Evansville Protestant Home

In the surveyor’s words

From the most serious findings on record at Evansville Protestant Home, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 1, 2025

  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. […]

• No harm, potential for more than minimal, widespreadF801Apr 1, 2025

  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. […]

• No harm, potential for more than minimal, patternF812Apr 1, 2025

  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… […]

• No harm, potential for more than minimal, patternF761May 16, 2022

  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]. […]

• No harm, potential for more than minimal, patternF880May 16, 2022

  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. […]