West River Health Campus: Fall Care Plan Failures - IN
The family called West River Health Campus to notify staff of the fall on August 2nd. An anonymous source told federal inspectors that staff were not assisting the resident during toileting or transfers, contradicting the facility's own care plan.
Resident F was severely cognitively impaired and required supervision from staff for transfers, according to the most recent assessment from June 25th. The resident's care plan, dating back to June 22nd of the previous year, specifically stated: "Resident is at risk for falling related to weakness and immobility, staff to assist resident with transfers as needed."
Yet facility records show staff documented the exact opposite on the day of the fall.
Point of care responses in the medical record revealed what actually happened. At 10:41 AM on August 2nd, staff recorded that the resident used the toilet "Independent" with "No setup or physical help from staff." For transferring, they again documented "Independent" with "No setup or physical help from staff" and noted that "None" were used for assistive devices.
The resident had been struggling with transfers for weeks. A nursing progress note from July 25th indicated Resident F "had trouble transferring out of bed" and "after several minutes resident was transferred to wheelchair with assistance from two staff members."
The fall occurred during a urinary tract infection that was already causing confusion and mobility problems. An event report from July 31st documented that Resident F "experienced confusion and falling as symptoms of a UTI." The resident had been prescribed Macrobid, an antibiotic, starting August 1st for the infection.
When inspectors interviewed staff, the stories didn't match the documentation.
Certified Nurses Aide 4 told inspectors on August 14th that Resident F "required assistance of one for transfer and toileting." This directly contradicted the facility's own records showing staff provided no help during the fall incident.
The Director of Nursing offered a different explanation during her August 15th interview. She said Resident F was "typically independent" and "only required staff assistance while having a UTI." She maintained that "the care plan level of assistance was accurate in stating Resident F needed assistance with transfers."
But the resident was having a UTI on August 2nd when the fall occurred. The infection had already been documented as causing confusion and falling symptoms two days earlier.
The facility's own policy, provided by the Administrator during the inspection, stated that "Goals should be measurable and attainable, interventions should be reflective of the individual's needs" and "Comprehensive care plans need to remain current and accurate."
Federal inspectors found the facility failed to ensure the resident's plan of care was followed. The care plan required staff assistance with transfers, yet staff documented providing none on the day family members watched their loved one fall through a camera.
The inspection revealed a troubling pattern: a dementia patient with documented transfer difficulties, a urinary tract infection causing confusion and falls, a care plan requiring assistance, and staff who recorded providing no help whatsoever during the incident that resulted in a fall witnessed by family.
The resident's diagnoses included dementia, and assessments showed severe cognitive impairment requiring partial assistance for bathing and toileting, with staff expected to "do half of the work." Yet when it came to transfers on August 2nd, staff documented doing none of the work.
The facility received a minimal harm citation affecting few residents, but for Resident F and the family watching through a camera, the failure to follow the care plan had immediate consequences. The resident fell while staff who should have been providing assistance were nowhere to be found, despite clear documentation that help was needed and required by the facility's own care plan.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West River Health Campus from 2025-08-15 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WEST RIVER HEALTH CAMPUS in EVANSVILLE, IN was cited for violations during a health inspection on August 15, 2025.
The family called West River Health Campus to notify staff of the fall on August 2nd.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.