Evansville State Hospital
A psychiatric hospital in Evansville, Indiana 47714
3400 Lincoln Avenue, Evansville, Indiana 47714. (812) 469-6800.
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The short answer
Record last released by CMS on Oct 20, 2026.
- Not rated CMS’s overall rating
- Not rated patient survey rating
- 1 deficiency cited in the last three years
- 168 beds
Each figure’s source sits beside it, in its section below.
What these words mean2
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Nov 25, 2025: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Nov 2025. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Nov 25, 2025: complaint inspection1 deficiency
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Rn Supervision Of Nursing Care
The inspectors’ words, 698 words
“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 50584 Based on document review and interview, nursing services failed to complete two patient identifiers prior to administering medications to the wrong patient in 1 of 10 MRs reviewed (P2), and failed to give medications as ordered by the physician in 2 of 10 MRs reviewed. (P4, P7) Findings include: 1. Policy titled Medication Management-Medication Administration, Policy StatID: 18093029, Last Revised: 5/2025, page 1, Medication Administration Responsibilities & Precautions: A. All medications require a provider’s order and are reviewed by a nurse. D. Adhere to the following standard practices: Give the medication at the right time. Page 3, Med Pass Technique/Workflow: B. Patient identification: 2. Identify each patient using at least two ways to identify the patient. Ask the patient to state his/her name, verify with photo ID (identification), or ask another staff person to identify the patient. 2. Review of P2 MR indicated: a. On 9/21/25 at 0721 hours Progress Note indicated P2 was incorrectly administered Tylenol 1300 mg (milligrams), Gabapentin 600 mg, Vistaril 25 mg, Keppra 750 mg and Invega 12 mg orally. MR lacked documentation of two patient identifiers used prior to medication administration. On call provider was notified that another patient’s medications were given to P2, provider instructed staff to monitor for increased sedation and continue 15-minute checks. On-call provider also approved administration of the following P2 physician prescribed medications at that time: Levothyroxine 25 mcg (micrograms), medroxyprogesterone 5 mg and omega 3 1000 mg. c. On 9/21/25 at 1139 hours Progress Note indicated P2 was awake for lunch, he/she was slow to rise, gait steady with no problems eating. P2 was noted to have a blank stare and was unresponsive to staff questions. P2 fell over to his/her side onto the floor at approximately 1102 hours. Patient did not respond to attempts to arouse him/her. 3. Review of P4 MR indicated: a. Patient was admitted to the facility on 11/21/24 with diagnosis of Schizophrenia. b. On 7/1/25 at 1200 hours Progress Note indicated P4 did not receive his/her noon dose of Buspar 10 mg. Physician notified of missed dose on 7/1/25 at 1430 hours. No increased monitoring necessary. Medications were not given per physician’s order. 4. Review of P7 MR indicated: a. Patient was admitted to the facility on 7/2/2025 with diagnosis of Schizophrenia. b. On 7/5/25 at 0722 hours Progress Note indicated P7 was given morning dose of Haldol 10 mg when communication order said to hold medication until 7/7/25. Physician notified medication was administered and no increased monitoring was necessary. Medications were not given per physician’s order. 5. Report of Medication Occurrence on 9/21/25 indicated P2 was given another patient’s medication. Physician notified and order received for P2 to be on 15-minute checks and monitored for increased sedation. Medication error was a Category E indicating an error occurred that resulted in the need for treatment or intervention and caused temporary patient harm. N7 (Registered Nurse) failed to use two patient identifiers prior to medication administration. 6. Report of Medication Occurrence indicated P4 did not receive his/her noon dose of Buspar 10 mg (milligrams). Medication error was a Category C indicating an error occurred that reached the patient but did not cause harm. Medication was not given per physician’s order. 7. Report of Medication Occurrence on 7/5/25 indicated patient received Haldol 10 mg when communication order indicated to hold the Haldol until 7/7/25 for physician evaluation. Medication was not given per physician’s order. 8. In interview on 11/24/25 at approximately 1300 hours with A5 (DON [Director of Nursing]), he/she confirmed on 9/21/25 two patient identifiers were not used prior to administering P2 another patient’s medication. A5 also confirmed on the Reports of Medication Occurrence, medications for P4 and P7 were not given per physician’s order and education to staff should be marked yes, with comments or suggestions documented to prevent medication error from reoccurring. 9. In interview on 11/24/25 with N5 (Registered Nurse) at approximately 1520 hours with N5, he/she confirmed that medications were not given by the physicians order for P4 and P7.”
The one inspection in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Nov 25, 2025 | Complaint inspection | 1 deficiency cited |
How do patients fare?
- CMS gives no overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.: “Data are shown only for hospitals that participate in the Inpatient Quality Reporting (IQR) and Outpatient Quality Reporting (OQR) programs.”
- CMS publishes no patient survey results for it.
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | Not rated |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | Not rated |
Is it certified, and in good standing?
- Medicare-certified psychiatric hospital since Jan 6, 2012.
- Ownership: government - state.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Government - State.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- CMS’s HAC Reduction Program file has no result for it: the program covers general acute care hospitals Medicare pays under its inpatient prospective payment system.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- State of Indiana Auditor of State owns 100% directly since Jul 22, 2010.
- 3 owners or officers are people: Dhiann Kinsworthy (corporate director, 100%); Jeffrey Wedding (corporate director); Dhiann Kinsworthy (managing employee (on the payroll)).
- CMS’s Provider of Services file records 1 change of ownership.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
| Organisation | Role | Share | Since |
|---|---|---|---|
| State of Indiana Auditor of State | Owns 5% or more directly | 100% | Jul 22, 2010 |
How does it compare nearby?
- Of the 3 hospitals CMS lists in Vanderburgh County, 2 have an overall star rating from CMS: 1 rated 4 of 5, 1 rated 2 of 5.
- CMS gives this hospital no overall star rating to compare.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Deaconess Hospital Inc. | 2 |
| Ascension St Vincent Evansville | 4 |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
None. Replies aren’t open yet. When they open, the hospital will be able to answer any finding for free, and the reply will show beside that finding, unedited and dated.
Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.