Above average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
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 West River Health Campus during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and frequent incontinence had a physician's order for a urinalysis and culture due to suspected UTI. Over five days, only two documented attempts were made to obtain the urine sample, with no consistent documentation or timely physician notification when unsuccessful. The sample was eventually collected via in-and-out catheterization after a new order, resulting in delayed diagnosis and treatment.
A resident with severe cognitive impairment and a history of needing staff assistance for transfers and toileting was left without required support, leading to a fall. Documentation and interviews confirmed that staff did not follow the care plan, despite the resident's increased confusion and fall risk due to a UTI.
A resident had multiple medications observed at the bedside, including creams and unlabeled eye and saline drops, but the clinical record lacked a self-administration assessment, physician order, and care plan for self-medication. The resident was cognitively intact per MDS and had diagnoses including DM2 with diabetic kidney disease and hypertensive heart and CKD with HF. The DON stated bedside medications should not be present without an order and completed self-medication assessment.
A facility failed to keep a resident restroom free of pests when surveyors observed a moderate amount of small black ants in the bathroom on two occasions, including around the toilet, wall, and air conditioner. The resident reported the facility was to spray for the ants and also mentioned a cricket in the room. An LPN stated there should be no bugs in resident rooms, and the Administrator provided a pest control policy stating the building is to be kept pest free.
A resident with multiple neurological diagnoses was discharged without complete documentation, as required by facility policy. The discharge form lacked a selected reason for transfer, and the physician's order did not provide sufficient detail regarding the discharge. Staff interviews confirmed that required documentation fields were left blank or incomplete.
A resident with an indwelling urinary catheter developed a CAUTI, septic shock, and pneumonia due to inadequate care at the facility. The resident, who was cognitively impaired and dependent on staff, showed signs of complications like blood in the urine, but there was no documented assessment or physician notification. A catheter flush was performed without proper documentation or physician notification, and the resident was later hospitalized with severe health issues. The facility lacked a catheter assessment tool and comprehensive policy for CAUTI prevention.
The facility failed to provide adequate bathing care for residents dependent on staff for ADLs. A resident with cognitive impairment received only a few showers over two months, while another resident received none since admission. A cognitively intact resident reported not receiving scheduled showers and was not offered alternatives. The facility's policy required bathing at least twice a week, which was not followed.
The facility failed to maintain sanitary food service practices, with unlabeled food items observed in the kitchen and dementia unit refrigerator. The kitchen had soiled equipment and debris build-up, and the facility's food labeling policy was not followed.
The facility failed to ensure proper hand hygiene and sanitation practices during resident care. An LPN and a CNA did not perform hand hygiene after glove removal and before other tasks. An RN washed hands for only nine seconds after wound care. A sit-to-stand lift used by CNAs was dirty and had a peeling grip mat, indicating poor equipment sanitation.
Two residents in an LTC facility experienced deficiencies in supervision and intervention. A resident with a history of falls did not have updated care plans or necessary safety measures, leading to multiple falls. Another resident, on a puree diet due to dysphagia, was given inappropriate food during an activity, resulting in choking and hospitalization. The facility lacked effective implementation of care policies and supervision, contributing to these incidents.
A resident with Parkinson's, dementia, and dysphagia experienced significant weight loss due to the facility's failure to address nutritional needs and follow dietary recommendations. Despite orders for weekly weight monitoring and supplements, weights were inconsistently recorded, and improper weighing techniques were used. The facility's guidelines for weight tracking were not followed, leading to a deficiency.
A resident was observed receiving 5 liters of oxygen instead of the prescribed 3 liters, with an empty and undated humidification bottle and tubing. The staff was unclear about responsibilities for changing oxygen equipment, and the facility lacked a specific policy for following physician orders, although staff were expected to adhere to them.
A cognitively impaired resident experienced an unwitnessed fall resulting in a clavicle fracture due to the failure of staff to follow the care plan, which required the bed to be in a low position with a fall mat. The incident occurred after CNAs assisted the resident and left the bed in its highest position without the fall mat.
Delayed Urine Sample Collection and Physician Notification for Suspected UTI
Penalty
Summary
The facility failed to complete a physician's order to obtain a urine sample in a timely manner for a resident with diagnoses including Alzheimer's disease, dementia, and a disorder of the kidney and ureter. The resident, who had severe cognitive impairment and was frequently incontinent of bladder and bowel, had a physician's order for a urinalysis and culture due to suspected urinary tract infection (UTI). Documentation showed that after the initial order was placed, there were only two documented attempts to obtain the urine sample over a five-day period, with one refusal by the resident and one unsuccessful attempt to collect the sample. No further documented attempts were made until a new order for in-and-out catheterization was received and completed. The resident's clinical record indicated that staff did not consistently document attempts to obtain the urine sample as required, nor did they promptly notify the physician when the sample could not be obtained. The Assistant Director of Nursing confirmed that staff should document each attempt and notify the physician if unsuccessful, but this was not done. The Medication Administration Record and Treatment Administration Record also lacked documentation of ongoing attempts between the initial order and the eventual catheterization. As a result, the urine sample was not obtained until five days after the initial order, delaying the diagnosis and treatment of the resident's UTI.
Failure to Follow Care Plan for Transfer Assistance Results in Resident Fall
Penalty
Summary
A deficiency occurred when staff failed to follow a resident's care plan by not providing the required assistance during transfers and toileting. The resident, who had diagnoses including dementia and was severely cognitively impaired, was assessed as needing partial staff assistance for bathing and toileting, and supervision for transfers. Despite this, on the day of the fall, documentation indicated that the resident was left to transfer and toilet independently, with no staff setup or physical help provided. This lack of assistance was confirmed by point of care records and an anonymous interview, which revealed that the resident's family observed the fall via a camera and had to notify staff. Further review of the resident's clinical record and interviews with staff confirmed that the care plan accurately reflected the resident's need for assistance, especially during periods of illness such as a urinary tract infection (UTI), which was present at the time of the incident. Previous nursing notes and event reports documented the resident's difficulty with transfers and increased confusion and falls associated with the UTI. Despite these documented needs and care plan directives, staff failed to provide the necessary support, resulting in a fall.
Missing self-administration assessment and orders for bedside medications
Penalty
Summary
The facility failed to ensure that Resident 27 had a self-administration of medication assessment, physician orders, and a care plan for self-administration of medication despite medications being observed at the bedside during two random observations. On 8/12/25, surveyors observed Volteran Cream, dry eye drops with no name, saline drops with no name, Vicks Vapor Rub with no name, and a large white pill marked 196 on the resident’s over-bed table. On 8/13/25, surveyors again observed Volteran Cream, dry eye drops with no name, and saline drops with no name on the over-bed table. Resident 27’s clinical record was reviewed on 8/13/25 and showed diagnoses including type 2 diabetes mellitus with diabetic kidney disease and hypertensive heart and chronic kidney disease with heart failure. The current admission MDS indicated the resident was cognitively intact and required setup for eating, moderate help with hygiene, and moderate help with dressing. The record lacked an order for self-administration and an assessment, and a care conference held on 7/9/25 did not include a care plan for self-administration of medications. The DON stated there should be no medications at the resident’s bedside unless there was an order and a self-medication assessment completed. The facility policy provided by the Administrator stated residents would have a self-administration of medication assessment in the electronic health record and that results would be presented to the physician for evaluation and an order for self-medication.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to provide a safe environment free of pests when surveyors observed a moderate amount of small, black ants in Resident 27’s restroom on two separate observations. The ants were seen along the base of the toilet, the bathroom wall, and the air conditioner, and on the second observation they were again noted around the base of the toilet and along the wall. Resident 27 stated that the facility was to spray for the ants, and also reported that her son killed a larger cricket the prior night. The resident had food in drawers, and each item was individually sealed. During interview, an LPN stated there should be no bugs in resident rooms. The Administrator later provided a pest control policy stating the facility maintains an ongoing pest control program to keep the building pest free.
Incomplete Discharge Documentation for Resident Transfer
Penalty
Summary
The facility failed to complete the required discharge documentation for a resident with diagnoses including hemiplegia, hemiparesis following cerebral infarction, aphasia, and dysphagia. The resident was admitted with intact cognition and had a care plan to return to their previous living environment after rehabilitation. Upon review, the transfer/discharge documentation was found to be incomplete, with key sections left blank. Specifically, the 'Reason for Transfer or Discharge' was not selected from the provided options, and instead, 'Resident Request' was handwritten. The physician's order indicated approval for discharge but did not provide further details regarding the discharge reason. Additionally, the clinical record lacked comprehensive documentation from the physician related to the discharge, aside from the order to discharge. The facility's policy requires recording the reasons, effective date, and location of transfer or discharge in the medical record and on the discharge form, as well as physician documentation of medical reasons for transfer or discharge. These requirements were not met, as confirmed by staff interviews and record review, resulting in incomplete discharge documentation for the resident.
Inadequate Catheter Care Leads to CAUTI and Hospitalization
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling urinary catheter, leading to the development of a catheter-associated urinary tract infection (CAUTI) and subsequent septic shock and pneumonia. The resident, who was significantly cognitively impaired and completely dependent on staff for daily activities, had an indwelling catheter due to obstructive uropathy. The clinical record lacked current orders for catheter care and documentation of physician notification for catheter use. Despite the resident showing signs of complications, such as blood in the urine, there was no documented assessment or physician notification. On one occasion, a catheter flush was performed without specific documentation of the technique or physician notification. The resident was later found with abnormal vital signs and was sent to the hospital, where they were diagnosed with septic shock secondary to a urinary tract infection and pneumonia. The facility's policy on catheter care did not address flushing or CAUTI prevention, and there was no catheter assessment tool in place. The lack of proper documentation, assessment, and physician notification contributed to the resident's severe health decline.
Failure to Provide Adequate Bathing Care for Dependent Residents
Penalty
Summary
The facility failed to ensure that residents who were dependent on staff for activities of daily living (ADL) received adequate bathing care. Four residents, identified as Resident 11, Resident 32, Resident 148, and Resident 6, were not bathed according to their care plans. Resident 32, who was significantly cognitively impaired and completely dependent on staff, received only four showers or complete bed baths in July and one in August, despite the care plan indicating showers per schedule. Similarly, Resident 11, who was moderately cognitively impaired and completely dependent on staff, received only two showers or complete bed baths in July and none in August. No shower schedule was available for review for either resident. Resident 148, who lacked a completed MDS assessment, had not received any showers or complete bed baths since admission. Resident 6, who was cognitively intact and required substantial assistance, reported not receiving showers as scheduled and was not offered a bed bath as an alternative when refusing a shower. The facility's policy indicated that bathing should occur at least twice a week, but this was not adhered to, as evidenced by the Point of Care History report and observations of Resident 6's condition.
Deficiency in Food Service Safety and Sanitation
Penalty
Summary
The facility failed to ensure food was served in a sanitary manner in accordance with professional standards for food service safety. During observations in the kitchen, surveyors noted that food items such as lunch meat and cookies in the walk-in cooler and freezer were not labeled. Additionally, the kitchen had soiled shelves under the grill and steamer, sides of the stove were dirty, and there was debris build-up on the floors under equipment and storage racks. The dishwasher area, edges of walls, and sides of the ice machine had calcium build-up, and vents were dusty. Further observations on the locked dementia unit revealed a refrigerator containing unlabeled food items, including a bowl of purple pureed food, muffins, macaroni salad, and orange pureed food. The Dietary Manager acknowledged that the pork chops delivered the previous week should have been labeled and explained that food was typically labeled after being opened and placed in a two-gallon bag. The facility had a policy on food labeling and dating, revised in 2019, which required labeling of any food product removed from its original container or with a broken seal, including the item name, date and time of labeling, use-by date, and initials of the person labeling the item.
Inadequate Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to ensure proper hand hygiene and sanitation practices were followed by staff during care activities for several residents. An LPN was observed not performing hand hygiene after removing gloves and before engaging in other tasks, such as assisting another staff member and charting on the computer. Similarly, a CNA did not perform hand hygiene after removing gloves and handling various items and tasks, including giving a resident a drink, stripping bed linens, and disposing of trash, before eventually washing hands after leaving the room. Additionally, during a wound care observation, an RN was noted to have washed hands for only nine seconds after removing gloves and gown, which is below the recommended duration. Furthermore, a sit-to-stand lift used by two CNAs to transfer a resident was found to have dirty buildup and a peeling grip mat, indicating a lack of proper equipment sanitation. The facility's policies on hand hygiene and standard precautions were provided, highlighting the expectations for hand hygiene before and after resident contact and the proper handling of potentially contaminated equipment.
Inadequate Supervision and Intervention for Residents
Penalty
Summary
The facility failed to ensure adequate supervision and interventions to prevent accidents for two residents. Resident 30, who was admitted following left hip surgery and had a history of Alzheimer's disease and muscle weakness, experienced multiple falls. Despite being at high risk for falls, the care plan interventions were not consistently updated or implemented effectively. For instance, nonskid strips were not placed in front of the toilet as required, and the resident had fallen 10 times since admission, often while attempting to self-toilet. The facility's failure to maintain a safe environment and provide necessary assistance contributed to these repeated incidents. Resident 32, diagnosed with Parkinson's disease, dementia, and dysphagia, required a modified diet and assistance with eating. However, during a group activity, the resident was given banana bread by another resident, despite being on a puree diet. This led to choking, requiring the Heimlich maneuver and subsequent hospitalization for aspiration and pneumonia. The facility lacked a policy on resident supervision during activities and failed to ensure staff followed diet orders, resulting in a serious health incident for Resident 32. The facility's policies on falls management and comprehensive care plans were not effectively implemented. The interdisciplinary team was expected to update care plans with new interventions following incidents, but this was not consistently done. The lack of adherence to these policies and the absence of a supervision policy contributed to the deficiencies observed in the care of Residents 30 and 32.
Failure to Address Nutritional Decline and Weight Monitoring
Penalty
Summary
The facility failed to address a resident's decline in nutritional status and follow dietary recommendations, leading to a significant weight loss for a resident with Parkinson's disease, dementia, and dysphagia. The resident required moderate assistance with eating and was on a modified diet due to swallowing difficulties. Despite physician orders for weekly weight monitoring and dietary supplements, there were inconsistencies in weight documentation, and several weekly weights were not recorded. The resident's weight fluctuated significantly, with a notable drop from 231 pounds to 175.4 pounds within a short period. The registered dietitian noted that some weight records were likely errors and recommended re-weighing the resident, but this was not consistently done. The assistant director of nursing acknowledged that the weight fluctuations were due to incorrect weighing practices and issues with the weight machine, which required calibration. Interviews with facility staff revealed that the weight discrepancies were attributed to improper weighing techniques and potential equipment malfunctions. The clinical record lacked thorough documentation of the resident's condition and the weight loss, and there was no evidence of diarrhea or edema during the period of weight loss, despite claims to the contrary. The facility's guidelines for weight tracking were not adequately followed, contributing to the deficiency.
Failure to Provide Proper Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident by not ensuring that oxygen equipment was properly labeled and that oxygen services were provided according to the physician's order. Resident 6 was observed receiving 5 liters of oxygen via nasal cannula, despite the physician's order indicating 3 liters. Additionally, the humidification bottle was empty and not dated, and the tubing was also not dated. Resident 6, who was cognitively intact, expressed uncertainty about the discrepancy in the oxygen level she was receiving. Further investigation revealed a lack of clarity among the staff regarding the responsibility for changing oxygen tubing and humidification bottles. An LPN was unsure about who was responsible for these tasks, and the ADON indicated that the night shift nursing staff was expected to change them according to the physician's order or as needed. However, the facility did not have a specific policy for following physician orders, although staff were expected to adhere to them. The Respiratory Equipment policy provided by Clinical Support 5 stated that sterile distilled water should be used for humidification over 4 liters per minute and that oxygen cannula and tubing should be changed monthly and as necessary.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure effective supervision for a cognitively impaired, dependent resident, resulting in an unwitnessed fall and a left clavicle fracture. Resident B, who had severe cognitive impairment and required substantial assistance for bed mobility, was found on the floor beside his bed with a skin tear on his left elbow. The care plan for Resident B included the use of a low bed with a fall mat, but these interventions were not in place at the time of the fall. On the day of the incident, CNA 1 and CNA 2 assisted Resident B with a check and change. After completing the task, CNA 1 left the bed in its highest position without placing the fall mat, contrary to the care plan. Approximately 20-30 minutes later, Resident B was found on the floor by CNA 1, who then called the nurse for an assessment. The Director of Nursing (DON) confirmed that the bed was not in the low position with a fall mat immediately after the fall. The facility's policies required that care plan interventions be communicated to the nursing staff and implemented to address the resident's risk factors. However, the failure to follow these protocols led to Resident B's fall and subsequent injury. The incident was documented in progress notes and a state reportable incident, and interviews with the involved CNAs corroborated the findings.
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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) |
|---|---|---|---|---|
| Terrace At Solarbron The | 1 mi | ★★★★★ | 25 | 0 |
| Park Terrace Village | 1.8 mi | ★★★★★ | 1 | 0 |
| River Bend Nursing And Rehabilitation | 3.7 mi | ★★★★★ | 23 | 0 |
| Parkview Care Center | 4.8 mi | ★★★★★ | 25 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 5.7 mi | ★★★★★ | 0 | 0 |
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