Average — CMS composite of the measures below.
The next survey window likely opens 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 Riverwalk Post Acute during CMS and state inspections, most recent first.
A resident with Wernicke’s encephalopathy, who was generally alert and ambulatory with a cane, was last seen in common areas before being discovered missing from his room, triggering the facility’s missing resident code and a search of the building and grounds. Although the charge nurse notified law enforcement and the MD when the resident could not be found, the resident’s designated family contact was not notified at that time, contrary to facility policy requiring family notification when a resident is not located on-site. Interviews with the LVN, RN, and DON confirmed that nursing staff were responsible for notifying the family and documenting it, and that this did not occur until the next day, many hours after the initial discovery that the resident was missing.
A resident with Wernicke’s encephalopathy, described as sometimes confused and unhappy with placement, was observed moving between his room and common areas and was last seen in the lobby before staff later discovered he was missing. Staff reported that they did not check on him further because he was considered independent, and surveillance footage later showed him exiting the unsecured, unalarmed front door in regular clothes. After the receptionist left, no specific staff member was assigned to monitor the front entrance; instead, nurses and CNAs at the nearby station were expected to watch it, though they acknowledged this was not consistently possible during busy evening hours. The resident was subsequently found wandering offsite and transported to a GACH, demonstrating a failure to maintain an accident-hazard-free environment and provide adequate supervision to prevent elopement.
A resident with a history of repeated falls and high fall risk was admitted without fall prevention interventions included in the baseline care plan. Despite assessments indicating high risk, the BCP did not address falls, and the resident subsequently fell and was hospitalized. Staff interviews confirmed the omission of fall-related interventions in the care plan.
Facility assessment was not updated to accurately reflect the resident census or staffing needs. The ADM stated the assessment listed a census of 20-41 with an average of two charge nurses and six CNAs per shift, but this was inaccurate and likely came from another sister facility’s assessment. He stated the facility’s maximum census had always been 146, and the assessment did not accurately reflect the staffing needed to meet resident needs.
The facility failed to follow and document care for several residents. A resident with glaucoma and a right cataract had ophthalmology consults and post-op eye care that were not documented or care planned, another resident with CHF and a 1500 mL fluid restriction was not properly monitored for fluid intake and output, a resident ordered to wear a CTO brace when out of bed did not have a comprehensive care plan for brace use, and a resident with multiple skin discolorations had no documented assessment or physician notification.
Initial physician visits were not completed by the attending MD for four residents. Record review showed the initial H&P/face-to-face assessment was completed by PAs or NPs instead of the primary physicians, and the MRD confirmed the visits were not done by the residents’ primary physicians. The facility policy stated the attending physician must make visits in accordance with applicable state and federal regulations, while NPs and PAs may perform required visits only as permitted by those regulations.
Infection control practices were not followed for multiple residents. An LVN returned shared BP equipment to a cart without cleaning it after use, a resident’s foley tubing was left disconnected and on the floor without a care plan for self-care, respiratory tubing was not changed on the weekly schedule, and EBP was not in place for a resident with a foley catheter despite facility policy requiring gown and glove use for high-contact care with indwelling devices.
Nonfunctioning Call Light: A resident with a below-the-knee amputation and gait/mobility issues reported that the call light button had not worked since admission. During observation, pressing the button did not activate the signal light outside the room, and the resident said staff knew about the issue, had to unplug and replug the device to make it work, and that the resident sometimes had to wait for someone to pass by to ask for help. A CNA said the call light often became unplugged when the bed was moved, and maintenance said the issue was only fixed after a nurse asked him to repair it; the maintenance log had no report of the problem.
Baseline Care Plan Not Provided in Writing: A resident admitted after a BKA surgery stated she did not receive a written copy of her baseline care plan and did not know her discharge plan or plan of care during her stay. Record review showed the baseline care plan was completed by an LPN and discussed with the resident, but the facility did not provide a printed/written summary, and the DSS stated the facility usually did not give residents a copy.
Failure to develop a care plan for a resident with an indwelling foley catheter. A resident with urinary retention and obstructive reflux uropathy was observed with a foley catheter and drainage bag, and record review showed a physician order for catheter use. The DON confirmed there was no care plan addressing the catheter, despite the facility policy requiring a comprehensive, person-centered care plan with measurable goals and interventions.
An LVN administered medications to a resident despite incomplete and inappropriate physician orders. The resident had a Vitamin D3 order without a specified strength and a Toprol XL order with an incorrect hold parameter of HR <110; staff confirmed the missing strength and inappropriate parameter were not clarified before administration, and the DON stated unclear orders were expected to be clarified.
Smoking Materials Kept at Resident Bedside: A resident was observed with a carton of cigarettes between his legs in a motorized wheelchair and later had a lighter on his bedside table. The AD and DON stated facility process required the activity dept to keep all smoking materials and distribute them during smoke breaks, and the Smoking Policy prohibited residents from keeping cigarettes, lighters, or other smoking items in their room or on their person. The resident’s record showed HTN, CHF, and that he had decision-making capacity.
A resident with dysphagia, a gastrostomy tube, pulmonary fibrosis, and dementia was observed receiving enteral feeding while the HOB was flat instead of elevated 30 to 45 degrees. A CNA later raised the HOB, and the LVN who started the TF stated the HOB should be elevated during feeding to prevent aspiration but could not recall whether she had done so. The DON confirmed the HOB should have been elevated, and the resident’s orders and care plan directed elevation during enteral feeding.
An LVN left prepared meds unattended during a med pass while checking a resident’s BP, and the DON confirmed meds should not be left out of direct observation. For another resident with an oxycodone order for pain, staff gave only 1 tab when the order called for 2 tabs for severe pain. Controlled substance records also did not match the MAR for two residents, with missing CDR documentation for one oxycodone dose and missing MAR documentation for one oxycodone-acetaminophen dose.
Medication administration errors resulted in an 11.11% error rate after an LPN gave a resident chewable aspirin instead of the ordered delayed-release form and gave PRN oxycodone to two residents without first assessing or asking about pain. The LPN acknowledged the incorrect dosage form and that the pain levels documented in the MAR were not based on the residents' verbal reports, while the DON confirmed the medications should have been given according to the physician orders and pain assessment requirements.
A resident's legal representative did not receive requested medical records within the required timeframe after submitting a written request with proper authorization. The DMR forwarded the request to the legal department, but the records were not released within the facility's policy timeframe, resulting in a deficiency.
A resident with multiple medical conditions receiving palliative care had several personal belongings go missing after passing away. The facility did not update the inventory of the resident's belongings when new items were brought in, and a search for the missing items was unsuccessful. Staff interviews confirmed that facility policy required updating the belongings list, but this was not followed, resulting in the loss of items with potential sentimental value for the family.
A nurse held an antihypertensive medication for a resident despite the physician's order specifying it should only be held if systolic blood pressure was below 110, while the resident's reading was 119. The nurse did not notify the physician or document the deviation, and the DON confirmed the order was not followed.
A resident with a gluten allergy and physician orders for a gluten-free diet was served cornbread containing gluten. The resident identified the issue and declined to eat the cornbread, while staff interviews confirmed awareness of the allergy and the use of a cornbread mix with wheat gluten. Facility policies required avoidance of gluten for such residents.
A resident with muscle wasting and atrophy experienced severe weight loss over two consecutive months, but staff did not document weekly weight monitoring as required by facility policy. The DON confirmed that weekly weights should have been taken after the initial loss, but records showed this was not done.
Surveyors found that some resident rooms had adhesive residue, chipped paint, black marks on the walls, chipped baseboards, and stained floors. The MTD confirmed these issues were due to contact from beds or wheelchairs and previous electrical work, and stated that the floors could not be adequately cleaned. Renovations had not been completed in these rooms because residents and families did not want to move, and staff acknowledged the rooms were not in acceptable condition.
A facility failed to notify a resident's POA when a physician ordered lorazepam for anxiety, leaving the POA unaware of the resident's condition. Despite facility policy requiring notification of changes in medical condition, there was no documentation that the POA was informed, as confirmed by staff interviews and record reviews.
The facility failed to address significant weight loss in two residents, one with obstructive uropathy and another with diabetes mellitus. Despite notable weight loss, there was no evidence of physician or RD notification, nor were interventions initiated. The RD struck out an initial weight entry without informing the DON, causing confusion. The facility's policy for notifying the dietitian for weight changes was not followed, leading to unaddressed nutritional needs.
A resident with cerebral palsy and moderate risk for pressure injuries developed an unstageable pressure injury on the right hip due to the facility's failure to follow its prevention policy. The resident's wound was not properly assessed or documented, and the Treatment Nurse was unaware of the wound until it was observed by a CNA. The facility's policy required daily skin inspections and documentation, which were not adhered to, resulting in the oversight.
A facility failed to document a care conference for a resident with a fracture, mild intellectual disability, and cerebral palsy. Despite the care conference being conducted, it was not recorded in the electronic health record, PointClickCare (PCC). Interviews revealed that the Social Service Director (SSD) was unable to open the care conference note, and the interdisciplinary team (IDT) did not document their notes. The facility lacked a policy for mandatory documentation of care conferences, potentially impacting the resident's care plan.
A resident with moderate cognitive impairment was unable to reach their call light, which was found on the floor behind their bed. This deficiency was confirmed by a CNA, an LVN, and the DON, who all stated that the call light should be within reach to prevent delays in care. The facility's policy supports this practice, but it was not followed in this instance.
A facility failed to monitor a dialysis catheter for a resident with ESRD, leading to improper care. Another resident with CHF and CKD did not receive physician-ordered fluid restrictions, with records showing excess fluid intake. Additionally, a resident's skin condition was not assessed or treated, resulting in dry and scaly skin. Staff interviews confirmed these deficiencies.
The facility failed to implement infection control practices for two residents. A resident's oxygen nasal cannula was left exposed on the bed, contrary to the facility's policy of storing it in a plastic bag to prevent infection. Another resident's wound vacuum device and tubing were left on the bedside table after a dressing change, with the Treatment Nurse admitting to not discarding the used tubing or disinfecting the equipment, risking cross-contamination. Both incidents were acknowledged by the facility's staff as breaches of infection control protocols.
A resident with a history of behavioral issues was discharged from a facility without proper documentation after being cleared from a psychiatric hold. Despite being initially given a 30-day discharge notice, the facility failed to issue a new notice or re-evaluate the resident's condition after hospital clearance. Interviews with staff indicated ongoing behavioral challenges, but the facility did not follow its procedures for re-evaluation, leading to a deficiency in the discharge process.
A facility failed to provide an updated discharge notice for a resident who was not readmitted after a hospital stay. The resident was initially transferred for psychiatric evaluation, and a 30-day discharge notice was issued. However, after the psychiatric hold was lifted, no new notice was sent to the resident or the Ombudsman, despite the decision not to readmit the resident. Interviews revealed that staff did not complete or send an updated notice, contrary to facility policy.
A resident with major depressive disorder and generalized anxiety disorder was transferred to a hospital due to aggressive behavior without being provided a notice of bed-hold. The facility's staff, including the Social Services Director and DON, were unaware of the requirement to issue such a notice, despite the facility's policy mandating it for all residents during periods of absence.
A resident with a history of violent behavior was not re-evaluated for re-admission after being cleared from a psychiatric hold at a hospital. Despite being cleared, the facility refused re-admission, citing ongoing behavioral issues. The facility did not provide a new discharge notice or document a re-evaluation of the resident's condition, failing to adhere to its policies on transfer and discharge.
The facility failed to ensure timely response to call lights, with residents reporting waits of up to an hour, leading to unmet care needs and potential risks. Staff confirmed the importance of prompt responses, and facility policies were reviewed, highlighting the deficiency.
Failure to Notify Family of Resident Elopement
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s family member when the resident eloped from the facility. The resident was admitted with diagnoses including Wernicke’s encephalopathy and had a family member listed as emergency contact number one. An elopement and wandering risk assessment indicated the resident was alert and oriented to person, place, and time and able to follow instructions. Nursing notes documented that on the evening in question, the resident was alert, oriented to two spheres, able to follow commands, and ambulatory with a cane. The resident was last seen at the nurses’ station around 6:30 p.m. and later in the lobby doing word search puzzles, and then was noted to be missing from his room at approximately 8:50 p.m., prompting a facility-wide search and activation of the facility’s missing resident code. When the resident could not be located within the building or on the grounds, staff initiated external search efforts, and the charge nurse notified law enforcement and the physician. However, the charge nurse did not notify the resident’s family member at that time, despite the facility’s policy requiring family/responsible party notification when a resident is not found in the facility or on the grounds. Interviews later confirmed that the LVN did not contact the family because staff were still looking for the resident, and the LVN acknowledged the family should have been notified. The RN stated she had asked the LVN to call the family, and the DON stated that the RN or LVN is responsible for notifying the family and documenting it in the record. Documentation showed that social services did not attempt to contact the family until the following day, nearly 15 hours after the resident was first noted missing, at which time the family reported the resident was at a general acute care hospital. This sequence of events demonstrates that the facility did not follow its own emergency procedure for missing residents regarding timely family notification.
Failure to Prevent Resident Elopement Through Unmonitored Front Door
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment and adequate supervision to prevent a resident from exiting the facility without staff knowledge. The resident was admitted with Wernicke’s encephalopathy and was described in various assessments as alert and oriented to name and place, sometimes to time, but also forgetful, confused at times, and unhappy or not accepting of placement. An elopement and wandering risk assessment documented that the resident was alert and oriented x3 and able to follow instructions, while also expressing dissatisfaction with being in the facility. Nursing notes indicated the resident was ambulatory with a cane and moved between his room, the lobby, activity room, and patio. On the day of the incident, staff documented that the resident was in his room at approximately 3:15 p.m., later seen in the lobby doing word search puzzles, and received medications in the lobby around 4:00 p.m. The resident ate dinner in his room between about 4:30 and 5:00 p.m., and was again seen at the front nurse station asking for a pen and sitting in the lobby. The charge nurse reported noticing during rounds between 6:00 and 6:30 p.m. that the resident was not in his room, and staff initiated the facility’s missing resident code and searched the building and surrounding area without locating him. A CNA reported last seeing the resident around 5:50 p.m. when picking up the dinner tray and stated he did not check further on the resident because he considered the resident independent. Review of surveillance footage with maintenance staff showed the resident, dressed in regular clothes, exiting through the front door at 6:59 p.m. It was noted that the front door did not have an alarm at that time and was routinely locked at 8:00 p.m. Interviews with nursing staff and the DON revealed that after the receptionist leaves, there is no specific person assigned to monitor the front door; instead, LVNs, the desk nurse, charge nurse, RN, or a CNA at Station 1 are expected to keep an eye on it. Staff acknowledged that although there should always be someone at Station 1, this was not guaranteed, especially during busy hours between 6:00 and 9:00 p.m. The resident was later reported by a GACH RN to have been found by law enforcement wandering on a college campus and transported to the hospital. The facility’s policy stated that the environment should be as free from accident hazards as possible and that resident safety, supervision, and assistance to prevent accidents are facility-wide priorities.
Failure to Include Fall Prevention in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan (BCP) was developed within 48 hours of admission to address a resident's high risk for falls. Upon admission, the resident had a documented history of repeated falls, left-sided weakness, was non-ambulatory, and required assistance with transfers and dressing. The admission and fall risk assessments both indicated the resident was at high risk for falls, yet the BCP did not include any mention of the resident's fall history or interventions to prevent falls. Subsequently, the resident experienced a fall while attempting to reach for clothes independently, resulting in injury to the shoulder and head, and required transfer to an acute hospital. Interviews with facility staff, including an LVN, DON, and ADON, confirmed that the BCP lacked necessary fall prevention interventions and did not communicate the resident's fall risk to staff. The facility's policy required a baseline care plan to address immediate health and safety needs, but this was not followed in the resident's case.
Facility Assessment Did Not Reflect Actual Census or Staffing Needs
Penalty
Summary
The facility failed to review and update its facility assessment to accurately reflect the current resident census and the sufficient staffing levels needed to meet residents’ needs. During a concurrent interview and record review on December 11, 2025, the Administrator stated he was responsible for conducting the facility assessment and that the last update was completed on November 11, 2025. When the facility assessment dated [DATE] was reviewed, the Administrator stated the assessment should reflect the accurate census of the facility and sufficient staffing needs. The general staffing plan in the facility assessment indicated the facility census was between 20-41 and required an average of two charge nurses and six CNAs per shift. The Administrator stated this section was inaccurate and probably came from another sister facility’s assessment. He stated the facility had always had a maximum census of 146, and that the facility assessment dated [DATE] did not accurately reflect the facility census and sufficient staffing needs of the residents. The facility policy titled Facility Assessment, revised October 2018, stated that once a year, and as needed, a designated team conducts a facility-wide assessment to ensure resources are available to meet the specific needs of residents and to help determine budget, staffing, training, equipment, and supplies needed.
Failure to Follow Orders and Document Care for Eye Treatment, Fluid Restriction, CTO Use, and Skin Changes
Penalty
Summary
The facility failed to provide appropriate treatment and care according to orders, resident preferences, and goals for four residents reviewed for quality of care. For Resident 130, the record showed ophthalmology consults related to poor vision, glaucoma, and a visually significant right eye cataract, but there was no documented evidence that licensed nurses assessed or evaluated the resident before the referral, no progress notes documenting the consult results, and no care plan developed or initiated to address the eye conditions. The resident was observed with redness, swelling, and dry white crusted discharge on the right lower eyelid after reporting a right cataract surgery, and the record also lacked documentation of assessment and monitoring after the surgery and monitoring for side effects of the prescribed eye antibiotic. For Resident 33, the physician ordered a 1500 mL fluid restriction in 24 hours related to CHF, with intake divided across nursing shifts and meals. During observation, the resident had water pitchers at bedside and stated he was not on a fluid restriction diet, while staff interviews indicated the resident was not being monitored for fluid restriction or intake and output. The record included a care plan intervention for fluid restriction and monitoring intake and output, but there was no documented evidence that the fluid restriction order was followed correctly or that intake and output monitoring was performed during the restriction period. For Resident 78, the physician ordered a CTO brace when out of bed for a compression fracture of T5 to T6. The resident was observed without the brace at one point and stated she was uncomfortable and did not want it on, while staff later observed the brace in the closet and stated CNAs were expected to apply it when the resident was out of bed. The DON acknowledged the resident did not have a comprehensive care plan developed to address CTO use. For Resident 178, multiple purplish to reddish skin discolorations were observed on the hands, arms, shoulders, and left calf, but staff stated they were not aware of the discolorations, and there was no documented evidence that the skin changes were identified, assessed, or reported to the physician.
Initial Physician Visit Not Completed by Attending Physician
Penalty
Summary
The facility failed to ensure that a physician conducted the initial face-to-face visit for four residents reviewed for physician services: Residents 5, 12, 57, and 160. Record review showed that Resident 5’s progress note dated March 12, 2025, documented the history and physical assessment as completed by PA 1; Resident 12’s progress note dated May 31, 2025, documented the history and physical assessment as completed by NP 2; Resident 57’s progress note dated November 14, 2025, documented the history and physical assessment as completed by NP 1; and Resident 160’s progress note dated October 12, 2025, documented the history and physical assessment as completed by PA 1. During a concurrent interview, the Medical Records director stated that these residents’ initial history and physical assessments were not done by their primary physicians. The Medical Records director stated the facility encourages primary physicians to complete the initial visit, but she was not sure why it was not done, and stated that the primary physicians should conduct the residents’ initial history and physical assessments. The facility policy titled, Physician Visits, stated that the attending physician must make visits in accordance with applicable state and federal regulations, and that non-physician practitioners may perform required visits as permitted by state and federal regulations.
Infection control practices not followed for shared equipment, catheter care, respiratory tubing, and EBP
Penalty
Summary
The facility failed to implement infection prevention and control practices for four residents reviewed for infection control concerns. During observation of medication administration, an LVN used a shared blood pressure machine with an attached cuff for Resident 66 and then returned the equipment to the medication cart drawer without cleaning or disinfecting it. The LVN later acknowledged the equipment was shared and should have been cleaned and disinfected after use with disinfectant wipes kept in the medication cart. Another LVN and the DON stated shared BP equipment should be cleaned before and after each use, and the facility policy required reusable resident-care equipment, including BP cuffs, to be cleaned and disinfected according to CDC recommendations and manufacturer instructions. For Resident 2, who was admitted with chronic kidney disease, immunodeficiency, and benign prostatic hyperplasia, a disconnected foley catheter insertion tubing was observed at bedside on the floor and readily available for use. The resident stated he disconnected himself from the foley catheter bag to the leg bag twice daily and used the foley bag at night and the leg bag during the day. The LVN stated the tubing should not have been on the floor and that Resident 2 had not been care planned for self-care of the foley catheter. The DON stated the facility process was to care plan independent residents for foley catheter care and that Resident 2 should not have been disconnecting himself; the facility policy required catheter tubing and drainage bags to be kept off the floor. For Resident 94, who had asthma, orthopnea, and immunodeficiency, nasal cannula tubing connected to an oxygen concentrator was observed dated November 30, 2025. The LVN stated the facility process was to change respiratory tubing every seven days and that the tubing should have been changed the day before the observation. The DON confirmed the weekly change schedule and stated the tubing should have been changed on that date. The facility policy for respiratory equipment required the oxygen cannula and tubing to be changed every seven days or as needed. For Resident 57, who had obstructive reflux uropathy and a physician order for a foley catheter attached to gravity drainage, the facility did not have Enhanced Barrier Precaution in place when the resident was admitted with the catheter. An observation showed no EBP setup or sign outside the resident’s room at one point, and later an EBP setup and sign were present. The CNA stated the resident had not been on EBP before and that the setup had just been placed by the Infection Preventionist Nurse. The record review showed no documented EBP order or care plan related to the foley catheter since admission, and the IPN and DON both stated the resident should have been placed on EBP when admitted with the catheter. The facility policy stated EBPs are used for residents with indwelling medical devices, including urinary catheters, and include gown and glove use during high-contact care activities.
Nonfunctioning Call Light
Penalty
Summary
The facility failed to ensure the call light button was functioning properly for one resident who was reviewed for resident rights. During an observation and concurrent interview, the resident was in bed, alert, and interviewable, and stated that the call light button had not worked since admission the prior week. The resident demonstrated pressing the button, but the call light signal bulb outside the room did not turn on. The resident stated staff were aware of the problem and had to plug and unplug the call light from the wall for it to work, and that the resident often had to wait for someone to pass by the door to ask for help. The resident also stated that at one time the call light was turned on, but it was unclear whether anyone responded, and the resident eventually transferred from the bed to the commode unassisted. Record review showed the resident was admitted with diagnoses including absence of the right leg below the knee and abnormalities of gait and mobility. The physician history and physical indicated the resident had the capacity to understand and make decisions. The care plan identified the resident as at risk for mobility decline and needing assistance related to fluctuating ADLs, pain, recent hospitalization, recent surgery, and weakness, with an intervention to encourage use of the call light for assistance. A CNA stated the resident had been moved to another room and that the call light often became unplugged when the bed was moved, causing the button to stop working until staff plugged it back in. Maintenance staff stated a nurse asked him to fix the call light at the resident's previous bed because it was not working, and he replaced it that morning. The maintenance log did not show any report of the non-functioning call light from December 3 through December 9, 2025, despite the facility policy stating call lights are to be kept in good working order.
Baseline Care Plan Not Provided in Writing
Penalty
Summary
The facility failed to ensure that a written copy of the baseline care plan was provided to Resident 188 within 48 hours of admission. Resident 188 was admitted after a right below the knee amputation surgery and, during an observation and interview on December 8, 2025, was alert, conversant, and stated she had no idea about her discharge plan or the plan of care during her stay. She also stated she did not receive a written copy of her baseline care plan and did not recall discussing it with facility staff. Record review showed Resident 188 was admitted with diagnoses including absence of the right leg below the knee and abnormalities of gait and mobility. The physician history and physical dated December 5, 2025, indicated she had the capacity to understand and make decisions. The baseline care plan, completed by a licensed nurse on December 3, 2025, listed nursing services, cognition as alert/cognitively intact, and reasons for nursing services including ADLs and PT/OT management, but the section for baseline care plan summary did not indicate whether the resident or resident representative participated in the review with a printed or written summary provided. During interview, the DSS stated a baseline care plan discussion was conducted with Resident 188 on December 3, 2025, but a written copy was not provided, and the facility usually did not give residents a copy of the baseline care plan.
Failure to Develop Care Plan for Foley Catheter Use
Penalty
Summary
The facility failed to ensure a care plan was initiated and/or developed to address the need and use of an indwelling foley catheter for Resident 57. On December 8, 2025, Resident 57 was observed in bed, alert and interviewable, with a foley catheter and a covered urine drainage bag hanging by the bed and off the floor. During the concurrent interview, the resident stated she had been using the foley catheter since admission to the facility in November 2025. Record review on December 10, 2025 showed Resident 57 was admitted with diagnoses including obstructive reflux uropathy. A physician order dated November 11, 2025, directed use of a foley catheter 16# 10 cc bulb attached to gravity drainage bag for urinary retention. There was no documented evidence that a care plan had been developed or initiated to address the foley catheter use since admission. During interview, the DON stated Resident 57 did not have a care plan developed to address the use of a foley catheter and stated the care plan informs staff and residents about care procedures and interventions related to foley catheter use.
Unclear medication orders were not clarified before administration
Penalty
Summary
The facility failed to ensure medications were administered in accordance with professional standards of practice for one resident observed during medication administration. During an observation, an LVN prepared and administered medications to the resident while the clinical record showed a Vitamin D3 order that did not specify the medication strength. The MAR showed Vitamin D3 had been administered on prior dates, and during interview and record review, an LVN confirmed the strength was missing and stated the dose should have been clarified to determine which strength to administer. The DON stated nursing staff were expected to clarify unclear physician orders, including missing medication strength, upon receipt of the order or before administration. The facility also failed to clarify an order for Toprol XL 100 mg that included a holding parameter of hold if HR <110. The resident’s MAR showed the medication was administered even when the resident’s HR was less than 110 and SBP was greater than 110. During interview and record review, an LVN acknowledged the resident’s HR had been less than 110 and confirmed the medication had been administered daily, stating the holding parameter related to heart rate was inappropriate and should have been clarified. The DON stated the holding parameter of HR <110 was incorrect and that unclear physician orders, including inappropriate holding parameters, were expected to be clarified upon receipt of the order or before medication administration.
Smoking Materials Kept at Resident Bedside
Penalty
Summary
The facility failed to maintain a safe environment and provide adequate supervision to prevent accidents for one resident reviewed, Resident 2, when smoking materials were observed at the resident’s bedside. On December 9, 2025, Resident 2 was observed sitting in his motorized wheelchair, alert and interviewable, with a red carton of cigarettes between his legs. Later that morning, a clear yellow lighter was observed on his bedside table. Resident 2 stated that he kept his cigarettes and lighter with him at bedside. During a concurrent interview and record review, the Activity Director stated the facility process was for the activity department to keep residents’ cigarettes and lighters and distribute them during smoke breaks, and that residents were not allowed to keep smoking materials at bedside. The Director of Nursing later stated the facility process was for all smoking material to be kept with the activity department and that Resident 2 should not have had smoking materials at his bedside. Resident 2’s record showed he was admitted with diagnoses including hypertension and congestive heart failure, and his history and physical dated November 13, 2025, indicated he had the capacity to make decisions. His smoking assessment indicated he denied smoking or use of tobacco products. The facility’s Smoking Policy stated that no lighting materials, tobacco products, or smoking devices were allowed to be kept in the possession of the resident, either on the person or in the room, and that all smoking materials would be retained by staff.
Improper positioning during tube feeding
Penalty
Summary
Resident 7, who had diagnoses including dysphagia, gastrostomy, pulmonary fibrosis, dementia, and muscle wasting and atrophy, was receiving enteral nutrition through a gastrostomy tube when the head of the bed was observed flat rather than elevated. On December 8, 2025, at 12:35 p.m., the resident was seen awake and unable to communicate while tube feeding was infusing, and the bed was not positioned at the 30 to 45 degrees described by staff as required during tube feeding. At 12:44 p.m., a CNA entered the room and raised the head of the bed to approximately 30 degrees. During interviews, the CNA stated the head of the bed should have been elevated while the resident was receiving tube feeding. The LVN who started the tube feeding at noon stated the head of the bed should be elevated 30 degrees during tube feeding to prevent aspiration, but she did not remember whether she had done so. The DON also stated the head of the bed should have been elevated 30 to 45 degrees while the resident was receiving tube feeding. The resident’s physician orders included keeping the head of the bed elevated due to shortness of breath when lying flat and an enteral feeding order via gastrostomy tube, and the care plan directed that the head of the bed be elevated to at least 30 degrees to minimize complications related to enteral nutrition.
Medication Administration and Controlled Substance Documentation Errors
Penalty
Summary
Safe and effective pharmaceutical services were not provided when medications were left unattended during administration for a resident receiving folic acid and gabapentin. During a medication pass, an LVN prepared the medications, entered the resident’s room with the medication tray and blood pressure machine, and placed the tray on a bedside table away from the resident’s bed while the privacy curtain was drawn and the nurse measured the resident’s blood pressure. The medications remained out of the nurse’s direct observation until the blood pressure check was completed and the tray was retrieved for administration. The LVN later confirmed the medications had been left unattended, and the DON stated medications should not be left unattended during administration. Pharmaceutical services were also not provided according to physician’s orders for a resident with an oxycodone order for pain. The order directed 1 tablet for moderate pain and 2 tablets for severe pain. The resident’s record showed pain ratings of 8, 7, and 7 on three occasions, but nursing staff administered only 1 tablet each time. The DON reviewed the order and confirmed the medication was not administered in accordance with the physician’s directions on the dates when severe pain was documented. Controlled substance accountability records did not reconcile with the MAR for two residents. For one resident, the MAR showed oxycodone was administered, but the CDR lacked documentation showing removal of the tablet. For another resident, the CDR showed one tablet of oxycodone-acetaminophen was removed and signed out, but the MAR did not document the administration. The DON confirmed these discrepancies between the CDR and MAR, and the facility policy stated medications are to be administered in accordance with prescriber orders and documented on the MAR after administration.
Medication Administration Errors Involving Incorrect Aspirin Form and Missing Pain Assessments
Penalty
Summary
The facility had a medication error rate of 11.11% after three medication errors were identified during 27 medication administration opportunities for two residents. The errors involved Resident 142 and Resident 159 during observation, interview, and record review, and included administration of an incorrect dosage form and administration of as-needed pain medication without the required pain assessment before giving the medication. During a medication administration observation, LVN 1 prepared and gave aspirin 81 mg chewable tablet to Resident 142 even though the physician order was for Aspirin Low Dose Oral Tablet Delayed Release 81 mg, 1 tablet by mouth two times a day for CVA prophylaxis. LVN 1 later acknowledged that the delayed-release tablet should have been administered as ordered. The DON also reviewed the order and stated the correct dosage form should be given according to the physician's order. The facility policy stated medications are to be administered in accordance with prescriber orders and the label is to be checked three times to verify the right dosage before giving medication. The same observation showed LVN 1 administered oxycodone 5 mg to Resident 142 without first assessing or asking the resident's pain level, even though the order was for oxycodone 5 mg immediate release to be given every 4 hours as needed for moderate pain 4-6, and 2 tablets for severe pain 7-10. Resident 142's MAR later documented pain as 6, but LVN 1 stated that documentation was not based on the resident's verbal report. LVN 1 also administered oxycodone 5 mg to Resident 159 without first assessing or asking the resident's pain level, despite an order for oxycodone 5 mg every 6 hours as needed for severe pain 7-10. LVN 1 acknowledged the pain levels documented in the MAR were not based on the residents' verbal reports, and facility policies required pain assessment prior to administering analgesic pain medication.
Failure to Timely Provide Medical Records to Legal Representative
Penalty
Summary
The facility failed to provide copies of a resident's medical records upon request and within the required two business days after receiving a request from the resident's legal representative. The resident, who had diagnoses including respiratory failure and type 2 diabetes mellitus, had been transferred to an acute care hospital and did not return. The legal representative, through an attorney, submitted a written request for the resident's complete medical records, including a signed authorization form. The Director of Medical Records (DMR) received the request and forwarded it to the facility's legal department, following the facility's usual process for requests from law firms or subpoenas. Despite the DMR uploading the resident's entire medical record to a secure link provided by the legal department, the records were not released to the legal representative within the required timeframe. Interviews with the DMR, Director of Nursing (DON), and Nurse Consultant revealed confusion regarding responsibility for fulfilling such requests, with the DMR and DON deferring to the legal department. The facility's policy indicated that non-personnel representatives, such as legal firms, should have access to records within 30 days of a written request, but the records were not provided within this period, resulting in the deficiency.
Failure to Safeguard Resident Belongings After Death
Penalty
Summary
The facility failed to safeguard the personal belongings of a resident after the resident passed away. The resident, who had diagnoses including cerebrovascular disease, cerebral infarction, anemia, and was receiving palliative care, had an inventory of personal effects completed upon admission. After the resident's death, the family reported several missing items, including a radio/CD player, a jazz CD, a pair of pajama pants, and a pair of reading glasses. The facility's Social Worker confirmed that these items were not found despite a search and acknowledged that the belongings list was not updated when new items were brought in by the family. Interviews with facility staff, including the Social Worker and the DON, revealed that the facility's policy required updating the inventory of resident belongings as necessary, but this was not done in this case. The facility's own policy also stated that resident belongings should be treated with respect and that residents have the right to be free from theft or misappropriation of property. The failure to update the belongings list and secure the resident's property resulted in the loss of items that could have had sentimental value for the family.
Antihypertensive Medication Held Outside Physician Order Without Notification
Penalty
Summary
A deficiency occurred when a nurse failed to administer an antihypertensive medication, losartan-hctz, to a resident in accordance with the physician's order. The physician's order specified that the medication should be held only if the resident's systolic blood pressure (SBP) was less than 110 or pulse was less than 60. On the date in question, the resident's SBP was 119, which was above the hold threshold, but the nurse held the medication based on her own judgment, citing concern that the blood pressure was 'low.' There was no documentation that the resident's physician was notified about the medication being held outside of the ordered parameters. The Director of Nursing confirmed that the nurse did not follow the physician's order and that there was no progress note or physician notification regarding the held dose. The facility did not have a specific policy on holding blood pressure medications, but the expectation was that nurses would follow physician orders and document any deviations.
Failure to Provide Gluten-Free Diet as Ordered
Penalty
Summary
A resident with a documented gluten allergy and the capacity to make decisions was admitted with physician orders specifying a gluten-free diet. Despite these orders, the resident reported being repeatedly served food containing gluten, specifically cornbread, which she identified as containing gluten and therefore could not eat. During meal service, her tray was observed to include cornbread, and her meal ticket indicated her gluten allergy. The resident stated she would only eat the vegetables provided, as the cornbread would upset her stomach. Interviews with facility staff revealed that the dietary supervisor was aware of the resident's gluten allergy and that the facility used a standard cornbread mix containing wheat flour and wheat gluten. The dietary supervisor could not explain why the resident was served cornbread, and the director of nursing confirmed that dietary staff should ensure residents with gluten allergies do not receive gluten-containing foods. Facility policies reviewed indicated the importance of avoiding wheat products, including cornbread, for residents with gluten intolerance or allergies.
Failure to Monitor Weight Weekly After Significant Weight Loss
Penalty
Summary
The facility failed to follow its weight management policy for one resident who experienced significant weight loss. According to the resident's records, there was a loss of 17 lbs. between December 2024 and January 8, 2025, and a further loss of 13 lbs. by February 4, 2025. Despite this severe weight loss, there was no documentation of weekly weight monitoring after the initial loss was identified, as required by the facility's policy. The policy states that any weight change of 5% or more should prompt a retake the next day for confirmation and weekly monitoring thereafter. The deficiency was confirmed through record review and interview with the DON, who acknowledged that the resident should have been weighed at least weekly following the observed weight loss. The resident had diagnoses including muscle wasting and atrophy, making weight monitoring particularly important. The lack of weekly weight documentation after the significant weight loss was a direct violation of the facility's established procedures for weight assessment and intervention.
Failure to Maintain Clean and Comfortable Resident Rooms
Penalty
Summary
Surveyors observed that certain resident rooms were not maintained in a clean and comfortable condition. Specifically, one room had adhesive residue, chipped paint, black horizontal lines across the wall in front of the residents' beds, chipped baseboards, and yellow and black stains on the floor. Another room had adhesive residue, chipped paint, and black horizontal lines on the wall in front of the residents' beds. These conditions were directly observed during the survey, and the Maintenance Director confirmed the presence of these issues, attributing the black lines and chipped baseboards to contact with beds or wheelchairs, and the adhesive residue and chipped paint to recent electrical work. The Maintenance Director also acknowledged that the floor was old, stained, and could not be adequately cleaned. Interviews with facility staff revealed that renovations had begun three years prior, but some rooms, including those observed, had not yet been renovated because residents and their families were reluctant to move out. The Maintenance Director stated that repairs and renovations could not be performed while rooms were occupied. The Director of Nursing confirmed that room changes were necessary for renovations but were sometimes resisted by residents and families. The Administrator stated that maintaining resident rooms was a team effort, primarily overseen by the Maintenance Director, and acknowledged that the observed room conditions were not acceptable and could be off-putting to residents. Facility policy requires that all areas be maintained in a safe and operable manner, in compliance with regulations, and free from hazards.
Failure to Notify POA of Medication Change
Penalty
Summary
The facility failed to notify the power of attorney (POA) for Resident 1 when a physician ordered lorazepam, an anti-anxiety medication, for the resident. This oversight resulted in the POA being unaware of the resident's overall condition. The resident was admitted with diagnoses including obstructive uropathy and had a designated POA. On November 22, 2024, a Licensed Vocational Nurse (LVN) documented receiving a new order for lorazepam for the resident's anxiety and restlessness, but there was no evidence that the POA was informed of this new medication order. Interviews with facility staff, including LVN 2, the Assistant Director of Nursing (ADON), and the Director of Nursing (DON), confirmed that the POA should have been notified of the new orders. The facility's policy requires prompt notification of the resident's representative for changes in medical or mental condition. However, the medical record review and staff interviews revealed a lack of documentation indicating that the POA was informed, highlighting a failure to adhere to the facility's policy and procedure.
Failure to Address Significant Weight Loss in Residents
Penalty
Summary
The facility failed to evaluate and address significant weight loss in two residents, leading to potential nutritional deficiencies. Resident 1 was admitted with obstructive uropathy and was at risk for malnutrition. Despite a documented weight loss of 15 lbs. or 8.9% within two weeks, there was no evidence that the physician or registered dietician (RD) was notified, nor were any interventions initiated. The RD later struck out the initial weight entry, citing it as an outlier, but this action was not communicated to the Director of Nursing (DON), leading to confusion about the resident's weight status. Resident 2, diagnosed with diabetes mellitus, experienced a weight loss of 25 lbs. or 11% over two weeks. Although the Licensed Vocational Nurse (LVN) verbally notified the Physician's Assistant, this was not documented, and no change of condition report or care plan was initiated. The resident was aware of the weight loss but had not been consulted about his nutrition plan. The RD was informed of the weight loss but was not updated on any re-weighing results, and there was no documentation of physician notification or intervention initiation. The facility's policy required immediate notification of the dietitian for weight changes of 5% or more, but this protocol was not followed. The lack of documentation and communication among staff members contributed to the oversight in addressing the residents' nutritional needs, as evidenced by the unaddressed weight loss and absence of documented interventions.
Failure to Prevent and Address Pressure Injury
Penalty
Summary
The facility failed to adhere to its policy and procedure for the prevention of pressure injuries for a resident, resulting in an unstageable pressure injury on the resident's right hip. The resident, who was admitted with cerebral palsy and an unspecified local infection of the skin, was at moderate risk for developing pressure injuries according to the Braden Scale. Despite this, the facility did not conduct a proper assessment or follow-up after a dressing was placed on the resident's right hip. The deficiency was identified when a Certified Nurse Assistant (CNA) observed a wound on the resident's right hip and lower back, both covered with dressings. The Treatment Nurse (TN) confirmed that the resident was being treated for an abscess on the lower back but was unaware of any other wounds. Upon further examination, a yellow wound with slough was found on the resident's right hip, which was classified as an unstageable pressure injury. The wound had not been documented or addressed in the resident's medical records prior to this discovery. The facility's policy required daily skin inspections and documentation of any changes, which were not followed in this case. The Director of Nursing (DON) stated that the TN should have assessed the resident's skin, notified the medical doctor, and documented a treatment order when skin redness was reported. However, these steps were not taken, leading to the oversight and subsequent development of the unstageable pressure injury.
Failure to Document Care Conference in Resident's Medical Record
Penalty
Summary
The facility failed to ensure the completeness of a medical record for a resident when a care conference meeting was not documented. This deficiency was identified during an unannounced visit to investigate a complaint. The resident in question had been admitted with diagnoses including a fracture of the right tibia, mild intellectual disability, and cerebral palsy. Despite the care conference being conducted, it was not documented in the electronic health record system, PointClickCare (PCC), as confirmed by the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON). Interviews with facility staff revealed that care conferences are typically documented in PCC, with the Social Service Director (SSD) responsible for opening the care conference note. However, in this instance, the SSD was unable to open the note, and the interdisciplinary team (IDT) members did not document their notes. The facility lacked a policy mandating the documentation of care conferences, although the DON expected such documentation to occur. This oversight had the potential to impact the resident's plan of care by creating miscommunication among the care team and the resident's caregiver.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as Resident 126, by not ensuring the call light button was within reach. During an observation and interview, it was noted that the call light was on the floor behind the resident's bed, making it inaccessible. Resident 126, who has moderate cognitive impairment and the capacity to make his own decisions, was unaware of the call light's location and unable to reach it for assistance. This oversight was confirmed by a Certified Nursing Assistant (CNA) and a Licensed Vocational Nurse (LVN), both of whom acknowledged that the call light should be within the resident's reach to prevent delays in care and potential emergencies. The Director of Nursing (DON) also confirmed that the facility's practice is to keep call lights within easy reach of residents, as outlined in the facility's policy and procedure. The failure to adhere to this policy was observed during the survey, highlighting a deficiency in the facility's ability to meet the needs and preferences of Resident 126. The report does not mention any corrective actions taken to address this issue.
Failure to Monitor Dialysis Catheter, Fluid Restrictions, and Skin Condition
Penalty
Summary
The facility failed to properly identify, assess, and monitor a central dialysis catheter for a resident with End Stage Renal Disease. Despite the resident having a left chest tunneled catheter for dialysis, the facility's records and staff observations did not document or monitor this catheter upon admission or during subsequent shifts. The facility's staff were incorrectly monitoring an AV shunt on the resident's left upper arm, which was not in use, leading to a lack of proper care for the actual dialysis access site. Another resident with congestive heart failure and chronic kidney disease was not provided with the physician-ordered fluid restrictions. The resident's fluid intake records showed multiple instances where the daily fluid intake exceeded the prescribed 1500 ml limit. Interviews with facility staff confirmed that the fluid restrictions were not adhered to, which could potentially impact the resident's health condition. Additionally, the facility did not assess or monitor a skin condition for a resident, leading to dry and scaly skin on the resident's lower legs. The resident reported that no one had checked their legs, and the treatment nurse was unaware of the condition. The facility's policy required daily skin inspections and reporting of abnormalities, but this was not followed, resulting in a lack of necessary treatment for the resident's skin condition.
Infection Control Lapses with Oxygen and Wound Care
Penalty
Summary
The facility failed to implement proper infection prevention and control practices for two residents. For Resident 48, the oxygen nasal cannula tubing was left exposed on top of the resident's bed while the resident was not in the room. This was observed on multiple occasions, and both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) acknowledged that the tubing should have been stored in a plastic bag when not in use to prevent contamination and infection. Resident 48 had a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) and was prescribed oxygen therapy as needed. For Resident 39, a wound vacuum device and tubing with brown sediment were left on the bedside table after a wound dressing change. The Treatment Nurse (TN) admitted to forgetting to discard the used tubing and failing to disinfect the wound vacuum machine, which could lead to cross-contamination and infection. The Infection Preventionist (IP) and the DON confirmed that the used supplies should have been discarded immediately, and the equipment should have been disinfected. Resident 39 had a history of pressure ulcers and urinary tract infections, with specific physician orders for wound care.
Inadequate Discharge Documentation for Resident Post-Hospitalization
Penalty
Summary
The facility failed to adequately document the necessity for discharging a resident, identified as Resident 4, after the resident was cleared from a psychiatric hold during hospitalization. Resident 4, who had been admitted with diagnoses including spinal tumor resection, hemiplegia, major depressive disorder, and generalized anxiety disorder, was initially given a 30-day discharge notice due to behavioral issues. However, the facility did not issue a new discharge notice after the resident was cleared to return from the hospital, nor did they provide documentation justifying the discharge decision. The facility's records indicated that Resident 4 was transferred to a general acute care hospital for a psychiatric evaluation following violent and aggressive behaviors. Despite the hospital's clearance for the resident to return, the facility did not re-evaluate the resident's current behavior or condition to determine if they could meet the resident's needs. The facility's policy required such an evaluation, but it was not conducted, and no updated notice was provided to the resident or the Ombudsman. Interviews with facility staff, including the Director of Nursing, Administrator, Social Services Director, and Psychiatrist, revealed that Resident 4 had been abusive and refused treatment for behavioral issues. Despite these challenges, the facility did not follow its own procedures for re-evaluating the resident's condition post-hospitalization, leading to a deficiency in the discharge process. The lack of documentation and failure to issue a new discharge notice after the psychiatric hold was discontinued contributed to the deficiency identified in the report.
Failure to Provide Updated Discharge Notice
Penalty
Summary
The facility failed to provide a notice of discharge for a resident when it decided not to accept the resident back after a stay at a general acute care hospital (GACH). The resident, who had been living at the facility since 2015, was initially transferred to the hospital for a psychiatric evaluation. The facility issued a 30-day discharge notice on the same day as the transfer, indicating the resident would be moved to a board and care or preferred setting. However, after the psychiatric hold was discontinued, the facility did not issue a new notice of discharge to the resident or the Ombudsman, despite the decision not to readmit the resident. Interviews with facility staff revealed that the Discharge Planner was responsible for sending out discharge notices and notifying the Ombudsman, but a second notice was not completed after the resident's hospital treatment. The Director of Nursing and the Social Service Director confirmed that no updated notice was sent to the Ombudsman after the resident's psychiatric hold was lifted. The facility's policy required that any changes in the discharge notice be communicated to the resident and the Ombudsman as soon as practicable, but this was not done, leading to a deficiency in the facility's discharge notification process.
Failure to Provide Bed-Hold Notice for Transferred Resident
Penalty
Summary
The facility failed to provide a notice of bed-hold to a resident upon their transfer to an acute care hospital. The resident, who had been admitted to the facility with diagnoses including major depressive disorder and generalized anxiety disorder, was transferred due to aggressive behavior and threats to the safety of others. The transfer was initiated on the basis of a 5150 hold for danger to others, and the facility had issued a 30-day Notice of Discharge due to behavioral concerns. However, there was no documented evidence that the resident was informed of the bed-hold policy, which is a right of the resident. Interviews with the Social Services Director and the Director of Nursing revealed a lack of awareness and misunderstanding regarding the requirement to issue a notice of bed-hold. The Social Services Director acknowledged that the resident should have had a bed-hold on file, while the Director of Nursing stated that the resident was not offered a bed-hold due to the nature of the transfer and the existing discharge notice. The facility's policy, dated October 2022, clearly indicates that all residents should be provided with written information regarding bed-hold policies during periods of absence, such as hospitalization or therapeutic leave.
Failure to Re-evaluate Resident for Re-admission After Hospitalization
Penalty
Summary
The facility failed to re-evaluate a resident's clinical behavior or condition for re-admission after a therapeutic hospitalization. The resident, who had been living in the facility since 2015, was initially transferred to a general acute care hospital (GACH) for a psychiatric evaluation and placed on a 5150 hold due to violent and aggressive behaviors. Despite being cleared by the hospital and the psychiatric hold being discontinued, the facility refused to readmit the resident, citing ongoing behavioral issues. The resident's medical history included diagnoses such as spinal tumor resection, hemiplegia, major depressive disorder, and generalized anxiety disorder. The facility had issued a 30-day discharge notice, which was effective immediately, indicating the resident would be discharged to a board and care or preferred setting. However, this discharge did not occur as planned due to the resident's transfer to the GACH for psychiatric evaluation. The facility did not provide a new discharge notice after the resident was cleared to return. Interviews with facility staff, including the Administrator, Social Services Director, and Psychiatrist, revealed that the decision not to readmit the resident was based on the resident's history of violent and aggressive behavior. The facility did not document a re-evaluation of the resident's condition after the hospital clearance, nor did it provide written justification for the refusal to readmit. The facility's policies on transfer, discharge, and bed-holds require that residents be evaluated based on their current condition, not their condition at the time of transfer, which was not adhered to in this case.
Delayed Call Light Response
Penalty
Summary
The facility failed to ensure that call lights were answered in a timely manner, as evidenced by interviews and record reviews of four residents who required assistance with activities of daily living (ADLs). Residents reported waiting up to an hour or longer for their call lights to be answered, resulting in them sitting in soiled briefs and experiencing delays in receiving necessary care. This issue was observed during an unannounced visit, where residents expressed their concerns about the inconsistent response times, particularly during certain shifts or depending on the staff on duty. Certified Nursing Assistants (CNAs) and a Licensed Vocational Nurse (LVN) confirmed that call lights should be answered promptly to prevent falls, skin breakdown, and other adverse outcomes. They acknowledged that it was unacceptable for residents to wait an hour for assistance and emphasized that all staff members were responsible for responding to call lights. The Director of Nursing (DON) also stated that call lights should be answered timely to prevent accidents. The facility's policies on answering call lights and supporting ADLs were reviewed, indicating that residents' requests should be responded to as soon as possible and that residents unable to carry out ADLs independently should receive the necessary services to maintain good hygiene and nutrition. Despite these policies, the facility's failure to answer call lights promptly led to unmet care needs and potential risks for the residents involved.
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What surveyors actually found near you
We read the 1,131 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
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Nursing homes near Riverside
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Villa Health Care Center | 0.7 mi | ★★★★★ | 3 | 0 |
| Alta Vista Healthcare & Wellness Centre | 0.8 mi | ★★★★★ | 6 | 0 |
| Citrus Grove Post Acute | 1.2 mi | ★★★★★ | 20 | 0 |
| Mission Care Center | 1.3 mi | ★★★★★ | 4 | 0 |
| Arlington Gardens Care Center | 1.5 mi | ★★★★★ | 20 | 1 |
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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.