Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Care Center during CMS and state inspections, most recent first.
QAA/QAPI committee was not effective in using prior survey findings to drive current PI projects related to care plans. The administrator stated the prior survey POC had been discussed at QAPI but was not a current project, and the facility instead based projects on the [NAME] report and other internal reports. QAPI minutes showed current projects were food enjoyment and relationship, with no changes planned.
Incomplete comprehensive care plans for two residents. One resident had behavioral and psychosocial concerns, but the care plan lacked specific interventions for staff to follow when behaviors occurred, and staff interviews showed they were unaware of any detailed behavior interventions. Another resident had multiple triggered CAA areas, including cognitive loss, urinary incontinence, psychosocial wellbeing, falls, nutrition, pain, and psychotropic drug use, but the comprehensive care plan was not completed and did not reflect current needs such as weight loss, depression, or activity preferences.
The facility failed to provide the required Notice of Medicare Non-coverage (NOMNC) and Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) forms to residents in a timely manner. Two residents did not receive the NOMNC form 48 hours prior to discharge, and another resident received the SNFABN form with an incorrect date. The MDS coordinator and administrator confirmed these oversights, acknowledging the failure to meet CMS requirements for timely notification.
A resident with cognitive impairment and a history of falls, including a hip fracture, was inaccurately assessed on the MDS, which failed to document these incidents. Despite multiple falls documented in incident reports, the MDS indicated no falls or injuries. The DON confirmed the inaccuracies and the lack of a facility policy on completing assessments.
The facility failed to develop comprehensive care plans for two residents, leading to a lack of clear care direction and unimplemented therapy and dietary recommendations. One resident did not have a documented care plan, while another's plan lacked updates from occupational therapy and dietary, resulting in unmet care needs.
QAPI Committee Did Not Use Prior Survey Deficiencies in Current Projects
Penalty
Summary
The facility failed to ensure the QAA/QAPI committee was effective in implementing appropriate action plans to correct quality deficiencies identified in previous surveys related to care plans. During interview, the administrator confirmed the prior survey's plan of correction had been discussed at QAPI but was not being used as a current QAPI project. The administrator stated that after a recertification survey is completed, the results and plan of correction are reviewed, and once audits are completed within the plan's timeline, the issue is considered completed. The administrator also stated the facility did not use past survey results for current QAPI projects and instead generated projects from the [NAME] report and other facility reports. The QAPI meeting minutes dated 10/9/25 showed the current performance improvement projects were food enjoyment and relationship, and the minutes stated no changes were going to be made. The next meeting was scheduled for 1/15/26. The facility policy titled QAPI policy stated the purpose of QAPI is to take a proactive approach to improving the comprehensive range of care and services provided by the facility, including clinical care, quality of life, resident choice, and safety.
Incomplete comprehensive care plans for residents with behavioral, psychosocial, and care needs
Penalty
Summary
The facility failed to ensure comprehensive care plans were developed and maintained for 2 residents, R20 and R21. For R20, the quarterly MDS identified the resident as cognitively intact with diagnoses including heart failure, arthritis, and seizure disorder, while the quarterly CAA identified cognitive loss/dementia, behavioral issues, and psychosocial wellbeing concerns. R20’s care plan identified a potential for social emotional disturbances and listed target behaviors such as refusal of care, rude demeaning remarks, and abrasive behaviors, with interventions to monitor behaviors and document interventions and outcomes on the POC, but the care plan lacked specific planned interventions for staff to follow when behaviors occurred. Documentation reviewed for R20’s behaviors during shift report also lacked interventions staff were to follow if behaviors arose. During interviews, R20 stated she wanted to leave the facility and made hostile statements about political figures and groups of color. NA-A and LPN-A stated R20 had frequent behaviors and required calm redirection, reapproaching, reeducation, and redirection, but both were unaware of any specific behavior interventions. The MDS coordinator stated the facility would need to include every intervention because it was not sure what would work, and the DON designee confirmed the care plan lacked interventions for behavior. For R21, the admission MDS identified moderate cognitive impairment and dependence for toileting, dressing, and transferring, with diagnoses including diabetes, hypertension, hip fracture, Parkinson’s disease, malnutrition, and depression, and medications including antidepressants and opioids. The CAA triggered for multiple areas, including cognitive loss, visual function, ADLs, urinary incontinence, psychosocial wellbeing, behavioral symptoms, activities, falls, nutritional status, dehydration, dental care, pressure ulcer, psychotropic drug use, and pain, but the care plan only addressed risk for ADL dependence and lacked evidence of the other triggered areas. Staff interviews confirmed R21 had weight loss and was receiving supplements, but the care plan was not updated with current diet information; activity staff were unaware of preferred activities, and nursing assistants were unaware of depression or interventions. The MDS coordinator confirmed the comprehensive care plan was not completed, and the DON designee confirmed it should have been completed per regulations.
Failure to Provide Timely Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-coverage (NOMNC) form-10123 to two residents, R22 and R78, 48 hours prior to their discharge. R22's physical and occupational therapy discharge summaries indicated that services were no longer required as of 5/21/24, but the NOMNC form was signed on 5/28/24, with the last covered day being 5/29/24. Similarly, R78's therapy discharge notification indicated the last covered day was 9/4/24, but the NOMNC form was signed on 9/3/24, with the last covered day being 9/3/24. Additionally, the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) form-10055 for R17 was not provided in a timely manner, as the form was dated 11/24/24, despite the last covered day being 11/13/24. Interviews with the Minimum Data Set (MDS) coordinator and the administrator confirmed these findings. The MDS coordinator acknowledged responsibility for completing the forms and admitted to the oversight in providing them 48 hours prior to discharge. The coordinator also noted that R17 had put the wrong date on the form, which was supposed to be signed on 11/11/24. The administrator confirmed the MDS coordinator's responsibility and stated that the expectation was for the forms to be provided at least 48 hours in advance to allow residents time to appeal if necessary. The facility's policy on Medicare Denial Notice was reviewed, indicating a failure to meet the Centers for Medicare and Medicaid Services (CMS) requirements for timely notification.
Inaccurate MDS Coding for Resident's Falls and Injuries
Penalty
Summary
The facility failed to ensure accurate coding on the Minimum Data Set (MDS) for a resident, identified as R17, which led to an inaccurate assessment of the resident's health conditions. The MDS Section J: Health Conditions, which is intended to document health conditions such as falls, was completed incorrectly. Despite R17 having experienced multiple falls, including one resulting in a hip fracture, the MDS inaccurately indicated that R17 had no falls or injuries. This discrepancy was confirmed during interviews with the resident, a family member, and the facility's RN and Director of Nursing (DON). R17, who was moderately cognitively impaired and had a recent hip fracture, diabetes, and anxiety, required extensive assistance with activities of daily living. The resident's care plan noted decreased physical mobility and potential for falls, yet the MDS did not reflect the falls that had occurred. Incident reports documented falls on three occasions, with the last fall resulting in a hip fracture and hospitalization. The DON confirmed the assessment was completed inaccurately and acknowledged the absence of a facility policy on completing assessments.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive, person-centered care plans for two residents, R21 and R17, as required. R21, who had intact cognition and required limited assistance with mobility and personal care, did not have a comprehensive care plan documented in the electronic health record. Interviews with staff revealed that there was a lack of clear direction for R21's care, and the Minimum Data Set Coordinator (MDSC) confirmed that R21 was not on the list for care plan review, indicating a lack of an audit system to ensure care plans were completed. R17, who was moderately cognitively impaired and required extensive assistance with activities of daily living, had a care plan that was not updated with recommendations from occupational therapy and dietary. Observations showed that R17 was not receiving the prescribed dietary supplements and was not following occupational therapy guidelines, such as avoiding crossing legs. The registered dietician and dietary manager confirmed these discrepancies, and the MDSC acknowledged the care plan did not include the necessary updates. The Director of Nursing confirmed the findings and stated that care plans should be completed and updated as required.
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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.
Illustrative
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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) |
|---|---|---|---|---|
| Barrett Care Center Inc | 11.6 mi | ★★★★★ | 0 | 0 |
| Bethany On The Lake Llc | 17.2 mi | ★★★★★ | 14 | 0 |
| Knute Nelson Care Center | 18 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Society - Battle Lake | 19.6 mi | ★★★★★ | 1 | 0 |
| St Williams Living Center | 20.2 mi | ★★★★★ | 5 | 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.