Inspection Report
Re-Inspection
Census: 40
Capacity: 49
Deficiencies: 1
Jun 13, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey was conducted to verify compliance with fire safety and licensure requirements.
Findings
The facility was found in compliance with the Life Safety Code requirements, with all resident areas sprinklered except one detached wood framed storage shed. A continuing annual waiver was approved for the clear width of exit and exit access doors.
Severity Breakdown
SS=B: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Clear Width of Exit and Exit Access Doors not meeting required minimum widths as per NFPA 101 standards. | SS=B |
Report Facts
Facility capacity: 49
Census: 40
Inspection Report
Re-Inspection
Census: 56
Capacity: 77
Deficiencies: 0
Apr 29, 2025
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on April 1, 2025, including a PSR to the Investigation of Nursing Home Complaint IN00451230 and the State Residential Licensure Survey completed on April 1, 2025.
Findings
Evansville Protestant Home was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey and the PSR to the Investigation of Nursing Home Complaint IN00451230. The complaint was corrected.
Complaint Details
Complaint IN00451230 was investigated and found to be corrected.
Report Facts
Census: 56
Total Capacity: 77
Census Bed Type - SNF/NF: 22
Census Bed Type - SNF: 20
Census Bed Type - NCC: 14
Census Bed Type - Residential: 21
Census Payor Type - Medicare: 11
Census Payor Type - Medicaid: 13
Census Payor Type - Other: 32
Inspection Report
Life Safety
Census: 32
Capacity: 49
Deficiencies: 2
Apr 22, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included exit doors in resident sleeping rooms being less than the required 32 inches wide and failure to conduct required maintenance and documentation for Patient Care Related Electrical Equipment (PCREE).
Severity Breakdown
SS=B: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Sleeping room exit doors were less than 32 inches wide for 10 of 10 resident sleeping room doors in the North Unit. | SS=B |
| Failure to conduct required maintenance and maintain complete documentation of inspections for Patient Care Related Electrical Equipment (PCREE). | SS=F |
Report Facts
Certified beds: 49
Census: 32
Resident sleeping room doors deficient: 10
Residents potentially affected: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Michelle Perry | Administrator | Participated in observations, interviews, and exit conference regarding deficiencies |
| Housekeeping Supervisor | Provided measurements of door openings and participated in exit conference |
Inspection Report
Recertification
Census: 52
Capacity: 73
Deficiencies: 13
Apr 1, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey and Investigation of Nursing Home Complaint IN00451230, including a Non-Certified Comprehensive Survey and State Residential Licensure Survey.
Findings
The facility was found deficient in multiple areas including failure to notify physicians timely of lab results, incomplete care plans for high risk medications, failure to implement fall prevention interventions, delayed treatment of urinary tract infections, failure to ensure timely physician visits, failure to act on pharmacy recommendations, improper food storage, inaccurate catheter change documentation, failure to implement enhanced barrier precautions, and incomplete resident service plan signatures.
Complaint Details
Complaint IN00451230 - Federal/State deficiencies related to the allegations are cited at F880.
Severity Breakdown
SS=D: 10
SS=E: 1
SS=F: 1
SS=G: 1
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to ensure physician was notified when lab results were not obtained for a resident with catheter associated urinary tract infection. | SS=D |
| Failed to ensure care plans related to high risk medications were developed for residents reviewed for medication use. | SS=D |
| Failed to ensure resident’s plan of care was implemented for nutrition. | SS=D |
| Failed to revise care plans and follow interventions to reduce the risk of falls for a resident with major injury. | SS=G |
| Failed to ensure a resident was treated for a urinary tract infection in a timely manner. | SS=D |
| Failed to ensure a resident was assessed by a physician since admission for 1 of 2 residents admitted in the last 90 days. | SS=D |
| Failed to ensure pharmacy recommendations were acted upon for a resident reviewed for unnecessary medications. | SS=D |
| Failed to ensure residents were free from unnecessary medications, PRN antianxiety for greater than 14 days. | SS=D |
| Failed to ensure the Dietary Manager met required qualifications. | SS=F |
| Failed to safely store and label food under professional standards related to food items not labeled or stored properly. | SS=E |
| Failed to ensure a catheter change was accurately documented. | SS=D |
| Failed to implement infection control practices to ensure proper use of Enhanced Barrier Protocol and PPE for wound care. | SS=D |
| Failed to ensure service plans were completed and signed by the resident every six months. | SS=D |
Report Facts
Survey dates: 2025-03-25 to 2025-04-01
Census Bed Type: 73
Census Payor Type: 52
Number of residents reviewed for medication use: 6
Number of residents reviewed for unnecessary medications: 5
Number of residents reviewed for PRN anti-anxiety medication use: 3
Number of residents reviewed for catheter care: 2
Number of residents reviewed for falls: 1
Number of residents reviewed for physician assessment timeliness: 2
Number of residents reviewed for dietary manager qualifications: 1
Number of residents reviewed for food storage: 1
Number of residents reviewed for catheter documentation: 2
Number of residents reviewed for infection prevention: 2
Number of residents reviewed for service plan signatures: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Michelle Perry | Laboratory Director or Provider/Supplier Representative | Signed the report |
| RN 12 | Registered Nurse | Observed performing wound care without gown |
| RN 16 | Registered Nurse | Observed performing wound care without gown and changed catheter |
| QMA 7 | Qualified Medication Aide | Incorrectly documented catheter change |
| Director of Nursing | DON | Provided interviews and information on multiple findings |
| Administrator | Facility Administrator | Provided policies and interviews |
| Medical Director | Medical Director | Did not respond to pharmacy recommendations |
| Physical Therapy Assistant 9 | PTA | Provided interview regarding Resident 7 fall and mobility |
| Dietary Manager | Dietary Manager | Interviewed regarding qualifications and food storage |
| Dietitian | Dietitian | Interviewed regarding Dietary Manager visits |
| Medical Records Staff | Medical Records Staff | Provided interview regarding pharmacy recommendations |
| Infection Preventionist | Infection Preventionist | Provided interview regarding infection control practices |
Inspection Report
Complaint Investigation
Census: 43
Capacity: 81
Deficiencies: 0
Dec 17, 2024
Visit Reason
This visit was conducted for the Investigation of Complaint IN00449308.
Findings
No deficiencies were cited related to the allegations in Complaint IN00449308. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00449308 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 43
Total Capacity: 81
Census bed type - SNF: 19
Census bed type - SNF/NF: 24
Census bed type - Residential: 24
Census bed type - Non-Certified Comprehensive: 14
Census payor type - Medicare: 10
Census payor type - Medicaid: 14
Census payor type - Other: 19
Inspection Report
Complaint Investigation
Census: 57
Capacity: 83
Deficiencies: 0
Oct 31, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00437871.
Findings
No deficiencies related to the allegations are cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00437871 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type Total: 83
Census Payor Type Total: 57
SNF/NF Beds: 22
SNF Beds: 21
Residential Beds: 26
NCC Beds: 14
Medicare Residents: 7
Medicaid Residents: 13
Other Payor Residents: 37
Inspection Report
Complaint Investigation
Census: 55
Capacity: 78
Deficiencies: 0
Jun 11, 2024
Visit Reason
This visit was for the Investigation of Nursing Home Complaint IN00432804, which also included the Investigation of Residential Complaint IN00432804.
Findings
No deficiencies related to the allegations were cited. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00432804 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 78
Census Payor Type: 55
SNF beds: 18
SNF/NF beds: 22
Residential beds: 23
Non-Certified Comprehensive beds: 15
Medicare residents: 6
Medicaid residents: 16
Other payor residents: 33
Inspection Report
Plan of Correction
Deficiencies: 0
Apr 22, 2024
Visit Reason
Paper compliance review for the Recertification and State licensure, and the Non-Certified Comprehensive survey ending on February 2, 2024.
Findings
Evansville Protestant Home was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 regarding the paper compliance review for the Recertification and State licensure, and Non-Certified Comprehensive survey.
Inspection Report
Follow-Up
Census: 44
Capacity: 49
Deficiencies: 1
Apr 18, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 03/05/24.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. One deficiency related to the clear width of exit and exit access doors was noted but had an annual waiver requested.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Clear Width of Exit and Exit Access Doors did not meet requirements but has an annual waiver requested. | SS=C |
Report Facts
Certified beds: 49
Census: 44
Inspection Report
Life Safety
Census: 43
Capacity: 49
Deficiencies: 9
Mar 5, 2024
Visit Reason
A Life Safety Code Recertification and State Licensure Survey was conducted by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Life Safety Code requirements including deficiencies in emergency preparedness plan updates, fire alarm system maintenance, sprinkler system maintenance, fire drills documentation, exit door widths, fire safety in ceilings, and gas cylinder storage.
Severity Breakdown
SS=C: 5
SS=F: 3
SS=E: 1
Deficiencies (9)
| Description | Severity |
|---|---|
| Failed to develop and maintain an emergency preparedness plan reviewed and updated at least annually. | SS=C |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness communication plan reviewed and updated at least annually. | SS=C |
| Failed to develop and maintain an emergency preparedness training and testing program reviewed and updated at least annually. | SS=C |
| Sleeping room exit doors were less than 32 inches wide for 10 of 10 resident sleeping room doors in the North Unit. | SS=C |
| Failed to maintain fire alarm system visual inspections semi-annually as required by NFPA 72. | SS=F |
| Failed to maintain sprinkler system ceiling escutcheon rings and fire stop gaps properly, allowing sprinkler heads to not function fully. | SS=F |
| Failed to provide quarterly fire drill documentation for 1 of 3 shifts during 1 of 4 quarters. | SS=F |
| Failed to properly secure cylinders of nonflammable gases such as oxygen from falling in the oxygen transfilling room. | SS=E |
Report Facts
Certified beds: 49
Census: 43
Resident sleeping room doors: 10
Fire drill shifts missing documentation: 1
Fire drill quarters missing documentation: 1
Oxygen cylinders unsecured: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Michelle Perry | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Maintenance Director | Interviewed and confirmed deficiencies related to emergency preparedness plan, communication plan, training/testing, fire alarm inspections, and oxygen cylinder storage | |
| Administrator | Interviewed and reviewed findings during exit conference |
Inspection Report
Renewal
Census: 30
Capacity: 85
Deficiencies: 5
Feb 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey including a Non-Certified Comprehensive (NCC) Survey and a State Residential Licensure Survey conducted from January 29 to February 2, 2024.
Findings
The facility was found deficient in multiple areas including failure to assess residents for self-administration of medications, inadequate respiratory care practices such as unlabeled oxygen equipment, failure to perform proper infection control including hand hygiene and sanitizing equipment between residents, and improper medication administration practices where medications were left unattended without monitoring resident consumption.
Severity Breakdown
SS=D: 4
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to ensure residents self-administering medications were assessed for capability and had physician orders. | SS=D |
| Failure to date tubing and label humidification bottles, place oxygen use signs, and include oxygen care plans for residents on oxygen. | SS=D |
| Failure to perform proper infection control during wound care, including inadequate hand hygiene. | SS=D |
| Failure to ensure infection control during medication administration by not sanitizing blood pressure equipment and pulse oximeters between residents. | SS=D |
| Failure to ensure medication administration was monitored with medications left unattended in resident rooms without observation. | — |
Report Facts
Survey dates: 5
Census: 30
Total capacity: 85
Residents observed for medication administration: 6
Residents observed for respiratory care: 2
Residents observed for wound care: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Anna Michelle Perry | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report. |
| RN 3 | Registered Nurse observed during medication administration and interviewed regarding infection control and oxygen tubing. | |
| RN 5 | Registered Nurse observed during wound care and infection control procedures. | |
| LPN 12 | Licensed Practical Nurse observed during medication administration and sanitization practices. | |
| DON | Director of Nursing | Interviewed regarding medication self-administration and oxygen care plans. |
| Administrator | Interviewed regarding medication policies and oxygen use. | |
| Infection Preventionist | Provided infection control policies and education. |
Inspection Report
Complaint Investigation
Census: 57
Capacity: 83
Deficiencies: 0
Dec 13, 2022
Visit Reason
This visit was conducted for the investigation of Complaint IN00396462.
Findings
The complaint was substantiated; however, no deficiencies related to the allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00396462 was substantiated but no deficiencies related to the allegations were cited.
Report Facts
Census Bed Type Total: 83
Census Payor Type Total: 57
Inspection Report
Life Safety
Deficiencies: 0
Jun 14, 2022
Visit Reason
Paper compliance to the Life Safety Code Recertification and State Licensure Survey conducted on 06/14/22.
Findings
Evansville Protestant Home, Inc. was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the NFPA 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
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