West River Health Campus
Inspection Findings
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure a resident's plan of care was followed by providing assistance during transfers for 1 of 1 residents reviewed for falls. (Resident F) Finding includes: On 8/13/25 at 10:38 A.M., Resident F's clinical record was reviewed. Resident F was admitted on [DATE REDACTED]. Diagnoses included, but were not limited to, dementia. The most recent Significant Change Minimum Data Set (MDS) Assessment, dated 6/25/25, indicated Resident F was severely cognitively impaired, required partial assistance from staff for bathing and toileting (staff do half of the work), and required supervision from staff for transfers. During an anonymous interview on 8/12/25 at 8:15 A.M., it was indicated that Resident F had fallen on 8/2/25 where family viewed the fall through a camera and called the facility to notify staff of the fall, and staff were not assisting the resident during toileting or transfers. Physician orders included, but were not limited to: Macrobid (antibiotic medication) capsule; 100 mg (milligrams) oral, take one capsule by mouth twice a day for seven days for urinary tract infection (UTI); start date 8/1/25 Current care plan included, but was not limited to: Resident is at risk for falling related to weakness and immobility, staff to assist resident with transfers as needed; start date 6/22/24 A nursing progress note, dated 7/25/25 at 10:28 A.M., indicated Resident F had trouble transferring out of bed. After several minutes resident was transferred to wheelchair with assistance from two staff members. An event report, dated 7/31/25, indicated Resident F experienced confusion and falling as symptoms of a UTI. Point of care (POC) responses in the medical record were reviewed. The following indicated staff's responses to assisting Resident F with toileting and transfers the day of the fall: 8/2/25 at 10:41 A.M.: How did resident use the toilet? Independent; Staff support provided for toileting? No setup or physical help from staff 8/2/25 at 10:41 A.M. How did the resident transfer? Independent; Staff support provided for transferring? No setup or physical help from staff;What appliances or assistive devices were used for transferring? None During an interview on 8/14/24 at 11:15 A.M., Certified Nurses Aide 4 (CNA) indicated that Resident F required assistance of one for transfer and toileting. During an interview on 8/15/25 at 9:13 A.M., The Director of Nursing (DON) indicated Resident F was typically independent, only required staff assistance while having a UTI, and the care plan level of assistance was accurate in stating Resident F needed assistance with transfers. On 8/15/25 at 11:55 A.M., the Administrator provided a policy titled Comprehensive Care Plan Guidelines, dated 5/18, that indicated Goals should be measurable and attainable, interventions should be reflective of the individual's needs; Comprehensive care plans need to remain current and accurate 3.1-35(a)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
WEST RIVER HEALTH CAMPUS in EVANSVILLE, IN inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EVANSVILLE, IN, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WEST RIVER HEALTH CAMPUS or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.