Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Evansville Protestant Home during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and multiple comorbidities experienced repeated falls, including two with major injuries, due to the facility's failure to consistently update care plans and implement new fall prevention interventions after each incident. Despite changes in the resident's condition and increased fall risk, care plan revisions and follow-up actions were delayed or incomplete, and some interventions discussed by the IDT were not promptly added to the care plan.
The facility did not ensure the Dietary Manager had the required certification or was enrolled in a state-approved food service management course, as confirmed by interviews and employee file review. The Dietitian was aware of this but did not increase oversight, and the facility lacked a written policy on dietary manager qualifications.
Surveyors found that food items in the dietary area were not stored or labeled according to professional standards, including open and undated produce, outdated and molded items, and food stored directly on the floor. These practices did not comply with facility policy requiring proper labeling, dating, and storage above the floor.
The facility did not ensure timely physician notification for two residents: one with a catheter-associated UTI and new symptoms, and another receiving antianxiety medication for whom pharmacy recommendations to decrease dosage were not addressed. Documentation was lacking for physician notification regarding lab results, changes in condition, and pharmacy suggestions, and the medical director was not informed when the primary provider was unresponsive.
The facility did not create or implement care plans for several residents receiving high-risk medications, including antibiotics, opioids, anticoagulants, antipsychotics, antianxiety agents, antidepressants, and anticonvulsants. This deficiency was identified for three residents with complex medical conditions and medication regimens, and staff interviews confirmed the absence of required care plans to address medication monitoring and related risks.
A resident with chronic kidney disease and recent significant weight loss did not receive the prescribed daily ice cream supplement as outlined in their care plan. Despite documentation and meal tickets indicating the supplement was required, observations showed the resident did not receive it, and the dietary manager's list did not include the resident for this supplement.
A resident with a suprapubic catheter and history of chronic UTIs experienced delays in diagnosis and treatment due to lapses in communication, incomplete documentation, and lack of a specific care plan for UTI prevention. The facility did not have a written policy for UTI management, and staff failed to promptly act on lab results and physician orders, resulting in delayed antibiotic administration and insufficient monitoring of catheter-related complications.
A resident with severe cognitive impairment and dementia was admitted and did not receive a documented physician assessment as required. Review of the clinical record and confirmation by the DON showed no evidence of a physician visit or assessment since admission, despite facility policy mandating timely medical assessments.
A resident with an anxiety disorder received pharmacy recommendations on two occasions to decrease the dosage of an antianxiety medication, but there was no documentation that these recommendations were acted upon or addressed by the prescriber or Medical Director, despite facility policy requiring timely response and documentation.
A resident with an indwelling catheter and urine retention did not have their catheter change accurately documented according to physician orders. Documentation indicated a QMA performed the change, but the QMA denied doing so, and a nurse later completed the procedure after the scheduled date. Facility policy required complete and accurate medical record documentation.
Two residents with wounds did not receive proper infection control measures during wound care, as staff failed to use required gowns and EBP signage was missing or not followed. In both cases, RNs performed wound care without appropriate PPE, and one resident was not identified for EBP despite having an open wound, contrary to facility policy.
Failure to Revise Care Plans and Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to revise care plans and implement appropriate interventions to reduce the risk of falls for a resident with severe cognitive impairment and multiple comorbidities, resulting in repeated falls with major injuries. The resident experienced four falls over a three-month period, two of which resulted in fractures requiring hospitalization and a significant decline in activities of daily living (ADLs). Despite the resident's changing condition and increased fall risk, care plans were not consistently updated with new interventions following each incident, and some interventions discussed by the interdisciplinary team (IDT) were not promptly added to the care plan. After the first fall, the only intervention added was fluorescent tape to the walker, and the resident was still assessed as low risk for falls. Following subsequent falls, the resident's risk status was updated to high, but care plan revisions and implementation of new interventions were delayed or incomplete. For example, after the second fall, which resulted in pelvic fractures, the care plan was not updated with new interventions, and there was a lack of timely follow-up with the physician regarding the resident's ongoing pain and mobility decline. Documentation also showed gaps in communication and follow-up on diagnostic results, such as x-rays and urinalysis, and the IDT did not consistently meet to reassess and address the resident's needs after each fall. Observations and interviews revealed that some interventions, such as the concave mattress, were not added to the care plan until days after being discussed, and visual cues like fluorescent tape were not always present as required. The facility's own policies required ongoing assessment, documentation, and revision of care plans when goals were not achieved or when there was a significant change in the resident's condition. However, these procedures were not consistently followed, contributing to the resident's repeated falls and injuries.
Dietary Manager Lacked Required Certification
Penalty
Summary
The facility failed to ensure that the Dietary Manager met the required qualifications for the position. The Dietary Manager confirmed during an interview that she did not possess a dietary manager certification and had not enrolled in a certification program. The Dietitian was aware of the Dietary Manager's lack of certification but did not increase her oversight or visits, maintaining her current schedule of being in the facility once a week. Review of the Dietary Manager's employee file showed that the job description, signed by the manager, required completion of a state-approved food service management course or current enrollment in such a program, which had not occurred. Additionally, the Administrator stated there was no written policy regarding the qualifications for the dietary manager, and that the facility's practice was to follow state regulations.
Improper Food Storage and Labeling in Dietary Area
Penalty
Summary
Surveyors observed multiple failures in the facility's dietary area to store and label food according to professional standards. During a kitchen walkthrough, an open bag of mixed vegetables without a date, a chunk of ham dated over a month prior, a carton of molded strawberries, and containers of bran mixture and banana cake with outdated preparation labels were found in the walk-in refrigerator. In the dry storage room, rice crispy treats and a box of sandwich crackers were stored directly on the floor. In the walk-in freezer, a bag of pepperonis was double-bagged with conflicting dates on the inner and outer bags. The facility's policy requires food to be stored at least six inches above the floor, properly covered, labeled, and dated, with leftovers used within seven days or discarded, but these standards were not met in the observed instances.
Failure to Notify Physician of Significant Changes and Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure timely and appropriate physician notification regarding significant changes in condition and laboratory results for two residents. For one resident with a history of malignant neoplasm of the bladder and an indwelling suprapubic catheter, there were multiple instances where the clinical record lacked documentation of physician notification. These included situations where lab results were not obtained, the resident experienced new symptoms such as abdominal pain, pain at the catheter site, and redness at the catheter insertion site, and when the medical provider was unresponsive to facility attempts at contact. Additionally, there was no evidence that the medical director was notified when the primary physician or post-acute care provider did not respond to urgent communications regarding the resident's condition and lab findings. For another resident with an anxiety disorder who was receiving antianxiety medication, the facility did not document any action or physician notification in response to pharmacy recommendations to decrease the medication dosage. Pharmacy recommendations were made on two separate occasions, but there was no evidence that the attending physician or medical director was contacted to accept or decline these recommendations. Interviews confirmed that the medical director was not made aware of the lack of response from the attending physician, despite facility policy requiring follow-up in such cases. Facility policies required that recommendations from the consultant pharmacist be acted upon and documented, and that nursing staff notify the physician of acute changes in condition. However, the records reviewed showed that these protocols were not consistently followed, resulting in missed or delayed physician notifications for significant clinical changes and pharmacy recommendations for both residents.
Failure to Develop Care Plans for High-Risk Medications
Penalty
Summary
The facility failed to develop and implement comprehensive care plans addressing high-risk medications for three residents. For one resident with diagnoses including Fournier Gangrene, prostate cancer, and chronic pain syndrome, the clinical record showed the use of both an antibiotic (daptomycin) and an opioid (oxycodone), but there were no care plans in place for pain management or antibiotic monitoring. The resident was cognitively intact and dependent on staff for several activities of daily living. Another resident with congestive heart failure was receiving an anticoagulant (Eliquis) but did not have a care plan identifying interventions to monitor for side effects such as bleeding. Although the resident's care plan mentioned the use of Eliquis to prevent embolism, it did not address the specific risks associated with anticoagulant therapy. The resident was cognitively intact and required varying levels of assistance with daily activities. A third resident with Alzheimer's disease, anxiety, depression, and spinal stenosis was prescribed multiple high-risk medications, including antipsychotics, antianxiety agents, antidepressants, anticonvulsants, and opioids. Despite the complexity of the medication regimen and the resident's moderate cognitive impairment, the care plan did not address the use of these medications, the underlying disease processes, or interventions to monitor for side effects. Interviews with facility staff confirmed that care plans for high-risk medications were not in place for these residents.
Failure to Implement Care Plan for Nutritional Supplement
Penalty
Summary
A deficiency occurred when the facility failed to implement a resident's care plan related to nutrition. The resident, who had chronic kidney disease and was cognitively intact, experienced an unplanned weight loss of 5% or more in the last month. The care plan, updated after a significant change assessment, included providing daily ice cream to increase calorie intake due to recent weight loss. However, on multiple occasions, the resident did not receive the prescribed ice cream with lunch, as observed in both the dining room and in her room. The lunch ticket indicated that ice cream should have been included, but it was missing from the tray. Further review revealed that the dietary manager's list of residents receiving supplemental foods did not include this resident for the ice cream supplement, despite it being part of the care plan. The facility's policy required care plans to be reviewed and revised as needed, but the failure to ensure the care plan was followed resulted in the resident not receiving the intended nutritional intervention.
Delayed UTI Treatment and Inadequate Catheter Care Documentation
Penalty
Summary
The facility failed to ensure timely treatment of a urinary tract infection (UTI) for a resident with an indwelling suprapubic catheter. The resident, who had a diagnosis of malignant neoplasm of the bladder and was moderately cognitively impaired, experienced multiple episodes of UTI. Documentation revealed delays in obtaining and acting upon laboratory results, as well as lapses in communication with medical providers. For example, after a urine culture was collected in the emergency department, the final results were available within two days, but the resident did not begin antibiotic treatment until several days later. The clinical record did not show that staff directly contacted the hospital laboratory to expedite culture results, and there were repeated notes of difficulty reaching the physician or post-acute care line. Additionally, the resident experienced recurring issues with catheter care, including episodes of purple urine bag syndrome, blood in the urine, and pain at the catheter site. There were periods where no progress notes or observations were documented regarding the resident's catheter, pain, or UTI monitoring, particularly following reports of catheter occlusion and pain. In one instance, a contaminated urine specimen delayed diagnosis and treatment, and a subsequent order for antibiotics was not initiated promptly despite the resident exhibiting increased confusion and lethargy. The facility also lacked a care plan specifically addressing the resident's frequent UTIs and prevention strategies, such as promoting hand hygiene, despite documentation that the resident frequently handled his catheter tubing. Interviews with the DON and Administrator confirmed the absence of a written policy for UTI management, and the only protocols provided were general in nature, not specific to UTI prevention or timely intervention. These deficiencies contributed to delays in diagnosis and treatment of UTIs for the resident.
Lack of Physician Assessment for Newly Admitted Resident
Penalty
Summary
The facility failed to ensure that a resident was assessed by a physician since admission, as required. Resident 22, who was admitted with diagnoses including dementia and was noted to be severely cognitively impaired and in need of partial assistance for toileting and bathing, did not have any documented physician assessment in the clinical record following admission. This was confirmed through review of the resident's clinical record, which lacked physician assessments, progress notes, or related documentation, and was further corroborated by the DON, who was unable to locate any physician assessment for the resident. The facility's policy requires timely medical assessments by a physician in accordance with OBRA regulations, but this was not followed for this resident.
Failure to Act on Pharmacy Recommendations for Medication Regimen Review
Penalty
Summary
The facility failed to ensure that pharmacy recommendations regarding a resident's medication regimen were acted upon and documented as required. Specifically, a resident with an anxiety disorder, who was receiving buspirone for anxiety, had two separate pharmacy recommendations to decrease the medication dosage from 10 mg once a day to 5 mg once a day. These recommendations, dated over a month apart, lacked documentation showing that they were either accepted, acted upon, or rejected by the prescriber or facility staff. The resident's physician, who did not visit the facility, did not respond to the pharmacy recommendations, and the process for escalating unaddressed recommendations to the Medical Director was not followed, as there was no evidence the Medical Director accepted or declined the recommendations. Facility policy required that pharmacy recommendations be acted upon and documented by staff or the prescriber, with further escalation to the Medical Director if the prescriber did not respond within 30 days. Despite this policy, there was no documentation of any action taken in response to the pharmacy's suggestions for this resident. Interviews confirmed that the established process for handling unaddressed pharmacy recommendations was not followed, resulting in a lack of timely and appropriate response to the consultant pharmacist's input regarding the resident's medication therapy.
Failure to Accurately Document Catheter Change
Penalty
Summary
The facility failed to ensure accurate documentation of a catheter change for one resident with an indwelling catheter and a diagnosis of urine retention. The resident was cognitively intact and required maximal assistance for activities of daily living. Physician orders specified that the resident's Foley catheter was to be changed monthly, with a specific schedule outlined. Documentation provided by the Director of Nursing indicated that a Qualified Medication Aide (QMA) had performed the catheter change on a specified date; however, during an interview, the QMA denied performing the procedure and suggested that a nurse may have documented the task under her username. Further review of nursing progress notes revealed that the catheter change was not completed as scheduled, and a Registered Nurse subsequently performed the change several days later. Facility policy required that documentation in the medical record be objective, complete, and accurate.
Failure to Implement Enhanced Barrier Precautions and PPE During Wound Care
Penalty
Summary
The facility failed to implement proper infection control practices related to Enhanced Barrier Precautions (EBP) and Personal Protective Equipment (PPE) during wound care for two residents. In the first instance, a resident with severe cognitive impairment and a stage 4 pressure wound on the coccyx was observed receiving wound care from two registered nurses who did not wear gowns as required by the EBP protocol, despite signage indicating the need for such precautions. One of the nurses acknowledged forgetting to don the gown prior to performing wound care. In the second instance, another resident with an ulcer on the right buttock was not listed as being on EBP, and there was no EBP signage or documentation indicating the need for EBP in the care plan or physician orders. During wound care, two registered nurses were observed not wearing gowns, and the necessary EBP signage and PPE were not present. The Director of Nursing and Infection Preventionist later confirmed that the resident should have been on EBP and that staff should have used gowns and gloves during wound care.
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What surveyors actually found near you
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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.
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Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Envive Of Evansville | 1.7 mi | ★★★★★ | 7 | 0 |
| Aperion Care Lincoln | 2 mi | ★★★★★ | 13 | 0 |
| River Pointe Health Campus | 3 mi | ★★★★★ | 1 | 0 |
| Majestic Care Of Newburgh | 3.1 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Brentwood Care Center | 3.2 mi | ★★★★★ | 2 | 0 |
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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.