff were unsure of the facility policy for cleaning the carts between pharmacy visits, and the facility policy stated that medications and biologicals are to be stored safely, securely, and properly in their containers.
Failure to Follow Oxygen Orders and Equipment Requirements: A resident with chronic respiratory failure with hypoxia was observed receiving O2 above the ordered flow rate, and an LPN later verified the concentrator was set above the physician-ordered 2 to 3 L/min range and adjusted it down. The concentrator was also out of the resident’s reach and did not have a humidification bottle in place, despite the resident stating she wore oxygen continuously.
The facility failed to ensure required physician face-to-face assessments were completed within 30 days after admission for two residents. One resident with chronic respiratory failure on O2 reported not seeing a physician since admission, and the record lacked a post-admission physician assessment; another resident with dementia had a prior physician visit documented, but no required admission assessment was found in the chart. The DON and Administrator provided information and policy showing routine physician visits were required.
Failure to provide routine and emergency dental care was identified for a resident with dementia who needed extensive help with oral hygiene. Staff observed a chipped front tooth and a missing front tooth, but the record lacked documentation of the tooth loss and there was no documented family or dentist notification; the DON was unsure when the tooth was first noticed missing.
Incomplete weight documentation for two residents led to a deficiency. One resident with Parkinson’s disease had a documented 9.1 lb. weight loss in one day, but the chart lacked evidence of a re-weigh or follow-up. Another resident with protein-calorie malnutrition, dysphagia, GERD, and severe cognitive impairment had ordered weekly weights, but several weights were not entered into the clinical record even though staff said they were obtained and recorded elsewhere.
The facility failed to maintain accurate documentation for residents, leading to discrepancies in fall risk assessments and dialysis records. A resident's fall history was inaccurately recorded, and blood pressure readings were documented incorrectly. Additionally, required dialysis assessments were missing or improperly documented, highlighting significant gaps in record-keeping practices.
A facility failed to update a care plan after a resident experienced a fall. The resident, who had diagnoses including cerebral infarction and repeated falls, required substantial assistance with daily activities. Despite being at risk for falls, the care plan was not revised following an unwitnessed fall. The facility's policy required the IDT to review falls and update care plans, but there was no documentation of such a meeting, and the Administrator could not confirm if it occurred.
A resident at high risk for falls experienced multiple falls due to inadequate implementation of fall prevention interventions. Despite updates to the care plan after each incident, the facility failed to ensure personal items were within reach, contributing to the falls. The facility's policy emphasized a resident-centered fall prevention plan, but repeated falls indicate a failure in adherence.
The facility failed to provide necessary assistance with ADLs for several residents, including assistance with meals and bathing. A resident with dementia was not assisted to the dining table in a timely manner, and meal intake was not documented. Other residents did not receive showers according to their care plans, and a resident with a broken arm was not assisted with personal hygiene. The DON confirmed that showers were charted, but there was no written policy on shower timing.
The facility failed to serve meals at appropriate temperatures, as residents reported receiving cold food and a test tray confirmed temperatures below the required level. A cheeseburger was served at 100.6°F and sweet potato fries at 87°F, contrary to the facility's policy of maintaining hot foods at or above 135°F.
The facility failed to document attempts to contact a resident's family for discharge arrangements, leading to a delay. Additionally, inconsistent documentation regarding a fall incident for another resident resulted in unclear details about the resident's injury and care needs.
The facility was found deficient in maintaining a sanitary environment, with surveyors observing strong odors of bowel movements and urine in various halls and an unattended trash cart emitting a similar odor. Additionally, the Pavilion dining room floor had a large puddle of fluid and debris. Despite the Housekeeping Supervisor's claim that odors were managed daily, these issues persisted, contradicting the facility's policy for maintaining pleasant, neutral scents.
A facility failed to provide a SNF-ABN to a resident after the end of Medicare skilled services. The resident was scheduled for discharge but remained in the facility due to family not picking her up. The Administrator confirmed the absence of a SNF-ABN, and the facility's policy did not address SNF-ABN requirements, highlighting a procedural gap in notifying residents of financial responsibilities post-Medicare coverage.
A resident with moderate cognitive impairment was discharged without proper documentation in their clinical record. The facility failed to record essential discharge details, such as the destination and date of discharge, despite having a policy requiring a discharge summary and post-discharge plan. This deficiency was confirmed through record review and staff interviews.
A facility failed to update the PASARR for a resident with complex mental health needs, including Wernicke's encephalopathy and multiple psychiatric disorders. The resident's PASARR was outdated, completed eight months prior to admission, and not reviewed upon admission despite policy requirements. This oversight led to a deficiency in providing necessary social services to meet the resident's mental and psychosocial needs.
A facility failed to develop a baseline care plan within 48 hours for a resident with chronic respiratory failure and a tracheostomy. The resident's clinical record lacked documentation for respiratory equipment use and Enhanced Barrier Precautions, despite ongoing physician orders and facility policy requirements.
A resident with a history of falls and mild cognitive impairment experienced an unwitnessed fall with injury, but the facility failed to update the care plan with a new intervention as required. The care plan, which included interventions for medication review and pain management, was not revised following the incident, as confirmed by the facility administrator.
The facility failed to follow physician orders for two residents. One resident, with renal failure and diabetes, did not receive the ordered compression stockings for edema management. Another resident, with dementia, did not have the required weight monitoring conducted. Interviews revealed a lack of documentation and no written policy to ensure adherence to physician orders.
A resident with severe cognitive impairment and limited mobility developed pressure ulcers due to the facility's failure to implement a physician-ordered pressure-reducing cushion and an individualized repositioning schedule. The facility also failed to document and communicate changes in the resident's skin condition, as required by their policy.
The facility failed to conduct proper post-fall assessments and update care plans for three residents, leading to deficiencies in fall prevention. A resident with Alzheimer's experienced a fall and returned from the hospital with a fracture, but the care plan was not updated. Another resident with dementia had multiple falls without proper assessments or notifications. A third resident's fall was not immediately assessed, and care plan updates were delayed. These issues highlight systemic deficiencies in managing fall risks.
A facility failed to provide proper respiratory care for a resident with a tracheostomy by not labeling oxygen and suction tubing, and not placing signs indicating oxygen use. The resident's clinical record lacked a baseline care plan for tracheostomy and oxygen use, despite having physician orders for oxygen administration. The DON confirmed the need for labeling and signage, as per the facility's policy.
A facility failed to follow physician orders for a resident requiring dialysis care, including not taking blood pressure from the left arm and conducting timely pre-dialysis assessments. Blood pressures were repeatedly taken from the left arm, and pre-dialysis assessments often contained outdated vitals. The facility lacked a written policy for following physician orders, and no policy for dialysis patient assessment was provided.
A facility failed to ensure a resident, admitted with renal failure and peripheral vascular disease, was assessed by a physician since admission. The resident, who required substantial assistance for daily activities, reported not being assessed by a physician, and a review of her clinical record confirmed this absence. The facility's policy on physician responsibilities was not followed.
The facility failed to ensure proper use of Enhanced Barrier Protocol (EBP), PPE, and hand hygiene for residents requiring wound and tracheostomy care. A resident with a tracheostomy did not have an EBP sign, and an LPN did not follow hand hygiene protocols. Two residents with wounds did not receive care with appropriate PPE, despite EBP signs being present. The facility's policies on EBP and hand hygiene were not adhered to during care activities.
A resident with dementia and other conditions was moved from a locked dementia unit to another hall without prior written notice, violating their rights. The resident expressed a preference for their previous room and did not receive the required notification. Facility policy mandates written notice before room changes, which was not followed.
A facility failed to promptly report an incident of resident-to-resident abuse involving a resident with a history of inappropriate sexual behavior. The incident, where a resident inappropriately touched another, was not reported to the State Agency for seven days and lacked detailed information. Staff interviews revealed a delay in reporting the incident to the Facility Administrator, contrary to the facility's policy.
A facility failed to ensure adequate supervision and assistance devices for a resident with a history of falls. Despite having a care plan with specific interventions, such as a fall mat and motion sensor, these were not consistently in place. Observations showed missing non-skid mats, and staff were unaware of the interventions required. The facility lacked a policy to ensure adherence to the care plan, contributing to the deficiency.
The facility failed to provide adequate supervision for an aggressive resident, resulting in a cognitively impaired resident being pushed to the floor and sustaining a right femur fracture that required hospitalization and surgical repair. The aggressive resident had a history of Alzheimer's and dementia with agitation, and had previously shown aggressive behavior towards staff but not other residents.
Failure to Implement Fall Prevention and Weight Monitoring Care Plans
Penalty
Summary
The facility failed to implement care plan interventions for residents identified as being at risk for falls. Resident 92 had diagnoses including Parkinson’s disease, Alzheimer’s disease, and muscle weakness, and the most current MDS indicated severe cognitive impairment and dependence on staff for toileting. His fall risk care plan and physician orders required non-skid footwear or socks at all times and a non-skid mat at bedside, but he was observed wearing white socks without non-skid bottoms and without a non-skid mat at his bedside. The DON confirmed that the mat was not in the room and the socks were not non-skid. Resident 111 had diagnoses including multiple sclerosis and dementia, and the most current MDS indicated severe cognitive impairment, substantial to maximal assistance for toileting and transferring, and one fall without injury since the prior assessment. His care plan and physician orders required a non-skid mat in front of the toilet every shift, but the bathroom was observed without a non-skid mat. A CNA stated there was not a mat in place and was unsure if one was supposed to be there, and the DON confirmed that there was not a mat and that there should have been one. The facility also failed to follow the monitoring plan for Resident 6, who had dementia and was receiving hospice services. Her care plan included obtaining weight as ordered, and the physician ordered monthly weights with reweighing if the weight differed by more than three pounds. The record showed a refused weight on 2/1/26 with no recorded reweigh attempt, and the ordered weight on 3/1/26 was not completed. When weighed on 3/13/26, Resident 6’s weight was 98.8 pounds, compared with 115.2 pounds on the prior recorded weights. Resident 67, who had hemiplegia and hemiparesis following cerebral infarction and a history of falls, was also observed multiple times without the ordered non-skid mat at bedside despite care plan interventions and physician orders requiring it every shift.
Improper Medication Storage in Multiple Medication Carts
Penalty
Summary
The facility failed to ensure proper storage of medication for 4 of 4 medication carts observed. During observation, loose pills were found in the drawers of the Short Hall, Pavillion, Pathways, and North East Hall medication carts. The loose medications included multiple unidentified pills and pills with various markings, such as red, yellow, white, orange, blue, green, and speckled tablets and capsules, all stored outside of their original containers in the carts. During the observations, RN 3 stated that pharmacy came to the facility once a month and cleaned out the cart, but she was unsure of the facility's policy for cleaning the cart between pharmacy visits. LPN 4 stated that she cleaned the cart herself every time she passed medications, but she was not sure of the facility's policy regarding who was supposed to clean the carts. The facility later provided a Medication Storage in the Facility policy dated 2020, which stated that medications and biologicals are to be stored safely, securely, and properly, and that medications are kept and stored in their containers.
Failure to Follow Oxygen Orders and Equipment Requirements
Penalty
Summary
The facility failed to follow physician orders for oxygen administration for one resident with chronic respiratory failure with hypoxia. During an interview and observation, the resident stated she wore oxygen continuously, and the oxygen concentrator was observed set at 4 liters per minute. The resident’s record showed an order for oxygen at 2 to 3 liters per minute via nasal cannula continuously to maintain saturation above 90% every shift, along with an order to change the humidifier/bubbler monthly and as needed and one time a day every Sunday for routine oxygen. During a later observation and interview, the resident’s oxygen was found running at 3.5 liters per minute, and an LPN verified the concentrator was above 3 liters per minute and turned it down to 3. The oxygen concentrator was also out of the resident’s reach and did not have a humidification bottle on it. The Administrator provided the facility’s Oxygen Administration policy, which stated to verify there is a physician’s order and to check the mask, tank, humidifying jar, and water level to ensure proper function.
Missed Required Physician Assessments After Admission
Penalty
Summary
The facility failed to ensure that a physician completed required face-to-face assessments within 30 days following admission for 2 of 2 residents reviewed. Resident 41 was admitted with chronic respiratory failure with hypoxia, was cognitively intact, required substantial assistance with toileting and bathing, and was on oxygen, but the clinical record did not contain a physician assessment after admission. During interview, Resident 41 stated she had not seen a physician since admission, and the DON later stated Resident 41 had been on the list to be seen by the physician on 2/11/26, but no assessment was completed in the medical record. Resident 32 was admitted with dementia, was severely cognitively impaired, and required partial assistance with toileting and transfers. The record showed a physician assessment on 11/18/25, but no assessment within 30 days following admission was documented. The Administrator provided the facility policy titled Physician Services, which stated that supervising medical care includes participating in resident assessment and care planning, monitoring changes in medical status, and conducting routine required visits in accordance with OBRA regulations and facility policy.
Failure to Monitor and Document Dental Changes
Penalty
Summary
Provide routine and 24-hour emergency dental care for each resident was not met for one resident with dementia who was severely cognitively impaired and dependent on staff for toileting, bathing, transfers, and required maximal assistance with oral hygiene. The resident had physician orders and a care plan directing staff not to floss between the two front teeth because they had been fused after a recent dental procedure, and the daily oral task showed oral care was performed or the resident was set up to perform it twice daily. During interview and observation, the resident’s front right tooth was noted to be chipped and not fully intact, and the left front tooth was completely missing. A family member had previously visited and noticed the front tooth missing, but staff were unaware when it occurred. The clinical record lacked documentation about the tooth loss and lacked documentation of notification to the family or dentist. The DON stated the tooth likely fell out within the prior two weeks and was unaware whether staff had found the missing tooth in the facility.
Incomplete Weight Documentation for Two Residents
Penalty
Summary
The facility failed to ensure resident weight documentation was accurate and complete for 2 of 5 residents reviewed for significant weight loss. Resident 16, who had Parkinson’s disease and was moderately cognitively impaired, had a weight summary showing 221 lbs. on 3/1/26 and 211.9 lbs. on 3/2/26, a 9.1 lb. loss in one day. The clinical record did not show that the resident was re-weighed or that the weight loss was followed up on, even though the resident had orders for weekly weights and had a nutritional care plan related to Parkinson’s disease. Resident 75, who had protein-calorie malnutrition, dysphagia, GERD, and severe cognitive impairment, had orders for weekly weights for CAR and NAR review. The eMAR did not document weights on 2/16/26, 2/23/26, or 3/2/26, and there was no documentation that an attempt was made to re-weigh the resident when he was marked sleeping on 2/16/26. The DON stated staff did weigh the resident on those dates, but the weights were recorded on an internal audit tool and never entered into the resident’s clinical record. The facility policy required documentation in the medical record to be objective, complete, and accurate, and required the resident’s height and weight to be recorded.
Documentation Deficiencies in Resident Records
Penalty
Summary
The facility failed to ensure complete and accurate documentation for several residents, leading to deficiencies in record-keeping. Resident M's clinical records showed discrepancies in fall risk assessments, with incorrect documentation of falls and cognitive status. Despite having multiple falls, the assessments inaccurately indicated no falls in the past three months and that the resident was alert and oriented, which was contradicted by other records showing severe cognitive impairment. Resident B's records revealed that blood pressure readings were incorrectly documented as being taken from the left arm, despite physician orders to avoid this due to renal failure. Additionally, there was a lack of pre and post-dialysis assessments on a specified date, which were required by physician orders. Similarly, Resident H's records lacked a post-dialysis assessment, and the documentation process was flawed as the Assistant Director of Nursing (ADON) signed off on assessments she did not perform, relying on information received by phone without proper documentation. Resident D's records also showed inconsistencies, with fall risk assessments inaccurately reflecting the resident's fall history and use of assistive devices. There was a lack of documentation for a fall that occurred, and the incident report was not integrated into the clinical record. The Director of Nursing acknowledged the need for re-education on documentation practices, as errors in documentation led to inaccurate assessments and incomplete records.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident, identified as Resident D, after the resident experienced a fall. Resident D's clinical record indicated diagnoses including cerebral infarction, repeated falls, and muscle wasting and atrophy. The most recent Admission Minimum Data Set (MDS) Assessment showed that Resident D was cognitively intact and required substantial to maximal assistance with activities such as toileting and transferring. Despite being at risk for falls, as noted in a care plan initiated earlier, the care plan was not updated with new interventions following an unwitnessed fall on 3/10/25. The facility's policy required the Interdisciplinary Team (IDT) to meet the next clinical morning after a fall to review the incident and update the care plan with appropriate interventions. However, there was no documentation indicating that the IDT met to review Resident D's fall, and the care plan remained unchanged. The Administrator could not recall if the IDT had convened to address the fall, highlighting a lapse in the facility's adherence to its fall management policy.
Failure to Implement Effective Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure that interventions were in place to prevent falls for a resident identified as being at risk for falls. The resident, who was cognitively intact and required substantial to maximal assistance with mobility and toileting, experienced five falls over a short period. Despite being assessed as low risk for falls initially, the resident's fall risk was later updated to high risk after multiple incidents. The care plan was updated with new interventions after each fall, except for the last incident, where no new intervention was added. Observations revealed that the resident's personal items were not within reach, which could have contributed to the falls. The Director of Nursing acknowledged the oversight and indicated that staff were re-educated on following fall interventions. The facility's policy on managing falls emphasized the need for a resident-centered fall prevention plan and the importance of monitoring and documenting the resident's response to interventions. However, the repeated falls and lack of timely updates to the care plan suggest a failure in implementing and adhering to these policies effectively.
Failure to Provide Assistance with ADLs for Multiple Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADL) for seven out of eight residents reviewed. Resident L, who was moderately cognitively impaired, was observed sitting in a recliner and not assisted to the dining table until after other residents had finished eating. His meal intake was not documented for lunch or dinner on the observed day. Resident S, who required substantial assistance for bathing, reported not receiving showers according to the care plan, and records confirmed missed showers on specified days. Resident G, severely cognitively impaired, also did not receive showers on scheduled days. Resident U, who was cognitively intact and required supervision for bathing, did not receive showers as per her preference care plan. Similarly, Resident R, who required substantial to maximal assistance, did not receive showers on multiple scheduled days. Resident N, who required assistance due to chronic pain, also missed scheduled showers. An anonymous report indicated that Resident T, with mild to moderate cognitive impairment and a broken arm, was not receiving necessary assistance with personal hygiene, including showering and oral care. The Director of Nursing confirmed that showers were charted in the Point of Care system, but there was no written policy on the timing of showers. The facility's policy on meal assistance was provided, indicating that staff should help residents who require assistance with eating.
Failure to Serve Meals at Appropriate Temperatures
Penalty
Summary
The facility failed to ensure meals were served at a palatable temperature, as evidenced by observations and resident interviews. On multiple occasions, residents reported that their food was not served at the appropriate temperature, with hot foods being cold and cold foods not being adequately chilled. A test tray revealed that a cheeseburger was served at 100.6°F and sweet potato fries at 87°F, both below the required temperature for hot foods. Additionally, the cheeseburger was observed to be pink in the middle, despite being precooked. The facility's policy requires hot foods to be maintained at or above 135°F, which was not adhered to in this instance.
Incomplete Documentation for Discharge and Fall Incident
Penalty
Summary
The facility failed to ensure complete and accurate documentation for two residents, leading to deficiencies in their care. For Resident Z, the facility did not document attempts to contact the family regarding the resident's discharge from Medicare Part A. Although the Social Services Director left a voicemail for the family, there was no documentation of further attempts to reach them between January 15 and January 17, 2025. This lack of communication resulted in a delay in the resident's discharge, as the family was waiting for a call to set a discharge date. For Resident T, the facility's documentation was inconsistent regarding the details of an injury from a fall. The incident note indicated that the resident fell and complained of hip and neck pain, with bruising visible on the left arm. However, a nursing progress note documented bruising on the right arm. The Administrator later confirmed that it was not typical for the Social Services Director to decide on using a sling, and the progress note was inaccurately documented. This inconsistency in documentation failed to provide a clear and accurate account of the resident's condition and care needs.
Facility Fails to Maintain Sanitary Environment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment, as evidenced by multiple observations of unpleasant odors and unsanitary conditions. During seven random observations, surveyors noted strong odors consistent with bowel movements and urine in various areas, including the East Hall, 500-hall, and [NAME] Hall. Additionally, a rolling cart of trash emitting a bowel movement-like odor was left unattended in front of the East Hall nurses' station. The Pavilion dining room floor was observed with a large puddle of fluid and dirty debris. Despite the Housekeeping Supervisor's statement that managing odors was part of daily cleaning tasks and that odor-eliminating supplies were available, these issues persisted. The facility's Homelike Environment policy, effective August 2024, emphasized maintaining pleasant, neutral scents, which was not adhered to during the survey period.
Failure to Provide SNF-ABN to Resident Post-Medicare Coverage
Penalty
Summary
The facility failed to provide a Skilled Nursing Facility-Advanced Beneficiary Notice (SNF-ABN) to Resident Z after the end of Medicare skilled services. Resident Z began receiving Medicare Part A Skilled Services on December 4, 2024, with the last covered day being January 14, 2025. Although Resident Z was scheduled to be discharged home on January 15, 2025, the family did not pick her up, and she remained in the facility. The Administrator confirmed that a SNF-ABN was not issued to Resident Z, which is a requirement following the end of Medicare coverage. Upon review of Resident Z's clinical record, it was noted that the payer source changed from Medicare to private pay on January 15, 2025, and she was discharged from the facility on January 22, 2025. The facility's Notice of Medicare Non-Coverage (NOMNC) policy, revised on October 1, 2023, did not address the requirements for SNF-ABN forms. The Administrator acknowledged the absence of a policy for SNF-ABN forms and expected compliance with federal regulations, indicating a gap in the facility's procedures for notifying residents of their financial responsibilities post-Medicare coverage.
Failure to Document Resident Discharge
Penalty
Summary
The facility failed to document the discharge of a resident, identified as Resident 60, in the clinical record. Resident 60, who was moderately cognitively impaired and required substantial assistance for daily activities, was discharged with no anticipation of return. However, the clinical record lacked essential information regarding the discharge planning, including the destination of the resident, the date of discharge, and the documents sent with the resident. This oversight was identified during a review of the resident's clinical record and confirmed through an interview with the Admissions Director, who acknowledged the absence of discharge documentation. The facility's policy, titled Discharge Summary and Plan, mandates that a discharge summary and post-discharge plan be developed and documented for each resident. This includes an evaluation of the resident's discharge needs, a post-discharge plan, and a discharge summary, all of which should be reviewed with the resident and family at least 24 hours before discharge. Despite this policy, the facility did not adhere to these requirements for Resident 60, as evidenced by the lack of documentation in the clinical record and the inability of staff to provide the necessary discharge information.
Failure to Update PASARR for Resident with Complex Needs
Penalty
Summary
The facility failed to ensure that social services were provided to meet a resident's mental and psychosocial needs, specifically in relation to the Preadmission Screening and Resident Review (PASARR) process. The resident, who was admitted with multiple diagnoses including Wernicke's encephalopathy, alcohol use disorder, non-Alzheimer's dementia, seizures, anxiety, depression, and an unspecified psychiatric disorder, was found to have an outdated PASARR completed eight months prior to admission. The facility's policy required that all new admissions be screened for mental disorders, intellectual disorders, or related disorders per the Medicaid PASARR process, but this was not adhered to as the resident's diagnoses were updated after the PASARR was completed, and the Admissions Director did not review the PASARR upon admission to ensure it was current. The resident's clinical record indicated the use of multiple psychotropic medications and the presence of target behaviors such as psychosis, depression, and anxiety, which required monitoring and documentation. Despite these needs, the facility did not ensure that the PASARR was updated to reflect the resident's current condition and needs. The Administrator acknowledged that the PASARR should have been reviewed and updated upon admission, highlighting a lapse in the facility's adherence to its own admissions criteria policy. This oversight resulted in a deficiency related to the provision of necessary social services to address the resident's mental and psychosocial needs.
Failure to Develop Baseline Care Plan for Respiratory Care
Penalty
Summary
The facility failed to develop and complete a baseline care plan within 48 hours of admission for a resident requiring respiratory care. The resident, who was admitted with chronic respiratory failure with hypoxia and a tracheostomy, did not have a baseline care plan addressing the use of respiratory equipment, tracheostomy care, and Enhanced Barrier Precautions (EBP) to prevent the transmission of Multiple Drug-Resistant Organisms (MDROs). The absence of this care plan was identified during a review of the resident's clinical record, which showed ongoing physician orders for oxygen and humidifier changes, as well as the need for EBP due to the presence of a tracheostomy and PEG tube. Interviews with facility staff, including the Assistant Director of Nursing (ADON), revealed that the baseline care plan should have been based on the initial assessment completed by the admitting nurse. This assessment was supposed to include a physical evaluation and details on oxygen use, with the care plan initiated within 48 hours of admission. However, the clinical record lacked this essential documentation, which was confirmed by the facility's policy requiring a baseline care plan to be developed within the specified timeframe to meet the resident's immediate health and safety needs.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to update the care plan for a resident after a fall, which was identified during a review of the resident's clinical records and an interview with the facility's administrator. The resident, who was mildly cognitively impaired and required assistance with daily activities, had a history of falls and was at risk due to potential side effects of medications. Despite an unwitnessed fall with injury occurring on November 27, 2024, the care plan was not updated with a new intervention, as required by the facility's policy. The resident's care plan, which was initially developed in 2017 and revised in 2023, included interventions such as medication review, pain management, and ensuring a safe environment. However, after the fall, the clinical record did not document any new interventions being added to the care plan. The administrator confirmed that the care plan should have been updated with a new intervention following the fall, but this was not done, indicating a lapse in the facility's adherence to its care planning procedures.
Failure to Follow Physician Orders for Two Residents
Penalty
Summary
The facility failed to ensure physician orders were followed for two residents regarding their nutritional and medical care. For Resident 35, who was admitted with diagnoses including renal failure and diabetes mellitus, the physician had ordered the use of compression stockings to manage edema. However, during an observation, it was noted that the resident's lower extremities were swollen, and the resident reported that staff had not assisted in putting on the compression stockings as required. The clinical record confirmed the order for compression stockings, which was not adhered to by the staff. For Resident L, who was diagnosed with dementia and required substantial assistance from staff, the physician had ordered a weight check for monitoring purposes. Despite this order, the clinical record lacked documentation of any weight being recorded since the beginning of the month. Interviews with the Director of Nursing and the Administrator revealed that the ordered weights were not obtained, and there was no written policy in place to ensure physician orders were followed, although it was stated that the facility's policy was to follow such orders as written.
Failure to Prevent Pressure Ulcers in Resident
Penalty
Summary
The facility failed to prevent the development of pressure ulcers for Resident G, who was at risk due to severe cognitive impairment and required substantial assistance for daily activities. Despite a physician's order for a pressure-reducing cushion to be used in the resident's chair or wheelchair, observations revealed that Resident G was left sitting in a recliner without such a cushion, contributing to skin breakdown. The care plan for Resident G did not include an individualized repositioning schedule, which is crucial for preventing pressure ulcers in residents with limited mobility. Additionally, the facility did not adequately document or communicate changes in Resident G's skin condition. Progress notes indicated the presence of open wounds on Resident G's coccyx and bilateral buttocks, including two stage two wounds, yet there was no record of family or physician notification. Furthermore, skin observation tasks on multiple dates inaccurately documented no skin issues, highlighting a failure in monitoring and reporting Resident G's skin condition as per the facility's policy.
Deficiencies in Fall Management and Care Plan Updates
Penalty
Summary
The facility failed to ensure proper post-fall assessments, care plan updates, and interventions for three residents, leading to deficiencies in fall prevention and management. Resident W, diagnosed with Alzheimer's Disease, experienced a fall due to altered mental status and was sent to the ER, where a UTI was diagnosed. Despite returning with a new diagnosis of a femur fracture and an immobilizer, the care plan was not updated, and vital signs were not consistently monitored as required. The clinical record lacked documentation of the effectiveness of interventions and updates to the care plan after the resident's return from the hospital. Resident G, with a history of dementia and multiple falls, had several incidents where post-fall assessments were not conducted, and care plans were not updated with new interventions. The facility failed to document physician or family notifications for several falls, and the resident was not receiving therapy due to insurance issues. The lack of post-fall assessments and care plan updates for multiple falls indicates a systemic issue in managing fall risks for Resident G. Resident P, with Alzheimer's Disease and a history of a femur fracture, experienced a witnessed fall without immediate assessment or documentation. The care plan was updated with an intervention to apply anti-rollbacks to the wheelchair, but the initial assessment was delayed until later that night. The facility's failure to conduct timely assessments and update care plans after falls highlights deficiencies in their fall management protocols, as outlined in their policies.
Failure to Provide Proper Respiratory Care and Equipment Labeling
Penalty
Summary
The facility failed to provide respiratory care services in accordance with professional standards for a resident with chronic respiratory failure and a tracheostomy. Observations revealed that the resident's oxygen tubing, suction tubing, and oxygen concentrator were not labeled or dated, and there were no signs indicating oxygen use in the resident's room. Additionally, during tracheostomy care, the obturator for emergency use was not identified in the room. These deficiencies were noted during observations on two consecutive days. The resident's clinical record included diagnoses of chronic respiratory failure with hypoxia and a tracheostomy, with physician orders for oxygen administration and equipment changes. However, the clinical record lacked a baseline care plan for the tracheostomy and oxygen use. The Director of Nursing confirmed that the equipment should have been labeled and that a sign indicating oxygen use should have been placed on the door. The facility's Oxygen Administration policy, revised in August 2024, also required such signage.
Failure to Follow Dialysis Care Protocols
Penalty
Summary
The facility failed to adhere to physician orders and provide proper dialysis care for a resident with renal failure and peripheral vascular disease. The resident, who was cognitively intact and required substantial assistance for daily activities, had specific physician orders that included not obtaining blood pressure from the left arm and conducting pre- and post-dialysis assessments on designated days. However, the facility documented blood pressures taken from the left arm on multiple occasions, directly contradicting the physician's orders. Additionally, the facility did not consistently perform pre-dialysis assessments as required, with some assessments containing outdated vital signs from previous dates. Interviews with the Director of Nursing and the Administrator revealed that there was no written policy for following physician orders, although it was stated that the facility's policy was to follow them as written. A policy related to the assessment of dialysis patients was requested but not provided, indicating a lack of proper documentation and adherence to care protocols.
Failure to Conduct Physician Assessment for Resident
Penalty
Summary
The facility failed to ensure that a resident was assessed by a physician since admission, as required. Resident 35, who was admitted with diagnoses including renal failure and peripheral vascular disease, reported during an interview that she had not been assessed by a physician in the facility since her admission. A review of Resident 35's clinical record confirmed the absence of any physician assessments since admission. The facility's policy on the choice of attending physician, which outlines the responsibilities of participating in resident assessments and care planning, was not adhered to in this case.
Inadequate Use of PPE and Hand Hygiene in Resident Care
Penalty
Summary
The facility failed to ensure proper use of Enhanced Barrier Protocol (EBP), Personal Protective Equipment (PPE), and hand hygiene for residents requiring wound and tracheostomy care. Resident 277, diagnosed with chronic respiratory failure and a tracheostomy, did not have an EBP sign in their room. During tracheostomy care, an LPN did not wear a gown, failed to wash hands before donning gloves, and did not perform hand hygiene between glove changes. The Infection Preventionist confirmed that gloves should be changed between dirty and clean tasks, with handwashing in between. For Resident 18, who had peripheral vascular disease and ulcers, LPNs did not wear gowns during wound care despite an EBP sign indicating necessary precautions. The clinical record lacked orders and a care plan for EBP. Resident 13, with stage three pressure ulcers, had an EBP sign in the room, but LPNs did not wear gowns during dressing changes. The Director of Nursing stated that proper PPE, including gowns and gloves, should be worn for residents on EBP. The facility's policies on EBP and hand hygiene were not followed, as evidenced by the lack of proper PPE use and hand hygiene during care activities.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide a resident with written notice prior to a room change, violating the resident's rights. Resident B, who had diagnoses including dementia with mood disturbance and agitation, anxiety, and major depressive disorder, was moved from a locked dementia unit to a different hall without prior or documented notification. The resident's most recent MDS assessment indicated no cognitive impairment, and physician orders specified that the resident may reside on a locked secured memory unit. Despite this, the resident was relocated, and all personal belongings and medications were moved to the new unit without prior written notice. During an interview, Resident B expressed that he did not receive notification before the room change and preferred his previous room. Social Service 4 confirmed that residents should be notified in writing prior to a room change using an intra-facility room change form, which should be documented in the resident's record. However, SS4 was not working on the day of the transfer and was unaware if the notification was provided. The facility's policy on room transfers, dated August 2024, mandates informing residents before moving them to a new room, which was not adhered to in this case.
Failure to Timely Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that staff immediately reported an alleged incident of resident-to-resident abuse to the Facility Administrator and did not include all relevant information in the report. The incident involved Resident B, who was reported to have inappropriately touched Resident K. The incident was not reported to the State Agency until seven days after it occurred, and the report lacked details about all residents involved and a comprehensive description of the incident. Interviews revealed that staff members were aware of the incident but did not report it immediately as required by the facility's policy. Resident B had a history of dementia with mood disturbance and agitation, sexual dysfunction, and high-risk heterosexual behavior. The resident's care plan noted sexually inappropriate behaviors, and a psychiatry visit note indicated concerns about increased inappropriate sexual behaviors. Despite these documented concerns, the facility's response to the incident was delayed, and the reporting process was not followed according to the established guidelines. The facility's policy required immediate notification of the Executive Director and the State Department of Health, which was not adhered to in this case.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent falls for Resident K, who was reviewed for falls. Resident K had a history of Alzheimer's disease, dementia with psychotic disturbance, and repeated falls. The resident's care plan included interventions such as a fall mat at the bedside, a non-skid mat in front of the toilet, and a motion sensor while in bed. Despite these interventions, Resident K experienced four falls between August and September 2024, with one resulting in injury. Observations and interviews revealed that the interventions were not consistently in place. On October 22, 2024, a non-skid mat was not observed in front of the toilet in Resident K's room. Additionally, LPN 24 was unaware of Resident K's falls and the interventions in place, and QMA 43 was unsure about the presence of a non-skid mat or the functioning of the bed alarm. The facility's staff did not have a clear understanding of the interventions required for Resident K, and there was no policy in place to ensure adherence to the physician's orders and the resident's care plan. The facility's Falls and Fall Risk Managing Policy indicated that staff should implement a resident-centered fall prevention plan and that position-change alarms should not be the sole intervention to prevent falls. However, the lack of consistent implementation and monitoring of the interventions for Resident K contributed to the deficiency. The facility administrator acknowledged the absence of a policy to guide staff in following the physician's orders and the resident's plan of care.
Failure to Provide Adequate Supervision Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision for Resident C, an aggressive resident, which resulted in Resident B, a cognitively impaired resident, being pushed to the floor. This incident led to Resident B sustaining a right femur fracture that required hospitalization and surgical repair. Resident B reported that a man got mad, pushed her, and grabbed her hair. The clinical record review indicated that Resident B had a history of anxiety disorder and vascular dementia, and her mobility was generally independent with some assistance required for certain activities. On the night of the incident, Resident B was found on the floor with a large raised area on her head and complained of hip pain. She was transferred to the hospital for evaluation and treatment. Resident C, who had a history of Alzheimer's disease and unspecified dementia with agitation, had previously shown aggressive behavior towards staff but not towards other residents. On the night of the incident, Resident C entered Resident B's room and attacked her, leading to her fall and subsequent injuries. The facility's records indicated that Resident C had frequent episodes of anger and frustration, often refusing care and being verbally and physically aggressive towards staff. Despite these behaviors, there was no documentation of previous outbursts towards other residents. The facility's policy for unmanageable residents, which was last revised in April 2010, was reviewed but did not prevent the incident from occurring. The facility's failure to provide adequate supervision and ensure a safe environment for Resident B resulted in significant harm to her.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 299 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aperion Care Lincoln | 1.5 mi | ★★★★★ | 13 | 0 |
| Evansville Protestant Home | 1.7 mi | ★★★★★ | 0 | 0 |
| River Pointe Health Campus | 2.1 mi | ★★★★★ | 1 | 0 |
| Brickyard Healthcare - Brentwood Care Center | 2.7 mi | ★★★★★ | 2 | 0 |
| Columbia Healthcare Center | 2.9 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.