EVANSVILLE PROTESTANT HOME
Non profit - Corporation
49 Beds
Independent
Data: November 2025
Trust Grade
50/100
#345 of 505 in IN
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Last Inspection: April 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Evansville Protestant Home has received a Trust Grade of C, indicating that it is average and sits in the middle of the pack among nursing homes. It ranks #345 out of 505 facilities in Indiana, putting it in the bottom half, and #7 out of 17 in Vanderburgh County, meaning only six local options are better. The facility is experiencing a worsening trend, with issues increasing from 3 in 2024 to 12 in 2025. While staffing is a strength with a 4 out of 5 rating and a turnover rate of 51%, which is about average for Indiana, there are some concerning deficiencies. For example, one resident suffered two falls leading to fractures due to inadequate revisions of their care plan, and the dietary manager lacked required qualifications, raising questions about oversight in food safety practices. However, it is worth noting that the facility has no fines on record and provides more RN coverage than 81% of Indiana facilities, suggesting a solid level of nursing attention.
- Trust Score
- C
- In Indiana
- #345/505
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 51% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Indiana facilities.
- Skilled Nurses ✓ Good
- Each resident gets 63 minutes of Registered Nurse (RN) attention daily — more than 97% of Indiana nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 19 deficiencies on record. Higher than average. Multiple issues found across inspections.
50/100
Bottom 32%
Needs review
3 → 12 violations
★★☆☆☆
2.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2024: 3 issues
2025: 12 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
2-Star Overall Rating
Below Indiana average (3.1)
Below average - review inspection findings carefully
Staff Turnover: 51%
Near Indiana avg (46%)
Higher turnover may affect care consistency
The Ugly 19 deficiencies on record
1 actual harm
Apr 2025
12 deficiencies
1 Harm
SERIOUS
(G)
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on observation, interview, and record review, the facility failed to revise care plans and follow interventions to reduce the risk of falls for 1 of 1 resident reviewed for falls with major inju...
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Based on observation, interview, and record review, the facility failed to revise care plans and follow interventions to reduce the risk of falls for 1 of 1 resident reviewed for falls with major injury. This deficient practice resulted in two falls with fractures requiring hospitalization and a significant decline in the resident's Activities of Daily Living (ADLs). (Resident 7)
Finding includes:
On 3/26/25 at 10:11 A.M., Resident 7's clinical record was reviewed. Diagnoses included, but were not limited to, displaced comminuted fracture of shaft of right femur, fracture of upper end of right humerus, fracture of superior rim of right pubis, and vascular dementia.
The most recent Annual Minimum Data Set (MDS) Assessment, dated 11/23/24, indicated Resident 7 had severe cognitive impairment, required setup assistance of staff (staff sets up/cleans up; resident completes the activity) with eating, required supervision of staff (staff provides verbal cues or touching/steadying assistance as resident completes the activity) for toileting and sit to stand transfers, was independent rolling left and right, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and had no falls since the prior assessment.
An annual fall risk assessment was completed on 11/23/24 that indicated Resident 7 was at low risk for falls.
A current falls care plan, initiated 5/7/23 and last revised on 3/3/25, indicated Resident 7 was at risk for falls due to weakness. Interventions included:
Assure I have appropriate footwear before ambulating, dated 5/17/23
Fluorescent tape added to call light as a visual cue, dated 5/17/23
Keep call light and personal items within reach, dated 5/17/23
Educated resident to utilize the call light for assistance when not feeling well, dated 1/22/24
Gripper socks when shoes are not on, dated 4/1/24
Fluorescent tape to walker to remind resident to take walker to restroom, dated 12/29/24
Concave mattress, dated 3/3/25
A care conference was most recently completed on 3/20/25. Care plan conference notes indicated that all current care plans were reviewed.
The clinical record indicated Resident 7 fell four times between 12/29/24 and 3/1/25.
Fall 1
On 12/29/24 at 10:00 A.M., Resident 7 sustained an unwitnessed fall without injury while walking without her walker. Fluorescent tape to walker to remind resident to take walker to restroom was added to the care plan on 12/29/24. A fall risk assessment was completed on 12/29/24 that indicated Resident 7 was at low risk for falls.
Fall 2
On 1/4/25 at 10:15 P.M., Resident 7 sustained an unwitnessed fall while getting out of bed. At that time, no injury was noted. A fall risk assessment was completed on 1/4/25 that indicated Resident 7 was at high risk for falls.
A nursing progress note, dated 1/4/25 at 10:49 P.M., indicated staff notified the physician of the fall, confusion, and a high blood pressure of 154/80. An order was received for a urinalysis (UA) to check for infection.
A nursing progress note, dated 1/4/25 at 11:26 P.M., indicated the resident complained of right hip pain with no bruising or swelling noted upon assessment.
A nursing progress note, dated 1/5/25 at 6:02 A.M., indicated the resident complained of hip and back pain with difficulty ambulating. Pain medication was given. Urine was collected at that time.
A nursing progress note, dated 1/5/25 at 10:52 P.M., indicated the resident complained of hip pain and was observed with a slow and unsteady gait.
A nursing progress note, dated 1/6/25 at 3:35 A.M., indicated the physician was notified of the resident's continued complaints of bilateral hip pain and back pain.
Progress notes from 1/6/25 at 3:35 A.M. to 1/7/25 at 1:14 P.M lacked documentation to indicate the physician responded or staff attempted to follow up with the physician or the medical director.
An Interdisciplinary Team (IDT) note, dated 1/6/25 at 10:40 A.M., indicated Resident 7's 1/4/25 fall was reviewed. The new intervention was a clinical assessment. The care plan was not updated with a new intervention at that time.
A nursing progress note, dated 1/7/25 at 5:08 A.M., indicated the resident complained of hip and back pain, was unable to ambulate, and required assistance of two staff for toileting and transferring.
A nursing progress note, dated 1/7/25 at 1:14 P.M., indicated the resident complained of bilateral hip pain and had a decline in mobility. Staff attempted to call the physician to request an x-ray of the bilateral hips.
A nursing progress note, dated 1/7/25 at 6:09 P.M., indicated a transfer order was received from the physician and the resident was transferred to the hospital for evaluation and x-rays.
Hospital discharge paperwork, dated 1/7/25 at 10:50 P.M., indicated Resident 7 had superior and inferior pubic ramus fractures and multiple closed stable lateral compression fractures of the pelvis that did not require surgery. The resident was recommended to start physical therapy and follow up as needed.
A nursing progress note, dated 1/8/25 at 1:45 A.M., indicated the resident returned to the facility from the hospital with no new orders.
A therapy evaluation indicated Resident 7 began physical therapy on 1/9/25.
A nursing progress note, dated 1/10/25 at 9:19 A.M., indicated the urine obtained on 1/5/25 was negative and did not indicate an infection was present.
A review of progress notes from 1/6/25 to 1/20/25 lacked documentation to indicate the IDT met to follow up on the negative UA and determine a new intervention following the resident's fall on 1/4/25 to prevent further falls.
Fall 3
On 1/20/25 at 12:15 A.M., Resident 7 sustained an unwitnessed fall while attempting to self-transfer to the bathroom. A fall risk assessment was completed on 1/20/25 and indicated that Resident 7 was at high risk for falls.
A nursing progress note, dated 1/20/25 at 12:26 A.M., indicated the resident complained of pain and moved all extremities as normal for resident with a pelvic fracture.
An IDT Note, dated 1/20/25 at 10:21 A.M., indicated Resident 7's 1/20/25 fall was reviewed. The new interventions were concave mattress and offer the opportunity to lay in bed between 9 P.M. and 11 P.M. The interventions were not added to the care plan at that time.
A Significant Change MDS Assessment was completed on 1/20/25. It indicated Resident 7 had severe cognitive impairment, required setup assistance of staff (staff sets up/cleans up; resident completes the activity) with eating, required supervision of staff (staff provides verbal cues or touching/steadying assistance as resident completes the activity) for toileting and sit to stand transfers, was independent rolling left and right, required partial to moderate assistance of staff (staff does less than half of the effort) for bathing, and had one fall since the prior assessment.
A nursing progress note, dated 1/22/25 at 2:35 P.M., indicated the resident complained of pain while walking.
A nursing progress note, dated 1/22/25 at 10:32 P.M., indicated the resident complained of pain in the right hip. Staff attempted to notify the physician of the increased pain.
A nursing progress note, dated 1/23/25 at 11:56 A.M., indicated staff attempted to contact the physician about the resident's pelvic pain.
A nursing progress note, dated 1/23/25 at 12:15 P.M., indicated the physician's nurse returned the call to obtain more information. Staff reported that the resident was having increased pain and more difficulty ambulating. The physician's nurse indicated she would forward the information to the physician.
A nursing progress note, dated 1/23/25 at 1:47 P.M., indicated a new order was received for an x-ray of the pelvis and the hips.
A nursing progress note, dated 1/23/25 at 4:44 P.M., indicated a mobile x-ray service completed a bilateral hip and pelvis x-ray in the facility.
A nursing progress note, dated 1/23/25 at 10:34 P.M., indicated x-ray results were received. Results indicated Cannot exclude nondisplaced right pubic rami fracture. Consider follow up with a three view pelvis series vs. Computed Tomography (CT) scan (a medical imaging technique used to obtain detailed internal images of the body) for further evaluation.
Therapy discharge paperwork, dated 2/6/25, indicated Resident 7 was discharged from physical therapy because she had reached her highest practical level.
Fall 4
A nursing progress note, dated 3/1/25 at 5:50 P.M., indicated Resident 7 sustained an unwitnessed fall while walking in her room. The resident complained of pain in her right shoulder, right arm, and right hip. Her right leg was noted to appear shorter than her left leg, her right foot was rotated outward, and it was tender to touch. An ambulance was called and the resident was taken to the emergency room.
A fall risk assessment was completed 3/1/25 that indicated the resident was at high risk for falls.
A Hospital Trauma Services note, dated 3/2/25 at 12:51 A.M., indicated the resident was admitted to the hospital with diagnoses of a right humoral surgical neck fracture (shoulder) and a right femur fracture (long bone in the leg).
An IDT note, dated 3/3/25 at 10:09 A.M., indicated Resident 7's 3/1/25 fall was reviewed. The new intervention was Resident sent to the hospital.
Concave mattress was added to the care plan on 3/3/25.
Hospital discharge paperwork, dated 3/5/25 at 2:25 P.M., indicated that the resident was being discharged back to the facility after receiving an open reduction and internal fixation (ORIF) (a surgical procedure used to treat severe fractures or dislocations by realigning the broken bones and stabilizing them with internal hardware, such as screws, plates, or rods) on her right distal femur fracture. The right shoulder fracture did not require surgery and the resident's right arm was placed in a sling for comfort.
A nursing progress note, dated 3/5/25 at 5:15 P.M., indicated the resident returned to the facility from the hospital with new orders.
admission physician orders included, but were not limited to:
tramadol (an opioid pain-relieving medication) tablet - give 50 milligrams (mg) every six hours as needed, dated 3/5/25
Safety Device: Bed pad alarm. Check placement and function every shift, dated 3/5/25
Safety Device: Chair pad alarm. Check placement and function every shift, dated 3/5/25
Concave Pressure Relieving Mattress, dated 3/5/25
Sling in place to right arm, dated 3/5/25
Immobilizer in place to right leg. May remove for skin care and therapy only, dated 3/7/25
A nursing progress note, dated 3/6/25 at 2:17 P.M., indicated the resident returned from the hospital with a wound vacuum device to a right hip incision, a long leg immobilizer to the right leg, and a sling to the right arm. The skin underneath the immobilizer was intact with bruising at the back of the brace where the metal rod was positioned. There was a very large bruise on the right arm and shoulder.
A review of progress notes from 1/23/25 to 3/26/25 lacked documentation to indicate the physician was notified of or reviewed the x-ray results or a follow up scan was completed.
A Significant Change MDS Assessment was completed on 3/11/25. It indicated Resident 7 had severe cognitive impairment, required partial to moderate assistance of staff (staff does less than half of the effort) with eating, was dependent on staff (staff does everything) for rolling left to right, toileting, bathing, sit to stand and toilet transfers were not attempted, and there were no falls since the prior assessment.
On 3/26/25 at 2:35 P.M., Resident 7 was observed lying in bed with a concave mattress with an immobilizer on her right leg. The call light did not have fluorescent tape on it.
During an interview on 3/27/25 at 11:00 A.M., Physical Therapy Assistant (PTA) 9 indicated Resident 7 was up ad lib (as desired) for three years before she broke her pelvis. After she broke her pelvis, she was weight bearing as tolerated with assistance of one staff. She was discharged from therapy on 2/6/25 and was able to ambulate with a walker and assistance of one staff. After her fall on 3/1/25 she became non weight bearing on her right leg and right arm. At that time, she indicated the intervention put in place after the fall on 1/20/25 was to add a concave mattress. She was unsure why it was not added to the care plan until 3/3/25 and was unsure when the resident received the concave mattress. After the resident fell on 3/1/25, new fall interventions were not added to the care plan because the resident became non weight bearing, was not trying to get up, and was not using her walker.
During an interview on 3/27/25 at 1:25 P.M., the Director of Nursing (DON) indicated that after a resident fell, the nurse created a fall event. IDT staff ran a report daily of the new fall events, and new falls were discussed in morning meeting to identify appropriate and new interventions. The new intervention determined went into the care plan at that time. If the intervention was a lab or assessment, the results were followed up on. If the lab or assessment was not the cause of the fall, the resident would not always get a new intervention because it was hard to find things that worked.
On 4/1/25 at 10:47 A.M., the Administrator provided a current Falls - Clinical Protocol policy, revised March 2018, that indicated For an individual who has fallen, the staff and practitioner will begin to try to identify possible causes . The staff and physician will continue to collect and evaluate information until either the cause of the falling is identified, or it is determined that the cause cannot be found or is not correctable . Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address the risks of clinically significant consequences of falling . If underlying causes cannot be readily identified or corrected, staff will try various relevant interventions, based on assessment of the nature or category of falling . If the individual continues to fall, the staff and physician will re-evaluate the situation and reconsider possible reasons for the resident's falling (instead of, or in addition to those that have already been identified) and also reconsider the current interventions. As needed, and after an appropriately thorough review, the physician will document any uncorrectable risk factors and underlying causes.
On 4/1/25 at 10:47 A.M., the Administrator provided a current Goals and Objectives, Care Plan policy, revised April 2009, that indicated When goals and objectives are not achieved, the resident's clinical record will be documented as to why the results were not achieved and what new goals and objectives have been established. Care plans will be modified accordingly . Care plan goals and objectives are derived from information contained in the resident's comprehensive assessment . Goals and objectives are entered on the resident's care plan so that all disciplines have access to such information and are able to report whether or not the desired outcomes are being achieved . Goals and objectives are reviewed and/or revised: when there has been a significant change in the resident's condition .
On 4/1/25 at 10:47 A.M., the Administrator provided a current Physician Services policy, revised April 2013, that indicated The resident's attending physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status, providing consultation or treatment when called by the facility, and overseeing a relevant plan of care for the resident. The attending physician will determine the relevance of any recommended interventions from any discipline . The medical director will identify attending physician qualifications and responsibilities, based on clinical and regulatory requirements .
3.1-45(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified when lab results were not obtaine...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure the physician was notified when lab results were not obtained for a resident with a catheter associated urinary tract infection for 1 of 2 residents reviewed for indwelling catheters and when medication suggestions were made by the pharmacist for 1 of 2 residents reviewed for pharmacy reviews with recommendations. (Resident 27 and Resident D)
Findings include:
1. On 3/26/25 at 10:22 A.M. Resident 27's clinical record was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, malignant neoplasm of bladder.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident 27 was moderately cognitively impaired, required partial to moderate assistance (staff does less than half of the effort) for toileting, and had an indwelling catheter.
Physician orders included, but were not limited to:
May re-anchor catheter if becomes dislodged or occluded as needed, Contact Medical Doctor (MD), dated 3/27/24
Foley catheter: Anchor 16 french, 30cc (cubic centimeters) balloon, provide catheter care every shift, supra pubic catheter(a thin tube inserted into the bladder through a small incision in the lower abdomen), cleanse around insertion site with soap and water, pat dry; Start date 3/7/25
Current care plans included, but were not limited to:
Report signs of complications such as urinary tract infection (UTI) (acute confusion, bladder spasms, pain, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine), dated 3/27/24
A nursing progress note, dated 6/9/24 at 2:32 P.M., indicated a nurse was alerted to Resident 27's room by housekeeping that the resident was covered in blood. Resident was unsure of how it happened and he denied falling. There was no evidence that the resident had fallen. Family later came in to visit resident and were informed. Family expressed concern related to resident's catheter bag being purple. Leg bag examined per nursing and it did have a purple tint, however, urine output was darker yellow and concentrated. Minimal research revealed a possible cause being purple catheter bag syndrome which was usually indicative of a longstanding Foley catheter and chronic UTI. MD notified of all the above.
A nursing progress note, dated 6/10/24 at 2:04 P.M., indicated a new order was received for a urinalysis and culture and sensitivity from a new catheter bag due to urine bag being purple in color.
A nursing progress note, dated 6/10/24 at 11:32 P.M., indicated the current catheter was removed and a new catheter was placed suprapubic using aseptic technique with no urine return.
A nursing progress note, dated 6/11/24 at 10:36 A.M., indicated Resident 27's suprapubic catheter was not in place. No urine return. The nurse adjusted catheter and when it was in place, yellow urine mixed with blood returned. Nurse attempted to replace catheter but was unable to re-anchor catheter. Orders received to send to [hospital] emergency department for catheter replacement.
A nursing progress note, dated 6/11/24 at 11:13 A.M., indicated family arrived and transported Resident 27 to the emergency department. Catheter bag with blood noted.
A nursing progress note, dated 6/12/24 at 4:07 P.M., indicated a urine report was faxed to facility. Nitrite positive, no new orders written with report. Nursing staff called the PAC (post acute care line for physicians) and there was no answer.
The clinical record lacked notification to the physician or medical director of PAC not responding to the facility.
A nursing progress note, dated 6/13/24 at 3:29 P.M., indicated a request was sent to PAC to follow up on resident's urine obtained during emergency room visit which was nitrite positive, no culture report available yet.
A nursing progress note, dated 6/15/2024 at 5:03 P.M., indicated a nurse called PAC related to urine culture results. Unable to obtain results at that time. The MD was notified to try and obtain results. Resident continued to have purple catheter bags despite dark yellow urine output.
A nursing progress note, dated 6/18/24 at 5:24 P.M., indicated Resident 27 complained of not feeling well in his abdomen. Encouraged to eat a good dinner and milkshake.
The clinical record lacked notification to the medical director of PAC not responding to the facility, or notification to the physician about the new symptoms observed.
A nursing progress note, dated 8/1/24 at 11:17 A.M., indicated the catheter was changed due to occlusion.
A nursing progress note, dated 8/1/24 at 6:03 P.M., indicated Resident 27 complained of pain from the catheter site.
The clinical record lacked notification to the physician related to Resident 27's pain from the catheter site.
A nursing progress note, dated 8/29/24 at 11:25 A.M., indicated Resident 27 notified staff he was hurting and pointed to the right groin area. The area was assessed and PAC notified.
A nursing progress note, dated 8/31/24 at 9:55 A.M., indicated Resident's catheter insertion site was red.
The clinical record lacked notification to the physician related to the change in condition of the catheter site. 2. On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder.
The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, required setup assistance for eating, was dependent on staff for toileting, bathing, and transferring, and received an antianxiety medication during the 7-day look back period.
A current care plan, revised 2/21/25, indicated Resident D received antianxiety medication related to an anxiety diagnosis.
A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed.
Current physician orders included, but were not limited to:
buspirone tablet (an antianxiety medication) - 10 milligrams (mg) at bedtime, dated 9/27/24
Discontinued physician orders included, but were not limited to:
buspirone tablet - 10 mg once a day, dated 7/11/23 with a discontinued date of 7/10/24
buspirone tablet - 10 mg at bedtime, dated 7/11/24 with a discontinued date of 9/27/24
A pharmacy recommendation, dated 6/11/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon.
A pharmacy recommendation, dated 7/16/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon.
The clinical record lacked documentation that facility staff attempted to contact the physician or Medical Director to respond to the pharmacy recommendation to decrease Resident D's antianxiety medication.
During an interview on 3/27/25 at 11:05 A.M., Medical Records staff indicated Resident D's physician did not respond to the pharmacy recommendations on 6/11/24 or 7/16/24. At that time, she indicated that if a resident's physician did not respond, the pharmacy requests were sent to the Medical Director to accept or decline. The Medical Director did not accept or decline the pharmacy recommendations on 6/11/24 or 7/16/24.
During an interview on 3/31/25 at 1:34 P.M., the Medical Director indicated that he was not aware that there was a physician who did not review pharmacy recommendations. At that time, he indicated he was aware that staff had difficulty reaching PAC staff. He had been told by facility administration that they had reached out to PAC administration many times with no meaningful results. Consequently, he was the default contact for nursing and clinical staff when PAC could not be reached, and could be contacted directly by his direct cell phone number or text message.
On 4/1/25 at 10:47 A.M., the Administrator provided a Consultant Pharmacist Reports policy, revised December 2022, that indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Comments and recommendations concerning medication therapy are communicated in a timely fashion . Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director .
On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Acute Condition Change Clinical Protocol, dated December 2015, that indicated Nursing staff will contact the Physician based on the urgency of the situation. The attending Physician will respond in a timely manner to notification of problems or changes in condition and status.
3.1-5(a)(3)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure care plans related to high risk medications were developed for 3 of 6 residents reviewed for medication use. (Resident 3, Resident D...
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Based on interview and record review, the facility failed to ensure care plans related to high risk medications were developed for 3 of 6 residents reviewed for medication use. (Resident 3, Resident D, Resident 14)
Findings include:
1. On 3/25/25 at 2:26 P.M., Resident 3's clinical record was reviewed. Diagnoses included, but were not limited to, Fournier Gangrene, malignant neoplasm of prostate, and chronic pain syndrome.
The most current Significant Change Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated Resident 3 was cognitively intact, was dependent on transferring, toileting, bathing, and dressing, and received an antibiotic and an opioid during the 7-day look back period. Resident 3 had a pain assessment during this time.
Current physician orders included, but were not limited to:
daptomycin (an antibiotic) 600 milligrams (mg) daily Intravenous (IV) for 28 days per ID (infectious disease), infuse over 60 minutes dated, 3/16/25 to 4/13/25.
oxycodone (pain medication) 5 mg administer 1 tablet orally every 4 hours as needed for pain, dated 1/16/25.
The current care plan lacked care plans for pain and antibiotic monitoring.2. On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, congestive heart failure.
The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, required setup assistance for eating, was dependent on staff for toileting, bathing, and transferring, and received an anticoagulant medication during the 7-day look back period.
Current physician orders included, but were not limited to:
Eliquis (an anticoagulant medication) tablet - 5 milligrams (mg) twice a day, dated 11/7/24
A current activity intolerance care plan, initiated 9/30/24, indicated Resident D received Eliquis to prevent embolism.
A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed.
The clinical record lacked a care plan to identify interventions to monitor for the risks of side effects from the anticoagulant medication (such as risk for bleeding).
During an interview on 4/1/25 at 11:05 A.M., the Administrator indicated there was not a care plan for Resident D that addressed the risk of bleeding.
3. On 3/26/25 at 8:41 A.M., Resident 14's clinical record was reviewed. Diagnoses included, but were not limited to, Alzheimer's disease, generalized anxiety disorder, depression, and spinal stenosis.
The most current Annual Minimum Data Set (MDS) Assessment, dated 1/31/25, indicated Resident 14 had moderate cognitive impairment, required setup assistance for eating, partial to moderate assistance of staff (staff does less than half of the effort) for toileting and bathing, and received an antipsychotic medication, antianxiety medication, antidepressant, anticonvulsant, and an opioid during the 7-day look back period.
Current physician orders included, but were not limited to:
Ativan Benadryl Haldol gel (an antipsychotic medication) 2 milligrams (mg)- 25mg-2mg - apply 1 milliliter (ml) topically to the inner wrist every four hours as needed for agitation, dated 11/18/24
citalopram tablet (an antidepressant medication) - 10 mg once a day for depression, dated 10/6/23
gabapentin capsule (an anticonvulsant medication) - 300 mg twice a day for pain, dated 10/4/23
hydrocodone-acetaminophen tablet (an opioid pain-relieving medication) 7.5-325 mg - give one tablet every four hours as needed for pain, dated 10/4/23
hydrocodone-acetaminophen tablet 7.5-325 mg - give one tablet twice a day for pain, dated 11/12/24
lorazepam concentrate (an antianxiety medication) 2 mg/mL - give 0.25 ml sublingually every four hours as needed for anxiety and restlessness, dated 1/26/24
Roxanol (an opioid pain-relieving medication) liquid 20 mg/ml - give 0.25 ml sublingually every four hours as needed for pain and shortness of breath, dated 1/26/24
A care conference was most recently completed on 1/29/25. Care plan conference notes indicated that all current care plans were reviewed.
The clinical record lacked a care plan related to antipsychotic medications, antianxiety medications, antidepressants, anticonvulsants, and opioids, the disease processes that necessitated the medications, and interventions required to monitor side effects of the medications.
During an interview on 3/27/25 at 1:25 P.M., the Director of Nursing (DON) indicated that all high risk medications should have a corresponding care plan. Anticoagulants should have a risk for bleeding care plan.
During an interview on 3/27/25 at 1:43 P.M., the MDS Coordinator indicated that all high risk medications should have a corresponding care plan. Care plans were created upon admission or with a change of orders. Reports showing newly prescribed medications were run daily and care plans were updated as needed.
During an interview on 4/1/25 at 10:35 A.M., the Administrator indicated there were no care plans for Resident 14 that addressed antipsychotic medications, antianxiety medications, antidepressants, anticonvulsants, and opioids, the disease processes that necessitated the medications, or interventions required to monitor side effects of the medications.
On 4/1/25 at 10:47 A.M., the Administrator provided a current Comprehensive Assessment and the Care Delivery Process policy, revised December 2016, that indicated Comprehensive assessments, care planning and the care delivery process involve collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions . Define issues, including problems, risk factors, and other concerns . Identify the current interventions and treatments; and Link these to problems and diagnoses they are supposed to be treating . a person-centered plan of care includes: selecting and implementing interventions, based on the results of the above.
3.1-35(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure a resident's plan of care was implemented for ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, and record review, the facility failed to ensure a resident's plan of care was implemented for 1 of 1 residents reviewed for nutrition. (Resident 29)
Finding includes:
On 3/26/25 at 10:07 A.M., Resident 29's clinical record was reviewed. Resident 29 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease.
The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 3/6/25, indicated Resident 29 was cognitively intact, required setup assistance (staff setup meals before dining) for eating, and had an unplanned weight loss of 5% or more in the last month.
The current care plan included, but was not limited to:
Recent significant weight loss in part related to increase in diuretic but also due to inadequate calorie intakes; Start date 2/17/25
Ice cream daily for added calories due to weight loss; Start date 3/6/25
During an observation on 3/26/25 at 11:45 A.M., Resident 29 was observed in the dining room and did not receive an ice cream with lunch.
During an observation on 3/28/25 at 12:54 P.M., Resident 29 was observed sitting in her room eating lunch. Resident 29 indicated she was supposed to receive ice cream but did not receive it. There was not an ice cream on Resident 29's tray. The lunch ticket that indicated what Resident 29 should have received on the tray indicated vanilla ice cream was to be included.
On 3/27/25 at 1:04 P.M., the Dietary Manager provided a list of residents who received supplemental foods. Resident 29 was not listed to receive ice cream supplement as care planned.
On 4/1/25 at 10:50 A.M., the Administrator provided an undated policy titled Goals and Objectives, Care Plans that indicated Care plan goals and objectives are defined as the desired outcome for a specific resident problem. Goals and objectives are reviewed and revised when there has been a significant change in the resident's condition; when the desired outcome has not been achieved; when the resident has been readmitted to the facility; at least quarterly.
3.1-35(g)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was treated for a urinary tract infection in a ti...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident was treated for a urinary tract infection in a timely manner for 1 of 2 residents reviewed for indwelling catheter care. (Resident 27)
Finding includes:
On 3/26/25 at 10:22 A.M. Resident 27's clinical record was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, malignant neoplasm of bladder.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident 27 was moderately cognitively impaired, required partial to moderate assistance of staff (staff does less than half of the effort) for toileting, and had an indwelling catheter.
Physician orders included, but were not limited to:
May re-anchor catheter if becomes dislodged or occluded as needed, Contact MD (medical doctor); Start date 3/27/24
Foley catheter: Anchor 16 french, 30cc (cubic centimeters) balloon, provide catheter care every shift, supra pubic catheter(a thin tube inserted into the bladder through a small incision in the lower abdomen), cleanse around insertion site with soap and water, pat dry; Start date 3/7/25
Current care plans included, but were not limited to:
Resident requires a suprapubic catheter related to obstructive uropathy; Start date 3/27/24
Report signs of complications such as urinary tract infection (UTI) (acute confusion, bladder spasms, pain, low back/flank pain, malaise, nausea/vomiting, chills, fever, foul odor, concentrated urine, blood in urine); Start date 3/27/24
Resident 27's clinical record indicated the following urinary tract infection occurrences since June 2024:
UTI 1:
A nursing progress note, dated 6/9/24 at 2:32 P.M., indicated a nurse was alerted to Resident 27's room by housekeeping that resident was covered in blood. Resident unsure of how it happened. He denied falling and there was no evidence that resident had fallen. Family later came in to visit resident and were informed. Family expressed concern related to resident's catheter bag being purple. Leg bag examined per nursing and it did have a purple tint, however, urine output was darker yellow and concentrated. Minimal research revealed a possible cause being purple catheter bag syndrome which was usually indicative of a longstanding Foley catheter and chronic UTI. MD notified of all the above.
A nursing progress note, dated 6/10/24 at 2:04 P.M., indicated a new order was received for a urinalysis and culture and sensitivity from a new catheter bag due to urine bag being purple in color.
A nursing progress note, dated 6/10/24 at 11:32 P.M., indicated current catheter removed and new catheter placed suprapubic using aseptic technique with no urine return.
A nursing progress note, dated 6/11/24 at 10:36 A.M., indicated Resident 27's suprapubic catheter was not in place. No urine return. The nurse adjusted catheter and when it was in place, yellow urine mixed with blood returned. Nurse attempted to replace catheter but was unable to re-anchor catheter. Orders received to send to [hospital] emergency department for catheter replacement.
A nursing progress note, dated 6/11/24 at 11:13 A.M., indicated family arrived and transported Resident 27 to the emergency department, catheter bag with blood noted.
A nursing progress note, dated 6/12/24 at 4:07 P.M., indicated a urine report was faxed to facility. Nitrite positive, no new orders written with report. A facility nurse called the PAC (post acute care line for physicians) and there was no answer.
A nursing progress note, dated 6/13/24 at 3:29 P.M., indicated request sent to PAC to follow up on resident's urine obtained during emergency room visit which was nitrite positive, no culture report available yet.
A nursing progress, note dated 6/15/2024 at 5:03 P.M., indicated nurse called PAC related to urine culture results. Unable to obtain results at that time. MD notified to try and obtain results. Resident continued to have purple catheter bags despite dark yellow urine output.
A nursing progress note, dated 6/18/24 at 5:24 P.M., indicated Resident 27 complained of not feeling well in his abdomen. Encouraged to eat a good dinner and milkshake.
The clinical record lacked a direct call to the hospital laboratory to obtain culture results.
A nursing progress note, dated 6/19/24 at 10:25 A.M., indicated urine culture was >100,000 E-Coli and faxed to physician triage for review. Resident was to receive an injection that day.
The electronic medication administration record (EMAR) indicated Resident 27 started cephalexin 500mg (milligrams) twice a day for seven days on 6/20/24.
A hospital culture report indicated the urine collected in the emergency department on 6/11/24 had a final culture and susceptibility result available on 6/13/24 at 7:57 A.M.
UTI 2:
A nursing progress note, dated 8/1/24 at 11:17 A.M., indicated catheter was changed due to occlusion.
A nursing progress note, dated 8/1/24 at 6:03 P.M., indicated Resident 27 had complaints of pain from the catheter site.
The clinical record lacked any observation or progress notes related to catheter, pain, or UTI monitoring from 8/2/24 to 8/19/24.
A nursing progress note, dated 8/20/24 at 2:56 P.M., indicated the nurse practitioner (NP) was notified that Resident 27 had a purple urine bag again. The nurse indicated last time that happened, the resident had a UTI. No new orders at that time.
A nursing progress note, dated 8/22/24 at 1:56 P.M., indicated the NP was in the facility and gave orders for urinalysis and culture and sensitivity tests, and to change catheter to obtain urine.
A nursing progress note, dated 8/22/24 at 2:31 P.M., indicated the catheter was changed but unable to obtain enough urine at that time for urinalysis.
A late entry nursing progress noted, dated 8/22/24 at 3:10 P.M., indicated urine obtained.
A urine culture lab report, dated 8/22/24 at 3:35 P.M., indicated the method of urine collection was clean catch and indicated a contaminated specimen.
A nursing progress note, dated 8/23/24 at 3:11 P.M., indicated urine results faxed to PAC.
A nursing progress note, dated 8/24/24 at 5:05 P.M., indicated urine culture results received indicating contaminated sample. A voicemail was left for PAC.
A nursing progress note, dated 8/24/24 at 10:24 P.M., indicated the PAC gave new orders to recollect urine specimen. Urine specimen collected with purulent urine return.
A nursing progress note, dated 8/26/24 at 1:18 P.M., indicated an order for cephalexin was received on 8/23/24, but was not initiated. The resident was noted to be more confused and lethargic. Order received to start cephalexin 250mg (milligrams) three times a day for 10 days for urinary tract infection.
A nursing progress note, dated 8/27/24 at 1:24 P.M., indicated lab stated the second urine specimen was also contaminated.
A nursing progress note, dated 8/27/24 at 1:30 P.M., indicated resident always had his hands on his catheter tubing.
The clinical record lacked a care plan related to frequent urinary tract infection and prevention of urinary tract infection including promoting hand hygiene for Resident 27.
A nursing progress note, dated 8/29/24 at 11:25 A.M., indicated Resident 27 notified staff he was hurting and pointed to the right groin area. The area was assessed and PAC notified.
A nursing progress note, dated 8/31/24 at 9:55 A.M., indicated the resident's catheter insertion site was red.
UTI 3:
A nursing progress note, dated 9/8/24 at 6:01 P.M., indicated Resident 27's family expressed concern related to the catheter insertion site. Site was red with drainage and swelling. The resident complained of severe pain and tenderness to touch. PAC notified and orders given for a urinalysis and culture and sensitivity tests.
A nursing progress note, dated 9/9/24 at 6:33 A.M., indicated catheter changed and not enough urine to collect for specimen.
A nursing progress note, dated 9/9/24 at 10:31 P.M., urine was obtained and notified lab to pick up.
A nursing progress note, dated 9/12/24 at 3:04 P.M., indicated a new order was received for ciprofloxacin 250mg two times a day for seven days for UTI.
During an interview on 3/28/25 at 8:22 A.M., the Director of Nursing (DON) indicated Resident 27 had a history of chronic urinary tract infections, culture reports often resulted as contaminated specimens, and resident was not receiving any type of prophylactic measures.
During an interview on 4/1/25 at 11:31 A.M., a policy related to urinary tract infection protocol was requested. The Administrator indicated the facility did not have a written policy related to urinary tract infections and the facility's policy was to notify the physician and follow physician orders.
On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Acute Condition Change Clinical Protocol, dated December 2015, that indicated Before contacting a physician about someone with an acute change of condition, the nursing staff will make detailed observations and collect pertinent information to report to the physician. The nursing staff and physician will discuss possible causes of the condition change based on factors including resident history, current symptoms, medication regimen, and existing test results. The physician will help identify and authorize appropriate treatments.
On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Prevention and Screening Clinical Protocol, dated December 2012, that indicated Where medically indicated, the attending physician will identify primary, secondary, and tertiary preventative and screening measures. Primary prevention is aimed at reducing the incidence of a disease or condition by preventing its onset. Secondary prevention targets early identification of a condition to limit its course and complications. Tertiary prevention focuses on prevention of additional complications that is not preventable or fully correctable.
3.1-41(a)(2)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0712
(Tag F0712)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was assessed by a physician since admission for 1...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident was assessed by a physician since admission for 1 of 2 residents admitted in the last 90 days reviewed for accidents. (Resident 22)
Finding includes:
On 3/26/25 at 1:55 P.M., Resident 22's clinical record was reviewed. Resident 22 was admitted on [DATE]. Diagnoses included, but were not limited to, dementia.
The most recent admission Minimum Data Set (MDS) Assessment, dated 1/26/25, indicated Resident 22 was severely cognitively impaired and required partial assistance (staff does less than half of the effort) for toileting and bathing.
The clinical record, including assessments, progress notes, and documents, lacked assessment of Resident 22 by a physician in the facility since admission.
During an interview on 3/28/25 at 8:22 A.M., the Director of Nursing (DON) indicated she could not find a physician assessment for Resident 22.
On 4/1/25 at 10:47 A.M., the Administrator provided an undated policy titled Physician Services that indicated The physician will perform pertinent, timely medical assessments; visit the resident at appropriate intervals . Physician visits, frequency of visits, emergency care of residents, etc., are provided in accordance with current OBRA regulations and facility policy.
3.1-22(d)(1)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure pharmacy recommendations were acted upon for 1 of 5 residents reviewed for unnecessary medications. (Resident D)
Finding includes:
O...
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Based on interview and record review, the facility failed to ensure pharmacy recommendations were acted upon for 1 of 5 residents reviewed for unnecessary medications. (Resident D)
Finding includes:
On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, anxiety disorder.
The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, required setup assistance for eating, was dependent on staff for toileting, bathing, and transferring, and received an antianxiety medication during the 7-day look back period.
A current care plan, revised 2/21/25, indicated Resident D received antianxiety medication related to an anxiety diagnosis.
A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed.
Current physician orders included, but were not limited to:
buspirone tablet (an antianxiety medication) - 10 milligrams (mg) at bedtime, dated 9/27/24
Discontinued physician orders included, but were not limited to:
buspirone tablet - 10 mg once a day, dated 7/11/23 with a discontinued date of 7/10/24
buspirone tablet - 10 mg at bedtime, dated 7/11/24 with a discontinued date of 9/27/24
A pharmacy recommendation, dated 6/11/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon.
A pharmacy recommendation, dated 7/16/24, requested a decrease of the buspirone from 10 mg once a day to 5 mg once a day. The recommendation lacked documentation it was acted upon.
During an interview on 3/27/25 at 11:05 A.M., Medical Records staff indicated the physician Resident D used did not come to the facility and all pharmacy reviews had to be faxed out. The resident's physician did not respond to the pharmacy recommendations on 6/11/24 or 7/16/24. At that time, she indicated that if an outside physician did not respond, the pharmacy requests were sent to the Medical Director to accept or decline. The Medical Director did not accept or decline the pharmacy recommendations on 6/11/24 or 7/16/24.
On 4/1/25 at 10:47 A.M., the Administrator provided a Consultant Pharmacist Reports policy, revised December 2022, that indicated Recommendations are acted upon and documented by the facility staff and/or the prescriber. Prescriber accepts and acts upon suggestion or rejects and provides an explanation for disagreeing . Comments and recommendations concerning medication therapy are communicated in a timely fashion . Recommendations are acted upon and documented by the facility staff and/or the prescriber. If the prescriber does not respond to recommendation directed to him/her within 30 days, the Director of Nursing and/or the consultant pharmacist may contact the Medical Director .
3.1-25(i)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 2 of 3 ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure residents were free from unnecessary medications for 2 of 3 residents reviewed for as needed anti-anxiety medication use. Residents' as needed anti-anxiety medication was ordered for greater than 14 days. (Resident 29 and Resident 27)
Findings include:
1. On 3/26/25 at 10:07 A.M., Resident 29's clinical record was reviewed. Resident 29 was admitted on [DATE]. Diagnoses included, but were not limited to, chronic kidney disease.
The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 3/6/25, indicated Resident 29 was cognitively intact, and was dependent (staff does all of the work) for transfers.
Current physician orders included, but were not limited to:
alprazolam (anti-anxiety medication) 0.25 milligrams (mg), one tablet by mouth three times daily as needed for pain; Start date 2/27/25 (no end date)
The clinical record lacked a physician reassessment of the medication, or indication of contraindication for discontinuation of the medication, beyond 14 days.
2. On 3/26/25 at 10:22 A.M., Resident 27's clinical record review was reviewed. Resident 27 was admitted on [DATE]. Diagnoses included, but were not limited to, atrial fibrillation.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 12/27/24, indicated Resident 27 was moderately cognitively impaired and required partial (staff does less than half of the work) assistance for toileting.
Current physician orders included, but were not limited to:
clonazepam (anti-anxiety medication) 1 milligram (mg) one tablet by mouth three times a day as needed for anxiety; Start date 3/14/25 (no end date)
The clinical record lacked a physician reassessment of the medication, or indication of contraindication for discontinuation of the medication, beyond 14 days.
During an interview on 3/28/25 at 8:22 A.M., the Director of Nursing (DON) indicated as needed anti-anxiety medication should only be ordered for 14 days and should be reviewed during monthly interdisciplinary team (IDT) meetings.
On 4/1/25 the clinical record continued with the current order of clonazepam without stop date, the last recorded dose administered was 3/22/25.
On 4/1/25 at 11:29 A.M., the Administrator provided a policy titled Medication Monitoring and Management, dated December 2022, that indicated As needed (PRN) orders for antipsychotic drugs are limited to 14 days without exception. If the attending physician or prescribing practitioner wishes to continue a PRN antipsychotic drug beyond 14 days, the attending physician or prescribing practitioner must first perform an in-person evaluation of the resident and then write a new order.
3.1-48(a)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a catheter change was accurately documented for 1 of 2 resid...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a catheter change was accurately documented for 1 of 2 residents reviewed for catheter associated urinary tract infections. (Resident 2)
Finding includes:
On 3/26/25 at 9:08 A.M., Resident 2's clinical record was reviewed. Resident 2 was admitted on [DATE]. Diagnoses included, but were not limited to, urine retention.
The most recent Quarterly Minimum Data Set (MDS) Assessment, dated 2/26/25, indicated Resident 2 was cognitively intact, required maximal assistance (staff does more than half of the work) for toileting, bathing, and chair to bed transfers, and had an indwelling catheter.
Physician orders included, but were not limited to:
Change Foley catheter monthly: 18 French with 30 mL (milliliter) balloon on the 27th of the month; 2/1/25-3/2/25.
Change Foley catheter monthly: 18 French with 30 mL (milliliter) balloon on the 2nd of the month; Start date 3/2/25.
On 3/28/25 at 1:15 P.M., the Director of Nursing (DON) provided a document titled Treatment Administration History that indicated Qualified Medication Aide (QMA) 7 had changed Resident 2's catheter on 2/27/25.
During an interview on 3/28/25 at 1:43 P.M., QMA 7 stated she did not change Resident 2's catheter on 2/27/25, and believed a nurse charted the catheter change under her username.
A nursing progress note, dated 3/2/25 at 12:38 P.M., indicated Resident 2 stated that his catheter was due to be changed on 2/27, however, the task was not completed. Registered Nurse (RN) 16 then used sterile technique to change the catheter.
On 4/1/25 at 11:29 A.M., the Administrator provided a document titled Charting and Documentation, dated July 2017, that indicated Documentation in the medical record will be objective, complete, and accurate.
3.1-50(a)(2)
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, record review, and interview, the facility failed to implement infection control practices to ensure the proper use of Enhanced Barrier Protocol (EBP) and Personal Protective Equ...
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Based on observation, record review, and interview, the facility failed to implement infection control practices to ensure the proper use of Enhanced Barrier Protocol (EBP) and Personal Protective Equipment (PPE) for 2 of 2 random observations of wound care. (Resident T and Resident D)
Findings include:
1. On 3/26/25 at 11:44 A.M., Resident T's clinical record was reviewed. Diagnoses includes, but were not limited to, Parkinson's Disease.
The most current Quarterly Minimum Data Set (MDS) Assessment, dated 1/13/25, indicated that the resident was severely cognitively impaired and was dependent on staff for eating, transferring, hygiene, and toileting. During that assessment, the resident was considered a risk for pressure wounds and had a stage 4 pressure wound present.
Current physician orders included, but were not limited to:
Skin preparation to bilateral heels every shift for protection dated 9/6/22.
Wound: Coccyx Stage 4, clean area with wound cleanser and pat dry with 4 x 4 gauze. Cut a strip of calcium alginate (wound dressing) into a thin long strip and pack loosely into the 11 o'clock tunnel and spread to cover wound bed and pack wound also, skin prep peri wound and cover with 4 x 4 Foam border dressing PRN (As Needed) dislodgment or soiling, dated 3/7/25.
Care plan conference notes indicated the care plan was reviewed on 1/13/25.
The current care plan for infection indicated that the resident had a need for EBP related to wound care. Interventions included, but were not limited to:
Enhanced Barrier Precautions Signs will be hung on the appropriate rooms, dated 4/10/24
PPE will be placed outside of rooms for staff use, dated 4/10/24.
Staff will use appropriate PPE during resident care, dated 2/21/25.
On 3/27/25 at 11:02 A.M., Registered Nurse (RN) 16 and RN 12 were observed performing wound care without a gown as noted on the Enhanced Barrier Protocol sign posted outside the resident's door.
During an interview on 3/27/25 at 11:15 A.M., RN 12 indicated that she forgot to put on the gown prior to wound care.2. On 3/26/25 at 9:20 A.M., Resident D's clinical record was reviewed. Diagnoses included, but were not limited to, unspecified ulcer on right buttock.
The most current Minimum Data Set (MDS) Assessment, dated 1/12/25, indicated Resident D was cognitively intact, was dependent on staff (staff does all of the effort) for toileting, bathing, and transferring, and had no pressure injuries.
Current physician orders included, but were not limited to:
Cleanse area to buttocks with wound cleanser and apply thin layer of hydrophilic wound paste (Coloplast) and cover with a large sacral foam border dressing daily and as needed when soiled, once a day every three days, dated 2/14/25
A current pressure ulcer care plan, initiated 12/12/24, indicated Resident D had a pressure ulcer on her buttock.
A care conference was most recently completed on 1/10/25. Care plan conference notes indicated that all current care plans were reviewed.
A wound management report, dated 2/4/25 at 4:14 P.M., indicated an unspecified ulcer that was not present on admission was identified on Resident D's right buttock. The ulcer measured 1 centimeter (cm) in length and 0.8 cm in width.
The most current wound management report, dated 3/22/25 at 9:00 A.M., indicated the ulcer on Resident D's right buttock measured 0.7 cm in length by 0.3 cm in width.
The clinical record lacked an order or care plan that indicated Resident D was on Enhanced Barrier Precautions (EBP) due to the wound.
On 3/27/25 at 10:31 A.M., Registered Nurse (RN) 16 and RN 5 were observed performing wound care on Resident D's ulcer on her right buttock. RN 16 and RN 5 were not wearing gowns during wound care. There was not an EBP sign observed in or near the resident's room.
On 3/28/25 at 8:31 A.M., the Director of Nursing (DON) provided a list of all residents on EBP, and Resident T was listed. Resident D's name was not on the list.
During an interview on 3/28/25 at 8:40 A.M., the DON indicated EBP was used for residents who had an indwelling catheter, wound, or open surgical incision. At that time, she indicated Resident D should be on EBP and staff should be wearing a gown and gloves while providing wound care to the resident.
During an interview on 3/28/25 at 10:36 A.M., the Infection Preventionist (IP) indicated that staff should use EBP with direct patient care if the resident had a wound or an indwelling catheter.
On 4/1/25 at 11:00 A.M., the Administrator provided a current undated Enhanced Barrier Precautions for Skilled Nursing Facilities policy that indicated .nursing staff ensures that the resident and staff are aware of need to use EBP and the necessary supplies are provided .EBP signage outside resident's room and provide readily available personal protective equipment (PPE), including gowns and gloves .
This citation relates to complaint IN00451230.
3.1-18(b)(2)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected multiple residents
Based on observation, interview, and record review, the facility failed to safely store and label food under professional standards related to food items not labeled or stored properly for 1 of 1 diet...
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Based on observation, interview, and record review, the facility failed to safely store and label food under professional standards related to food items not labeled or stored properly for 1 of 1 dietary areas observed.
Findings include:
During a kitchen walk through on 3/25/25 at 8:44 A.M., the following was observed:
Walk in refrigerator:
Bag of mixed broccoli, carrots, and celery open to air, no date
Chunk of ham, dated 2/15
Carton of molded strawberries
A container of bran mixture labeled prepped 3/8
A container of banana cake labeled prepped 3/16
Dry storage room:
Rice crispy treats directly on the floor
Box of sandwich crackers directly on the floor
Walk in freezer:
Bag of pepperonis doubled bagged; inside bag dated 12/21/23 and outside bag dated 6/29/24
On 4/1/25 at 10:44 A.M., the Administrator provided a policy titled Food Storage, dated 2017, that indicated Food will be stored a minimum of six inches above the floor . leftover food will be stored in covered containers or wrapped carefully and securely. Each item will be labeled and dated before being refrigerated. Leftover foods is used within seven days or discarded per federal food code.
3.1-21(i)(2)
3.1-21(i)(3)
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0801
(Tag F0801)
Could have caused harm · This affected most or all residents
Based on record review and interview, the facility failed to ensure the Dietary Manager met required qualifications for 1 of 1 dietary manager qualifications reviewed.
Finding includes:
During an in...
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Based on record review and interview, the facility failed to ensure the Dietary Manager met required qualifications for 1 of 1 dietary manager qualifications reviewed.
Finding includes:
During an interview on 3/25/25 at 9:01 A.M., the Dietary Manager indicated she did not have a dietary manager certification and had not enrolled in the program.
During an interview on 3/26/25 at 11:27 A.M., the Dietitian indicated she was aware the Dietary Manager was not certified but had not increased her visits; she was currently in the facility once a week.
On 3/28/25 at 1:16 P.M., the Dietary Manager's employee file was reviewed. The Dietary Manager job description, signed on 3/11/25, indicated qualifications to accepting the role of dietary manager required completion of state-approved food service management course, or presently enrolled in a program.
During an interview on 4/1/25 at 10:59 A.M., the Administrator indicated the facility did not have a written policy related to qualifications of the dietary manager, and the policy was to follow state regulations.
3.1-20(e)
Feb 2024
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0554
(Tag F0554)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medicat...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents that were self administering medications were assessed for capability to self administer medications for 1 of 1 residents observed with medications in their room. (Resident 246)
Finding includes:
On 1/29/24 at 10:36 A.M., a tube of hydrocortisone 1% cream was observed on Resident 246's bedside table. Resident 246 indicated that she received it from the hospital upon discharge and kept it in her room to use on her face as needed for itchiness.
On 1/30/24 at 9:05 A.M., a tube of hydrocortisone 1% cream was observed on Resident 246's bedside table.
On 1/31/24 at 8:51 A.M., a tube of hydrocortisone 1% cream was observed on Resident 246's bedside table.
On 1/30/24 at 8:23 A.M., Resident 246's clinical record was reviewed. Diagnosis included, but was not limited to, local infection of the skin and subcutaneous tissue.
Resident 246 was admitted to the facility on [DATE]. The admission MDS (Minimum Data Set) Assessment was still in progress.
A BIMS (Brief Interview for Mental Status) assessment, dated 1/29/24, indicated Resident 246 was cognitively intact.
A Functional Abilities Assessment, dated 1/30/24, indicated the resident required setup assistance for eating, supervision for transfers, and partial to moderate assistance for bed mobility and toileting.
Current physician orders lacked an order for hydrocortisone 1% cream and an order to self administer medications.
The clinical record lacked a self administration of medication evaluation.
Hospital discharge papers, dated 1/11/24, indicated the resident was discharged with hydrocortisone 1% cream - 1 application topically TID (three times a day).
On 1/30/24 at 9:30 A.M., RN (Registered Nurse) 3 indicated that no resident on the North Unit self administered medications.
On 1/30/24 at 2:16 P.M., the Administrator indicated that in order to keep medications at bedside, a resident needed a self administration of medication evaluation and a physician order.
On 1/31/24 at 11:27 A.M., the DON (Director of Nursing) indicated that Resident 246 did not have a completed self administration of medication evaluation. At that time, she indicated that she could not find an order for hydrocortisone 1% cream and wasn't aware the resident used it.
On 1/31/24 at 1:47 P.M., an Administering Medications policy, revised April 2010, indicated residents may self-administer their own medications only if the Attending Physician and Interdisciplinary Care Team, has determined that they have the decision-making capacity to do so safely.
3.1-11(a)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents received necessary respiratory care a...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview the facility failed to ensure residents received necessary respiratory care and services in accordance with professional standards of practice for 2 of 2 residents reviewed for respiratory care. The facility failed to date tubing and label humidification bottles, place signs indicating oxygen use, and lacked a care plan for oxygen for a resident on oxygen. (Resident 246 and Resident 11)
Findings include:
1. On 1/29/24 at 10:28 A.M., an oxygen concentrator was observed in Resident 246's room. The humidification bottle and tubing was not labeled or dated. There was no oxygen in use sign on the resident's door. At that time, Resident 246 indicated that she occasionally needed oxygen to help keep her oxygen saturation up and that she had used oxygen last night.
On 1/30/24 at 9:05 A.M., an oxygen concentrator was observed in Resident 246's room. The humidification bottle and tubing was not labeled or dated. There was no oxygen in use sign on the resident's door.
On 1/31/24 at 8:51 A.M., an oxygen concentrator was observed in Resident 246's room. The humidification bottle and tubing was not labeled or dated. There was no oxygen in use sign on the resident's door. At that time, Resident 246 indicated she used oxygen last night and the concentrator was just turned off.
On 1/30/24 at 8:23 A.M., Resident 246's clinical record was reviewed. Diagnoses included, but were not limited to, essential hypertension, paroxysmal atrial fibrillation, chronic respiratory failure with hypoxia - PRN (as needed) oxygen use, and obstructive sleep apnea.
Resident 246 was admitted to the facility on [DATE]. The admission MDS (Minimum Data Set) Assessment was still in progress.
A BIMS (Brief Interview for Mental Status) assessment, dated 1/29/24, indicated Resident 246 was cognitively intact.
A Functional Abilities Assessment, dated 1/30/24, indicated the resident required setup assistance for eating, supervision for transfers, and partial to moderate assistance for bed mobility and toileting.
Current physician orders included, but was not limited to:
Supplemental O2 (oxygen) 1-2LNC (liters nasal cannula) prn to maintain O2 sat (saturation) >92%, for respiratory failure, dated 1/27/24.
Check O2 sat every shift (prn supplemental if <92%) for COPD (chronic obstructive pulmonary disease), dated 1/27/24.
Hospital discharge paperwork, dated 1/27/24, indicated the resident needed to be on 1L continuous oxygen via nasal cannula.
A current baseline care plan, dated 1/27/24, lacked indication of oxygen use.
A vitals report indicated the resident received 2L oxygen on 1/27/24 at 11:16 P.M. and 1L oxygen on 1/29/24 at 6:55 A.M.
The January 2024 TAR (treatment administration record) indicated the resident did not receive oxygen.
On 1/31/24 at 8:56 A.M., the DON (Director of Nursing) indicated that nursing staff was responsible for changing out and dating humidification bottles and tubing. She indicated they performed the task when they saw the water in the bottle was getting low.
On 1/31/24 at 11:27 A.M., the DON indicated oxygen should be included on the baseline care plan under the cardiac or respiratory problems. She indicated if the resident came into the facility with oxygen, it should be addressed on the baseline care plan somewhere.
On 1/31/24 at 1:49 P.M., an Oxygen Administration policy, revised October 2010, indicated place an Oxygen in Use sign on the outside of the room entrance door.
On 2/01/24 at 8:37 A.M., a Care Plan - Baseline policy, revised December 2016, indicated The Interdisciplinary Team will .implement a baseline care plan to meet the resident's immediate care needs including but not limited to initial goals based on admission orders, physician orders .2. On 1/29/24 at 11:02 A.M., Resident 11 was observed lying in bed with oxygen tubing and a concentrator on the side of the bed without a date or initials.
On 1/31/24 at 9:41 A.M., Resident 11 was observed sitting in a wheelchair wearing oxygen at 2 liters (L) via nasal cannula. The tubing lacked a label with initials and date.
On 1/29/24 at 11:02 A.M., Resident 11's clinical record was reviewed. Diagnoses included, but were not limited to, cardiomegaly, cardiomyopathy, and sleep apnea.
The current quarterly MDS (Minimum Data Set) Assessment, dated 11/2/23, indicated Resident 11 was severely cognitively impaired. Resident 11 was dependent for transfer, eating, and toileting.
Current physician orders included, but were not limited to:
Supplemental oxygen at 2L/Minute for comfort measures as needed, dated 5/26/23.
The clinical record lacked an order to change the tubing.
During an interview on 2/2/24 at 10:34 A.M., RN (Registered Nurse) 3 indicated the oxygen tubing was changed out weekly on the night shift. At that time, she indicated there should be an order to change the tubing weekly and placed on the MAR (Medication Administration Record).
A current Departmental (Respiratory Therapy) - Prevention of Infection policy, dated November 2011, was provided on 2/2/24 at 12:20 P.M. by the Administrator. The policy indicated . the purpose of this procedure is to guide prevention of infection associated with the respiratory therapy tasks and equipment among staff and residents .infection control consideration related to oxygen administration include .change the cannula and tubing every 7 days or as needed.
3.1-47(a)(6)
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
2. On 1/30/24 at 1:10 P.M., Registered Nurse (RN) 5 and Certified Nurse Aide (CNA) 10 was observed performing a dressing change on Resident 16's stage 4 coccyx pressure ulcer. Upon entering the room a...
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2. On 1/30/24 at 1:10 P.M., Registered Nurse (RN) 5 and Certified Nurse Aide (CNA) 10 was observed performing a dressing change on Resident 16's stage 4 coccyx pressure ulcer. Upon entering the room and assisting the resident, RN 5 and CNA 10 put on gloves without performing hand hygiene. They rolled Resident 16 on to her side and removed her brief. Resident 16 had a liquid bowel movement which was cleaned with a washcloth using soap and water. RN 5 removed her gloves and put new ones on without performing hand hygiene. A new pad and clean towel were placed under the resident and a washcloth was used to clean the resident's bottom again. RN 5 removed her gloves and put new ones on without performing hand hygiene. RN 5 measured the wound. RN 5 removed her gloves and put new ones on without performing hand hygiene. RN 5 applied medicated gel and packing to the wound. RN 5 removed her gloves and put new ones on without performing hand hygiene. A dressing was placed on the wound. RN 5 rolled the resident to remove the dirty pad, wiped the front of the resident, put on a new brief, arranged the pillows and blankets on the bed, gathered trash, and handed the resident her call light. RN 5 removed her gloves and performed hand hygiene.
On 2/2/24 at 10:35 A.M., the Infection Preventionist indicated hand hygiene should be performed before wound care, between glove changes, between dirty and clean tasks, and when finished.
On 1/30/24 at 2:35 P.M., the Infection Preventionist provided a policy titled Handwashing/Hand Hygeine, revised 2015, that indicated Wash hands with soap and water a. when hands are visibly soiled. Use an alcohol based hand rub or soap and water b. Before and after direct contact with residents; g. Before handling clean or soiled dressings; i. After contact with a resident's skin; m. After removing gloves.
3.1-18(l)
Based on observation, interview, and record review, the facility failed to ensure infection control procedures were implemented, appropriate hand hygiene was not performed for 2 of 2 residents observed for wound care. (Resident 38 and Resident 16)
Findings include:
1. On 1/31/24 at 1:47 P.M. Registered Nurse (RN) 5 was observed performing a dressing change on Resident 38's right forearm. RN 5 entered Resident 38's room, put on gloves, used the bed remote to raise Resident 38's bed, and started wound care without performing hand hygiene. RN 5 removed Resident 38's previous dressing dated 1/29/24. RN 5 began pouring saline over Resident 38's wounds, touching the open areas of the wounds with the gloves. RN 5 then dried the wounds off using a wash cloth that was laying on Resident 38's bed. RN 5 removed gloves, applied hand sanitizer and rubbed hands together for 5 seconds, and put on another pair of gloves. RN 5 applied the dressings to the wounds and dated the wound. RN 5 removed gloves, assisted Resident 38 with pulling their shirt sleeve down, put gloves on, gathered soiled linens and trash, removed gloves before exiting the room, no hand hygiene was performed.
May 2022
4 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0698
(Tag F0698)
Could have caused harm · This affected 1 resident
Based on interview and record review, the facility failed to ensure dialysis care was provided for 1 of 1 residents reviewed for dialysis. Communication between the dialysis center and the facility wa...
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Based on interview and record review, the facility failed to ensure dialysis care was provided for 1 of 1 residents reviewed for dialysis. Communication between the dialysis center and the facility was not established and assessments were not obtained from the dialysis center. (Resident 142)
Finding includes:
During record review on 5/11/22 at 10:30 A.M., Resident 142's diagnoses included, but were not limited to, end stage renal disease (ESRD).
Resident 142's physician orders included, but were not limited to, dialysis on Tuesdays, Thursdays, and Saturdays (start date 4/30/22), and check dialysis catheter site every shift.
During a review of pre and post dialysis assessments from 4/30/22 thru 5/10/22, no dialysis communication was found between the facility and the dialysis center on the following dates; 4/30/22 (Saturday), 5/3/22 (Tuesday), 5/5/22 (Thursday), 5/7/22 (Saturday), and 5/10/22 (Tuesday).
During an interview on 5/11/22 at 11:00 A.M., LPN 15 indicated staff used to send a dialysis communication form with residents requiring dialysis on their dialysis days, but did not know if the facility still used the forms. LPN 15 then supplied a copy of a dialysis communication form. The form included the following information from the facility to the dialysis center; resident vital signs, medications received, time of last meal, if the resident needs a meal or snack, the resident's diet, if the resident is on a fluid restriction. The form included the following from the dialysis center; pre and post dialysis weights, amount of fluid removed, vitals signs, lab tests and results, how the resident tolerated the procedure, new orders and appointments.
During an interview on 5/11/22 at 1:00 P.M., LPN 9 indicated the facility did not use dialysis communication forms or communicate vitals or weights for Resident 142 on dialysis days.
On 5/12/22 at 12:30 P.M., the Facility Administrator supplied a facility policy, titled, End-Stage Renal Disease, Care of Residents with, and dated 09/2010. The policy included, Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.4. Agreements between this facility and the contracted ESRD facility include all aspects of how the resident's care will be managed, including: .b. How information will be exchanged between the facilities .
3.1-37(a)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in 2 of 3 medica...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure proper storage of medications in 2 of 3 medication carts and 1 of 1 medication storage room. Loose pills were found in the bottom of the medication cart drawers and expired IV tubing that did not belong to a current resident was found in a medication storage room. (North Unit medication cart, South Unit medication cart and storage room)
Findings include:
On [DATE] at 12:45 P.M., an IV tubing set was observed in the South Unit medication storage room with an expiration date of [DATE]. At that time, LPN 23 indicated the name on the IV tubing set was unknown and not a current resident at the facility.
On [DATE] at 12:55 P.M., the South Unit medication cart was observed with the following loose pills in the drawers:
Blue oval capsule with markings G231
White circle tablet with marking 20
Pink circle tablet with marking 34 E
Yellow circle tablet with marking M/721
1/2 purple oval tablet with undistinguishable markings
White circle tablet with undistinguishable markings
Orange oval tablet with marking 210/1010
1/2 white oval tablet with undistinguishable markings x2
At that time, LPN 15 indicated the medication carts were cleaned out every other week by night shift.
On [DATE] at 1:05 P.M., the North Unit medication cart was observed with the following loose pill in the drawer:
White circle tablet with marking 1/z
At that time, LPN 3 indicated the medications carts were cleaned out every Saturday and as needed through the week.
On [DATE] at 1:04 P.M., a current Storage of Medications policy, revised [DATE], indicated Drugs and biologicals shall be stored in the packaging, containers or other dispensing systems in which they are received . The nursing staff shall be responsible for maintaining medication storage .
3.1-25(o)
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On [DATE] at 12:55 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink.
On...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. On [DATE] at 12:55 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink.
On [DATE] at 1:21 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink.
On [DATE] at 1:18 P.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink.
On [DATE] at 8:30 A.M., room [ROOM NUMBER]'s bathroom was observed with an uncovered bedpan on the floor under the sink.
During an interview on [DATE] at 9:27 A.M., CNA (Certified Nursing Assistant) 7 indicated bedpans should be stored in a bag inside the closet.
5. On [DATE] at 9:12 A.M., CNA 7 was observed to provide incontinence care for Resident 9. CNA 7 washed her hands, donned gloves, and moved Resident 9's bedside table. CNA 7 opened the closet door, took washcloths to bathroom sink, wet the washcloths, and laid a trashbag on Resident 9's bed. CNA 7 uncovered the resident, pulled down the soiled brief, cleaned the resident peri area with the wet washcloths, pulled the resident's blanket, and walked across the room to obtain a clean brief. CNA 7 removed her gloves. No hand hygiene was observed. CNA 7 opened the closet door and obtained a clean brief. CNA 7 washed her hands and donned new gloves. She pulled the residents blanket down, rolled the resident to the left side, and cleaned the residents buttocks. CNA 7 removed the soiled pad under the resident and placed a clean brief on the resident. CNA 7 removed gloves. No hand hygiene was observed. CNA 7 pulled Resident 9's blankets up, placed the resident's bed in low position, moved the bedside table in front of resident, placed the resident's drink on the bedside table, and wiped the bedside table.
During an interview on [DATE] at 1:00 P.M., RN 4 indicated gloves should be changed immediately before care is performed if items were previously touched after putting gloves on.
6. During an observation on [DATE] at 2:11 P.M., LPN 9 was changing Resident's 24 surgical wound dressing. A biohazard container was in Resident 24's room with a sign that indicated Resident 24 should have contact precautions during the wound vac dressing changes. LPN 9 performed the dressing change while wearing an N95 respirator mask and surgical gloves.
During an interview on [DATE] at 10:25 A.M., IP 4 (Infection Preventionist) indicated Resident 24's surgical wound was infected and the resident required antibiotics for the infection. IP 4 indicated a culture had not yet been completed and the type of infection had not yet been identified. Resident 24 should be on contact precautions during the surgical wound dressing changes. Staff should wear a gloves and a gown during the dressing change.
On [DATE] at 10:00 A.M., a current Handwashing/Hand Hygiene policy, revised [DATE], was provided and indicated All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors . Vigorously lather hands with soap and rub them together, creating friction to all surfaces, for a minimum of 20 seconds (or longer) .
On [DATE] at 1:04 P.M., a current Urinary Catheter Care policy, revised [DATE], was provided and indicated, Be sure catheter tubing and drainage bag are kept off the floor
On [DATE] at 11:50 A.M., the Facility Administrator supplied a facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated, 01/2012. The policy included, .Contact Precautions . 5. Gown .a. Wear a disposable gown upon entering the Contact Precautions room or cubicle .
3.1-18(b)(1)
3.1-18(l)
Based on observation, interview, and record review, the facility failed to ensure infection control practices were followed for 7 of 9 residents observed for infection control. A blood glucose machine was cleaned with expired wipes, catheter tubing was on the floor, a bed pan on the floor, hands were not washed, and gloves were not changed between clean and dirty tasks. (South Hall treatment room, Resident 14, Resident 17, Resident 91, room [ROOM NUMBER], Resident 9, Resident 24)
Findings include:
1. On [DATE] at 11:25 P.M., LPN 9 was observed testing a blood glucose for Resident 91. At that time, LPN 9 indicated residents did not have their own machines, and they were used for any resident that needed blood glucose testing on that hall, and the machine was cleaned after each use. LPN 9 then observed to go to the treatment room, obtained a cleaning wipe from a container with an expiration date of 6/2021, then wrapped it around the blood glucose machine. The machine was not wiped with cloth.
During an interview on [DATE] at 8:20 A.M., LPN 15 indicated blood glucose machines on their side of the hall were also cleaned with the wipes in the treatment room with expiration date 6/2021.
2. On [DATE] at 11:59 A.M., Resident 14 was observed in the dining room with urinary catheter tubing hanging from the end of their pant leg. The urinary catheter tubing was rested on the resident's side and bottom of their shoe.
3. On [DATE] at 1:33 P.M., LPN 9 was observed performing a dressing change for Resident 17's coccyx and foot wounds. When pulling down Resident 17's pants from the back, a dark brown substance was observed on the inside of the brief as the pants and brief were folded inward to expose the coccyx wound. After the dressing was changed, the pants and the soiled brief were pulled back up over the dressing. LPN 9 washed his hands for a total of seven (7) seconds and completed a dressing change for Resident 17's foot. LPN 9 did not change his gloves between taking off the old dressing and placing the new dressing. When completed, LPN 9 washed his hands, obtaining soap from the dispenser and directly placing them under the water to rub his hands together, for a total of 7 seconds.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and record review, the facility failed to ensure accurate daily staffing sheets were posted for 3 of 3 days reviewed during the survey. (South Unit)
Findings include:
...
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Based on observation, interview, and record review, the facility failed to ensure accurate daily staffing sheets were posted for 3 of 3 days reviewed during the survey. (South Unit)
Findings include:
On 5/9/22 at 10:00 A.M., a staffing sheet was observed by the south hall nurses station with the date 5/9/22. The staffing sheet failed to indicate the number and actual hours worked by RN's (Registered Nurse), LPN's (Licensed Practical Nurse), QMA's (Qualified Medication Aid), and CNA's (Certified Nursing Assistant).
On 5/11/22 at 12:03 P.M., posted nurse staffing sheets dated 5/9/22 to 5/11/22 were provided. All forms lacked the number and actual hours worked by RN's, LPN's, QMA's, and CNA's.
On 5/12/22 at 12:04 P.M. a current staffing policy dated October 2017 was provided, but lacked information related to requirements of posted nurse staffing sheets. At that time, the Administrator indicated the facility's policy was to follow state regulations on posted nurse staffing.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • No fines on record. Clean compliance history, better than most Indiana facilities.
Concerns
- • 19 deficiencies on record, including 1 serious (caused harm) violation. Ask about corrective actions taken.
- • Grade C (50/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 50/100. Visit in person and ask pointed questions.
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About This Facility
What is Evansville Protestant Home's CMS Rating?
CMS assigns EVANSVILLE PROTESTANT HOME an overall rating of 2 out of 5 stars, which is considered below average nationally. Within Indiana, this rating places the facility higher than 0% of the state's 100 nursing homes. A rating at this level reflects concerns identified through health inspections, staffing assessments, or quality measures that families should carefully consider.
How is Evansville Protestant Home Staffed?
CMS rates EVANSVILLE PROTESTANT HOME's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 51%, compared to the Indiana average of 46%.
What Have Inspectors Found at Evansville Protestant Home?
State health inspectors documented 19 deficiencies at EVANSVILLE PROTESTANT HOME during 2022 to 2025. These included: 1 that caused actual resident harm, 17 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Evansville Protestant Home?
EVANSVILLE PROTESTANT HOME is owned by a non-profit organization. Non-profit facilities reinvest revenue into operations rather than distributing to shareholders. The facility operates independently rather than as part of a larger chain. With 49 certified beds and approximately 39 residents (about 80% occupancy), it is a smaller facility located in EVANSVILLE, Indiana.
How Does Evansville Protestant Home Compare to Other Indiana Nursing Homes?
Compared to the 100 nursing homes in Indiana, EVANSVILLE PROTESTANT HOME's overall rating (2 stars) is below the state average of 3.1, staff turnover (51%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Evansville Protestant Home?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Evansville Protestant Home Safe?
Based on CMS inspection data, EVANSVILLE PROTESTANT HOME has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 2-star overall rating and ranks #100 of 100 nursing homes in Indiana. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Evansville Protestant Home Stick Around?
EVANSVILLE PROTESTANT HOME has a staff turnover rate of 51%, which is about average for Indiana nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Evansville Protestant Home Ever Fined?
EVANSVILLE PROTESTANT HOME has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Evansville Protestant Home on Any Federal Watch List?
EVANSVILLE PROTESTANT HOME is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.