Evansville, IN

Evansville Protestant Home

3-star overall rating with 2-star inspections with 12 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle

3701 Washington Ave, Evansville, IN

(812) 476-3360

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

2 / 5

Survey and complaint cycles

Staffing

5 / 5

RN + nurse staffing

Quality measures

2 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

49

Certified beds

Average residents

36

Average occupied residents

Ownership

Non-Profit

Publicly displayed owner type

Chain

No chain reported

Operator or chain grouping

Approved since

2008-06-13

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Changed ownership

No

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

1.00

Registered nurse staffing · state 0.66 · national 0.68

LPN hours / resident day

1.24

Licensed practical nurse staffing · state 0.77 · national 0.87

Aide hours / resident day

2.93

Nurse aide staffing · state 2.27 · national 2.35

Total nurse hours

5.18

All reported nurse hours · state 3.71 · national 3.89

Licensed hours

2.25

RN + LPN hours · state 1.44 · national 1.54

Weekend hours

4.38

Weekend nurse staffing · state 3.24 · national 3.43

Weekend RN hours

0.52

Weekend registered nurse coverage · state 0.45 · national 0.47

Physical therapist

0.09

Reported PT staffing · state 0.06 · national 0.07

Adjusted RN hours

1.01

CMS adjusted RN staffing hours

Adjusted total hours

5.23

CMS adjusted total nurse staffing hours

Case-mix index

1.35

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 42% · national 45%

Total nurse turnover

49%

Annual nurse turnover · state 47% · national 46%

SNF VBP

Value-based purchasing

Program rank

4,281

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

40.60

Composite VBP score used to determine payment impact.

Payment multiplier

0.9935

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

3.90

Baseline 18.15% · Performance 19.62% · Measure score 3.90 · Achievement 3.90 · Improvement 0

Healthcare-associated infections

2.93

Baseline 7.89% · Performance 6.96% · Measure score 2.93 · Achievement 2.93 · Improvement 2.71

Total nurse turnover

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Adjusted total nurse staffing

5.36

Baseline 3.75 hours · Performance 4.60 hours · Measure score 5.36 · Achievement 5.36 · Improvement 3.69

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.78%	10.72% 0.1 pts worse	No Different than the National Rate · Eligible stays 119 · Observed rate 9.24% · Lower 95% interval 7.98%
Discharge to community	61.05%	50.57% 10.5 pts better	No Different than the National Rate · Eligible stays 109 · Observed rate 58.72% · Lower 95% interval 50.48%
Medicare spending per beneficiary	0.88	1.02 0.1 pts better
Drug regimen review with follow-up	98.46%	95.27% 3.2 pts better	Numerator 64 · Denominator 65
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 65
Discharge self-care score	51.06%	53.69% 2.6 pts worse	Numerator 24 · Denominator 47
Discharge mobility score	42.55%	50.94% 8.4 pts worse	Numerator 20 · Denominator 47
Pressure ulcers or injuries, new or worsened	1.54%	2.29% 0.8 pts better	Numerator 1 · Denominator 65 · Adjusted rate 1.82%
Healthcare-associated infections requiring hospitalization	6.96%	7.12% 0.2 pts better	No Different than the National Rate · Eligible stays 71 · Observed rate 5.63% · Lower 95% interval 4.4%
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 105
Staff flu vaccination coverage	13.29%	42% 28.7 pts worse	Numerator 19 · Denominator 143
Discharge function score	57.45%	56.45% 1 pts better	Numerator 27 · Denominator 47
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly.
Transfer of health information to patient	92.5%	96.28% 3.8 pts worse	Numerator 37 · Denominator 40
Resident COVID-19 vaccinations up to date	41.94%	25.2% 16.7 pts better	Numerator 13 · Denominator 31

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	2.1	1.6 0.5 pts worse	1.9 0.2 pts worse	Long Stay · 20240701-20250630 · Adjusted 2.1 · Observed 3.0 · Expected 2.8 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.7	1.5 0.2 pts worse	1.8 0.1 pts better	Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.9 · Expected 1.9 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	92.2%	93.6% 1.4 pts worse	93.4% 1.2 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 91.7% · Q2 90.6% · Q3 93.1% · Q4 93.8% · 4Q avg 92.2%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	100.0%	95.4% 4.6 pts better	95.5% 4.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0%
Percentage of long-stay residents experiencing one or more falls with major injury	4.7%	3.8% 0.9 pts worse	3.3% 1.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 6.2% · Q3 3.4% · Q4 3.1% · 4Q avg 4.7% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	7.5%	24.6% 17.1 pts better	11.4% 3.9 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.1% · Q2 10.0% · Q3 3.4% · Q4 7.1% · 4Q avg 7.5%
Percentage of long-stay residents who lose too much weight	7.5%	5.6% 1.9 pts worse	5.4% 2.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q4 4.8% · 4Q avg 7.5%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	30.7%	23.5% 7.2 pts worse	19.6% 11.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 30.4% · Q2 35.0% · Q3 27.3% · Q4 30.4% · 4Q avg 30.7%
Percentage of long-stay residents who received an antipsychotic medication	7.0%	14.8% 7.8 pts better	16.7% 9.7 pts better	Long Stay · 2024Q4-2025Q3 · 4Q avg 7.0% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	23.6%	13.3% 10.3 pts worse	16.3% 7.3 pts worse	Long Stay · 2024Q4-2025Q3 · 4Q avg 23.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	27.4%	11.7% 15.7 pts worse	14.9% 12.5 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 36.4% · Q3 22.7% · Q4 19.0% · 4Q avg 27.4% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.7%	0.4% 0.3 pts worse	1.0% 0.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.9% · 4Q avg 0.7% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	9.8%	1.2% 8.6 pts worse	1.7% 8.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 13.8% · Q3 3.7% · Q4 12.9% · 4Q avg 9.8% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	31.4%	24.2% 7.2 pts worse	19.8% 11.6 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 41.5% · Q2 35.6% · Q3 29.7% · Q4 14.9% · 4Q avg 31.4%
Percentage of long-stay residents with pressure ulcers	10.2%	4.1% 6.1 pts worse	5.1% 5.1 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 10.9% · Q3 15.0% · Q4 14.3% · 4Q avg 10.2% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	73.6%	81.6% 8 pts worse	81.7% 8.1 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 74.6% · Q2 68.9% · Q3 73.2% · Q4 78.7% · 4Q avg 73.6%
Percentage of short-stay residents who had an outpatient emergency department visit	12.1%	10.5% 1.6 pts worse	12.0% 0.1 pts worse	Short Stay · 20240701-20250630 · Adjusted 12.1% · Observed 11.0% · Expected 10.1% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	1.8%	1.3% 0.5 pts worse	1.6% 0.2 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.4% · Q4 4.0% · 4Q avg 1.8% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	60.0%	79.0% 19 pts worse	79.7% 19.7 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 60.0%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	34.2%	22.4% 11.8 pts worse	23.9% 10.3 pts worse	Short Stay · 20240701-20250630 · Adjusted 34.2% · Observed 27.4% · Expected 19.1% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-04-01 · Fire 2025-04-01

12 health deficiencies

Top issue: Resident Assessment and Care Planning (3 deficiencies)

2 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Cycle 2 Health 2024-02-02 · Fire 2024-02-02

3 health deficiencies

Top issue: Infection Control (1 deficiency)

9 fire-safety deficiencies

Top issue: Emergency Preparedness (4 deficiencies)

Cycle 3 Health 2022-05-16 · Fire 2022-05-16

4 health deficiencies

Top issue: Infection Control (1 deficiency)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-04-01

K921 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Ensure that testing and maintenance of electrical equipment is performed.

Corrected 2025-05-16

B · Minimal harm 2025-04-01

K233 · Egress Deficiencies

Fire Safety

Install resident room doors of proper design and width.

Corrected 2025-05-09

F · Potential for more than minimal harm 2024-02-02

K345 · Smoke Deficiencies

Fire Safety

Have approved installation, maintenance and testing program for fire alarm systems.

Corrected 2024-03-29

F · Potential for more than minimal harm 2024-02-02

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2024-03-29

E · Potential for more than minimal harm 2024-02-02

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2024-03-29

E · Potential for more than minimal harm 2024-02-02

K923 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have proper medical gas storage and administration areas.

Corrected 2024-03-29

C · Minimal harm 2024-02-02

E13 · Emergency Preparedness Deficiencies

Fire Safety

Develop Emergency Preparedness policies and procedures.

Corrected 2024-03-29

C · Minimal harm 2024-02-02

E29 · Emergency Preparedness Deficiencies

Fire Safety

Develop a communication plan.

Corrected 2024-03-29

C · Minimal harm 2024-02-02

E36 · Emergency Preparedness Deficiencies

Fire Safety

Establish emergency prep training and testing.

Corrected 2024-03-29

C · Minimal harm 2024-02-02

E4 · Emergency Preparedness Deficiencies

Fire Safety

Develop and maintain an Emergency Preparedness Program (EP).

Corrected 2024-03-29

C · Minimal harm 2024-02-02

K233 · Egress Deficiencies

Fire Safety

Install resident room doors of proper design and width.

Corrected 2024-03-29

F · Potential for more than minimal harm 2022-05-16

K374 · Smoke Deficiencies

Fire Safety

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Corrected 2022-07-25

E · Potential for more than minimal harm 2022-05-16

K233 · Egress Deficiencies

Fire Safety

Install resident room doors of proper design and width.

Corrected 2022-07-25

E · Potential for more than minimal harm 2022-05-16

K353 · Smoke Deficiencies

Fire Safety

Inspect, test, and maintain automatic sprinkler systems.

Corrected 2022-07-25

Inspection history

Recent health citations

G · Actual harm 2025-04-01

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2025-04-25

F · Potential for more than minimal harm 2025-04-01

F801 · Nutrition and Dietary Deficiencies

Health

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Corrected 2025-04-25

E · Potential for more than minimal harm 2025-04-01

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F580 · Resident Rights Deficiencies

Health

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F712 · Nursing and Physician Services Deficiencies

Health

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F758 · Pharmacy Service Deficiencies

Health

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F842 · Resident Assessment and Care Planning Deficiencies

Health

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Corrected 2025-04-25

D · Potential for more than minimal harm 2025-04-01

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-04-25

D · Potential for more than minimal harm 2024-02-02

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2024-03-02

D · Potential for more than minimal harm 2024-02-02

F695 · Quality of Life and Care Deficiencies

Health

Provide safe and appropriate respiratory care for a resident when needed.

Corrected 2024-03-02

D · Potential for more than minimal harm 2024-02-02

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2024-03-02

E · Potential for more than minimal harm 2022-05-16

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2022-06-15

E · Potential for more than minimal harm 2022-05-16

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-06-15

D · Potential for more than minimal harm 2022-05-16

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2022-06-15

C · Minimal harm 2022-05-16

F732 · Nursing and Physician Services Deficiencies

Health

Post nurse staffing information every day.

Corrected 2022-06-15

Penalties and ownership

What sits behind the stars

Ownership

Henry County Memorial Hospital

5% Or Greater Direct Ownership Interest · Organization

100% 31 facilities 2024-01-01

Carlisle Higgs, Lorrie