Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at North River Health Campus during CMS and state inspections, most recent first.
Surveyors found improper medication storage and labeling in 3 medication carts, including loose pills, unlabeled meds, and items without open dates. An RN acknowledged that employee drinks should not be in the med cart and that meds should have labels and open dates, and the DON stated employee food should not be stored in the carts.
Failure to Maintain Resident Dignity During Mealtime Assistance: A CNA was observed feeding a resident while standing, and another CNA later continued the same way in the dining area. While residents were present, the CNAs discussed job stress and burnout. The resident had Alzheimer’s disease, dysphagia, severe cognitive impairment, and required staff assistance for eating. A CNA stated staff should sit beside residents during feeding for dignity reasons, and the facility policy stated residents have the right to be treated with dignity and respect.
Care Plan Not Updated After Change in Condition: A resident with hypotension and a fall risk care plan had a fall while attempting to self-toilet, resulting in ER transfer with injuries to the head and extremities. The resident’s MDS later showed a significant decline in cognition and function, but the fall care plan was not revised even though the resident no longer walked. The resident was also observed wearing non-nonskid tube socks, and the facility policy stated care plans must remain accurate and current.
Improper Insulin Pen Administration: An LPN administered insulin glargine to a resident with diabetes mellitus without priming the insulin pen first. The resident had an order for 32 units SQ twice daily, and the insulin pen instructions stated the pen should be primed with 2 units before each injection.
The facility failed to follow infection control practices during 2 of 2 insulin administrations. An LPN and an RN were observed giving insulin to two residents without cleaning the rubber injectable ports of the insulin pens with an alcohol swab before attaching the needle. The insulin pen insert instructed staff to wipe the port with an alcohol prep.
A resident with severe cognitive impairment and a high risk for falls did not consistently receive a required Dycem anti-slip mat in their wheelchair, as ordered and outlined in their care plan. During a transfer, staff failed to ensure the intervention was in place, despite recent falls and clear policy requirements for consistent implementation and care plan updates.
The facility failed to ensure the MDS assessment was completed accurately for a resident reviewed for restraints. A family member indicated that restraints had never been used on the resident, and the clinical record lacked documentation related to physical restraints. The MDS Coordinator confirmed that the assessment was marked in error, and the Administrator stated that the facility follows the RAI manual for guidance on coding MDS Assessments.
A resident with COPD and respiratory failure was observed without oxygen being administered as ordered. The oxygen equipment was found unplugged, turned off, and not properly labeled. The facility did not comply with physician orders for continuous oxygen therapy and monthly tubing changes.
The facility failed to ensure accurate documentation of resident records for two residents with pressure ulcers and one resident with dental issues. Inconsistencies and errors in the records were identified, including mislabeling of wounds and incorrect dental assessments.
The facility failed to implement enhanced barrier precautions for a resident with a permcath dialysis catheter. Two CNAs did not wear PPE while transferring the resident and changing bed linens, despite the resident being on enhanced barrier precautions. The resident confirmed the lack of PPE use, and the care plan and physician orders required PPE during high-contact care activities.
Improper Medication Storage and Labeling in Medication Carts
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in 3 of 3 medication carts observed. On 5/6/26, surveyors found loose pills and unlabeled medications in the 200 Hall medication cart, including 2 medium-sized orange pills, 1 blue capsule, 1 small white oval pill, and 1 bottle of eye drops with no open date. In the 300 Hall medication cart, surveyors observed 1 open can of soda, 4 bottles of cough medicine with no open date, and 1 bottle of antacid pills with no label or open date. In the 400 Hall medication cart, surveyors observed 1 tube of ointment with no open date, 1 bottle of lactulose with no open date, 1 bottle of nasal spray with no open date, 2 bottles of extra strength acetaminophen with no open date, 2 bottles of cough medicine with no open date, and 2 bottles of antacid pills, one with no label or open date and one with no open date. During interview, RN 3 stated she should not have had the drink in the medication cart and that medications should have a label and an open date. The DON later stated there should be no employee food in the medication carts. The facility policy stated medications are to be kept in closed and labeled containers, with a date-opened sticker placed on medications, and that food is not stored there.
Failure to Maintain Resident Dignity During Mealtime Assistance
Penalty
Summary
The facility failed to treat a resident with dignity during mealtime for 1 of 1 random observations. On 5/6/25 at 11:46 A.M., CNA 5 was observed feeding Resident 3 lunch in the restorative dining area while standing up, and at 11:50 A.M. CNA 6 took over feeding the resident and was also standing up. During the same observation, CNA 5 and CNA 6 talked about the difficulties of their job and how burnt out they were while residents were present in the dining area. Resident 3’s record showed diagnoses including Alzheimer’s disease and dysphagia, and the most current Quarterly MDS dated 4/15/26 indicated severe cognitive impairment and dependence on staff for eating. The care plan and profile care guide included interventions to assist with meals and eating as needed. During interview, CNA 7 stated staff should sit next to residents while assisting them to eat and should not stand over residents for dignity reasons. The facility policy stated residents have the right to be treated with dignity and respect.
Care Plan Not Revised After Change in Condition
Penalty
Summary
The facility failed to revise a resident’s care plan after a change in condition following a fall with major injury. Resident 8’s record showed diagnoses including hypotension. A Quarterly MDS dated 2/4/26 indicated the resident was cognitively intact, needed supervision for bathing and toileting, and was independent in transfers. A Significant Change MDS dated 4/22/26 showed the resident was moderately cognitively impaired and required substantial assistance for bathing, toileting, and transfers. The care plan identified the resident as at risk for falls related to impaired mobility, history of syncope, atrial fibrillation, and pulmonary fibrosis, with interventions including proper footwear and nonskid footwear. A nursing progress note dated 4/4/26 documented that the resident fell while attempting to self-toilet and was sent to the ER with injuries to the left temple, left upper arm, left hip, and left knee. During observation on 5/8/26, the resident was lying in bed awake wearing black tube socks that were not nonskid. The Regional Support Nurse stated on 5/12/26 that the fall care plan intervention should have been revised after the resident’s change in condition because the resident no longer walked. The Administrator provided a policy stating comprehensive care plans need to remain accurate and current.
Improper Insulin Pen Administration
Penalty
Summary
The facility failed to ensure insulin was properly administered for 1 of 2 residents observed for insulin administration. On 5/8/26 at 9:10 A.M., an LPN administered insulin glargine to Resident 68 by attaching the needle to the Glargine insulin pen, dialing the pen to 32 units, and giving the injection without priming the pen first. Resident 68’s record reviewed later that day showed diagnoses including diabetes mellitus and a physician order for insulin glargine 100 units/mL, 32 units subcutaneously twice a day, dated 5/5/26. During interview, the Regional Support Nurse stated insulin pens should be primed with two units before dialing in the needed dose, and the Administrator provided the Kwik-Pen insulin insert stating the pen should be primed with 2 units and that failure to prime before each injection may result in too much or too little insulin.
Failure to Clean Insulin Pen Ports Before Administration
Penalty
Summary
The facility failed to provide infection control practices during 2 of 2 insulin administrations. On 5/8/26 at 6:45 A.M., LPN 2 was observed administering Lantus to Resident 68 without using an alcohol swab to clean the rubber injectable port of the insulin pen before placing the needle on the pen. On 5/8/26 at 11:49 A.M., RN 3 was observed administering Lispro to Resident 37 without using an alcohol swab to prepare the rubber injectable port of the insulin pen before placing the needle on the pen. During an interview on 5/11/26 at 9:36 A.M., the Regional Support Nurse stated the rubber injectable ports of insulin pens should be prepped with an alcohol swab prior to placing a needle on the pen. On 5/11/26 at 10:46 A.M., the Administrator provided the current Kwik-Pen insulin insert dated 7/2023, which instructed to wipe the port with an alcohol prep.
Failure to Consistently Implement Fall Prevention Interventions
Penalty
Summary
A deficiency occurred when a resident, identified as having severe cognitive impairment due to Alzheimer's disease and dementia, did not consistently receive required fall prevention interventions. During an observation, the resident was transferred from a wheelchair to a shower chair by two CNAs, and it was noted that the wheelchair lacked a Dycem anti-slip mat, which was ordered by the physician to be used during specific times of the day. The resident's care plan, which identified them as a high fall risk, included the use of a Dycem on the wheelchair cushion and keeping personal items within reach. However, this intervention was not in place at the time of observation. The resident's clinical record showed a recent fall incident where the Dycem was reportedly in place, but subsequent observations revealed lapses in the consistent implementation of this intervention. Staff interviews confirmed that the Dycem should have been in use, and facility policy required care plans to be updated after any fall or change in interventions. Despite these requirements, the intervention was not consistently applied, leading to a failure in providing adequate supervision and accident prevention for the resident.
Inaccurate MDS Assessment for Restraints
Penalty
Summary
The facility failed to ensure the MDS (Minimum Data Set) assessment was completed accurately for a resident reviewed for restraints. A family member indicated that restraints had never been used on the resident. The resident's clinical record, which included diagnoses of dementia and anxiety disorder, lacked any documentation related to the use of physical restraints. However, the most recent Quarterly MDS Assessment inaccurately indicated that physical restraints were used less than daily during the 7-day look-back period. The MDS Coordinator confirmed that this was marked in error and that the facility did not use restraints on any resident. The Administrator stated that the facility follows the RAI (Resident Assessment Instrument) manual for guidance on coding MDS Assessments.
Failure to Ensure Proper Respiratory Care
Penalty
Summary
The facility failed to ensure proper respiratory care for Resident 47, who was observed without oxygen being administered despite having a physician's order for continuous oxygen at 2 liters per nasal cannula. During observations on two separate days, the oxygen concentrator was found unplugged and turned off, and the humidification bottle, oxygen tubing, and oxygen tubing bag were not labeled with dates or initials. Additionally, a portable oxygen concentrator attached to the resident's wheelchair was not in use and also lacked proper labeling. Resident 47's clinical record indicated diagnoses of Chronic Obstructive Pulmonary Disorder (COPD), acute and chronic respiratory failure with hypoxia, and bronchopneumonia. The resident was cognitively intact and required limited assistance for transfers and mobility. Despite the physician's orders and care plans specifying the need for continuous oxygen therapy and monthly tubing changes, the facility did not comply with these directives. An interview with a registered nurse revealed a discrepancy in the facility's practice, stating that oxygen tubing was changed weekly and placed in a bag with the resident's name and date, which was not observed in practice. The facility did not provide a current oxygen administration policy when requested.
Inaccurate Documentation of Resident Records
Penalty
Summary
The facility failed to ensure resident records were accurate for two residents reviewed for pressure ulcers and one resident reviewed for dental issues. Resident 43's clinical record showed inconsistencies in the documentation of pressure ulcers. The records indicated various stages and conditions of the wounds, but the assessments were not entered timely, and there were discrepancies in the wound descriptions. The Clinical Support Nurse confirmed that the wounds should have been documented as moisture-associated skin damage (MASD) and not unstageable pressure ulcers. Additionally, the wound nurse was new and confused bruised tissue with necrotic tissue, leading to inaccurate documentation. Resident 101's clinical record also contained inaccuracies regarding a pressure ulcer on the left plantar foot. The wound was documented as necrotic, but the Regional Support Nurse later clarified that it was blanchable and more like a bruise. The person responsible for the assessment was new and had made an incorrect entry, leading to the mislabeling of the wound as necrotic. Resident 47's clinical record showed discrepancies in the documentation of dental issues. The admission observation indicated no oral cavity issues, but the most recent Admission MDS Assessment and care plan noted broken or missing teeth. The MDS Coordinator confirmed that the care plan contained incorrect information and that the admission assessment was marked in error. The Clinical Support Nurse stated there was no specific policy related to documentation, but it was company policy to document accurately and timely.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to ensure the implementation of enhanced barrier precautions (EBP) during a random observation for a resident with a permcath dialysis catheter. During the observation, two CNAs entered the resident's room with a Hoyer lift and did not apply personal protective equipment (PPE). The CNAs transferred the resident to a wheelchair and changed the soiled bed linens without wearing PPE, despite the resident being on enhanced barrier precautions due to the presence of a central line. The resident confirmed that staff did not wear PPE during transfers, and an RN indicated that staff were supposed to wear PPE during direct contact with residents on enhanced barrier precautions. The resident's clinical record showed diagnoses including complications of a vascular dialysis catheter and end-stage renal disease. The resident was cognitively intact and dependent on staff for mobility, transfer, and dressing. Physician orders and the care plan required staff to use enhanced barrier precautions, including wearing a gown and gloves during high-contact care activities. The facility's Enhanced Barrier Precautions Standard Operating Procedure also mandated the use of PPE during high-contact activities for residents with indwelling medical devices. Despite these requirements, the staff failed to follow the EBP protocol during the observed care activities.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bethel Manor | 6.4 mi | ★★★★★ | 32 | 0 |
| Heritage Center | 7.7 mi | ★★★★★ | 0 | 0 |
| North Park Nursing Center | 7.9 mi | ★★★★★ | 1 | 0 |
| Parkview Care Center | 8.6 mi | ★★★★★ | 25 | 0 |
| River Pointe Health Campus | 8.8 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.