Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Health & Rehabilitation Center during CMS and state inspections, most recent first.
Smoking Area Contained Hazards and Debris: The facility failed to keep the resident smoking area free from accident hazards. Surveyors observed a wooden pallet on the ground in the smoking area, a detached ash/butt receptacle lying on its side, and numerous cigarette butts between the pallet slats. Staff were unsure why the pallet was there or why butts were on the ground, and the DON/maintenance leadership stated environmental staff were responsible for cleaning and supervising the area during smoking times.
Ventilator and suction equipment were not consistently changed per facility policy for residents with trachs and ventilators. Two residents had ventilator circuit tubing dated from an earlier month, and one resident’s suction canister was still dated from the prior month despite orders for weekly suction equipment changes. RT and the DON of Respiratory stated ventilator circuit components and suction equipment were to be changed on a regular schedule, but the observed equipment did not match those expectations.
Medication Storage and Labeling Deficiencies: An RN found torn labels on resident-specific chlorhexidine bottles in a med room, and a locked narcotics box in the med refrigerator was not permanently affixed. In another med room, food items for residents were stored with medications, including sandwiches, packaged snacks, and an open cookie package, while a mini refrigerator used for narcotics was also not permanently affixed and held morphine and lorazepam. Staff stated they were unsure why some items were stored in the med rooms instead of the nourishment area.
Failure to Honor Resident Meal Choices: A resident with CHF, respiratory failure, and lymphedema, and another resident with DM, CKD, and weight changes, were documented as cognitively intact yet repeatedly did not receive requested meal items or substitutions they selected on menus. Surveyors found meal tickets and tray items did not match handwritten requests, staff did not consistently notify residents when selections could not be filled, and care plans did not consistently reflect food preferences or meal-choice communication needs. Other sampled residents also reported menu substitution concerns, with inconsistent documentation of discussions about unavailable items.
A resident with cardiac disease developed marked bradycardia, but staff did not timely notify the correct provider; the first documented provider call occurred many hours later, and the resident was later hospitalized with complete heart block and received a pacemaker. In a separate case, an LPN gave a resident’s scheduled Robaxin doses outside the allowed time window on multiple occasions without documentation or timely notification to the supervisor or APRN, despite facility policy requiring timely provider notification for late or otherwise not administered medications.
Failure to complete timely significant change assessment after ADL decline: A resident with a neuromuscular disorder, pressure ulcers, and DM had worsening ADL dependence, including increased assistance needs for eating, toileting, dressing, bed mobility, transfers, and bathing, along with an additional stage 3 pressure ulcer. RN stated the resident should have had a significant change MDS completed when the decline was recognized, but the decline in ADL status was overlooked.
Care plan not updated for PASRR status and contractures. A resident with depression had PASRR findings that changed over time, but the care plan remained listed as PASRR in progress and staff could not show it had been revised to reflect the updated PASRR results. Another resident with dementia, severe ROM limits, and contractures had APRN and therapy documentation of worsening stiffness and attempted splinting, yet the care plan lacked specific directions for the contractures and related care needs.
A resident with CHF, CAD, and hypercholesterolemia had an order for Metoprolol ER with hold parameters. An LPN noted bradycardia and did not give the medication, but the resident’s provider was not properly notified of the change in cardiac status. The resident was later sent to the hospital with HR in the 30s and complete heart block, and received a dual-chamber pacemaker.
Wander Guard devices remained on two residents after orders to discontinue them had ended, including one resident on a secure unit and another with an elopement care plan that did not include the device. In addition, a resident with chronic pain received scheduled Robaxin doses late, with no documented reason for the delay and no evidence the LPN notified the supervisor or APRN as expected.
Failure to address significant weight loss: A resident with dysphagia, dementia, MS, and feeding difficulties had repeated significant weight loss while on a regular, whole texture, thin liquid diet. The care plan identified the resident as at risk for weight loss, but the record showed no added MD orders or other nutrition interventions, and the RD acknowledged awareness of the loss but did not follow up.
Incomplete RN documentation after a resident's change in condition: a resident with CHF, CAD with angina, and hypercholesterolemia had bradycardia with heart rates in the 30s to 40s, and an LPN notified an RN. The RN said she assessed the resident and thought the resident seemed okay, but she forgot to document the RN assessment in the clinical record, despite the facility policy requiring a complete physical and mental evaluation with findings documented.
Two residents with histories of anxiety and aggression engaged in a verbal altercation that escalated to a physical assault in a common area, resulting in one resident sustaining serious facial injuries and requiring hospital transfer. The incident was witnessed by others and occurred despite both residents being identified as having aggressive tendencies in their care plans.
A resident with dementia and a history of falls experienced increased mobility and exhibited wandering and agitation over several days. Despite these changes, staff did not timely reassess the resident's elopement risk, as required by facility policy. The resident subsequently eloped from the facility and was found outside without injury.
A resident with a history of psychiatric disorders and suicidal ideation expressed intent to self-harm and was hospitalized twice for evaluation. Despite these incidents, the care plan was not revised to include specific interventions for managing suicidal behaviors, and facility policy requiring care plan updates after such events was not followed.
A resident with a history of mental disorders and repeated suicidal ideation was not adequately protected from environmental hazards, as staff failed to promptly remove access to knives and other potentially harmful items despite multiple incidents of self-harm attempts and hospital transfers. The care plan was not timely updated to address these risks, and hazardous items remained accessible in the resident's environment.
A resident with a history of stroke, dysphagia, and cognitive impairment did not receive the required supervision during a meal, as specified in their care plan. Due to miscommunication and incorrect documentation on care cards, staff believed only setup assistance was needed, leading to the resident being left unsupervised and experiencing a choking episode that required emergency intervention.
A nurse failed to accurately transcribe a hospital discharge order for Quetiapine, resulting in a resident receiving the medication in the morning instead of at night as prescribed. The error was not caught during the required double-check process, and the resident, who had multiple neuropsychiatric diagnoses, was subsequently evaluated for somnolence related to medication timing.
A resident with diabetes and end stage renal disease experienced multiple episodes of low blood sugar, including critically low readings and the need for Glucagon administration. Despite physician orders and facility policy requiring provider notification in these situations, staff did not inform the provider of these events, and documentation of such notifications was absent.
A resident dependent on staff for toileting and transfers was left unattended on the toilet for over an hour after a nurse aide failed to inform other staff before leaving the unit. Other staff responded to the call light but did not assist or notify anyone, resulting in the resident not receiving timely hygiene and transfer assistance as required by their care plan.
Staff did not consistently follow physician orders and facility policy for treating and monitoring hypoglycemia in a resident with diabetes and end stage renal disease. After multiple low blood sugar readings, required rechecks and provider notifications were not documented, and a scheduled endocrinology follow-up was missed and not rescheduled.
A resident with multiple medical conditions who required two staff for transfers using a mechanical lift was transferred by only one nurse aide, despite physician orders and facility training materials specifying the need for two staff. The aide was aware of the requirement but did not seek assistance, and the incident was confirmed through documentation and interviews.
A resident with diabetes and end stage renal disease experienced multiple episodes of hypoglycemia, during which the facility failed to maintain accurate physician orders for Glucagon administration and did not document nursing actions, symptoms, or provider notifications as required by facility policy. Staff confirmed that nursing notes were missing for these events and could not explain the lack of documentation.
Smoking Area Contained Hazards and Was Not Kept Free of Debris
Penalty
Summary
The facility failed to ensure the resident smoking area was free from accident hazards. On 1/22/2026 at 10:02 AM, observation of the outdoor smoking area with Environmental Worker #3 showed the area was located to the right outside the exit door in a parking space under a full overhang of the building. A wooden pallet was on the ground, and on the pallet was the bottom of an ash/butt receptacle with its long neck piece detached and lying on its side. Another receptacle was located to the right side of the area, and numerous cigarette butts were observed on the ground between the slats in various locations of the wooden pallet. During interview, Environmental Worker #3 was unsure why the pallet was on the ground and stated the receptacle may have been emptied but did not know why cigarette butts were on the ground within the pallet. The Administrator stated that environmental services were responsible for keeping the smoking area clean and safe, and the Director of Environmental Services/Maintenance stated Environmental Workers #1 and #3 were responsible for checking and keeping the smoking area clean, including supervising the two smokers and checking the area during smoking times for butts, cleaning the area, and emptying trash. Later, the Administrator observed the smoking area clean and stated the pallet had been placed in the parking spot used for the smoking area to prevent someone from parking there, but it should not have been placed there.
Ventilator and suction equipment not changed per policy
Penalty
Summary
The facility failed to ensure that ventilator equipment and suction equipment were consistently changed according to facility policy for residents with ventilators and tracheostomies. Resident #76 had chronic respiratory failure and ventilator dependence, and a 5-day MDS identified short-term and long-term memory problems and the need for tracheostomy and invasive mechanical ventilator care. A physician order dated 1/13/2026 directed that the ventilator circuit be changed on the first Saturday of every month starting 2/7/2026, and the record did not identify an earlier order for ventilator circuit changes. During an observation on 1/15/2026, Resident #76 was connected to the ventilator and the ventilator circuit tubing was dated 12/7/2025. Resident #198 had acute and chronic respiratory failure with carbon dioxide retention and ventilator dependence, and a quarterly MDS identified memory problems, dependence for self-care, and the need for tracheostomy care. Physician orders dated 12/26/2025 directed suction via tracheostomy every shift and changing the suction canister and tubing weekly and as needed. The TAR documented suction tubing and canister changes on 1/6/2026 and 1/13/2026, but respiratory therapy notes did not identify respiratory incidents on those dates. On 1/15/2026, the suction canister contained about 300 mL of green fluid and was dated 12/30/2025. Resident #261 had chronic respiratory failure with hypoxia and ventilator dependence, and a quarterly MDS identified memory problems and the need for tracheostomy and invasive mechanical ventilator care. A physician order dated 1/13/2026 directed ventilator circuit changes on the first Thursday of every month starting 2/5/2026, with no earlier order found in the record. On 1/15/2026, Resident #261 was connected to the ventilator and the ventilator circuit tubing and inhalation filter were dated 12/7/2025. RT stated suction canisters and tubing should be changed weekly and ventilator circuit tubing monthly, and the Director of Respiratory stated ventilator circuit tubing, including inhalation and exhalation filters, was a single-use component that should be changed in the first week of the month.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted professional principles in 3 of 4 medication rooms observed. In the 3AB medication room, two bottles of chlorhexidine gluconate 0.12% oral rinse were found on a shelf with other resident-specific medications, but the resident labels were torn and did not allow identification of the residents to whom the bottles belonged. In the same room, the medication refrigerator contained a locked narcotics box affixed to a shelf, but the shelf was not permanently affixed to the refrigerator and could be readily removed. Inside the box were five bottles of lorazepam 3 mg/1 mL, including three unopened bottles with 30 mL each and two open bottles with over 22 mL each. The nurse manager stated she was not sure why the chlorhexidine bottles had torn labels and said medications no longer being used would be set aside for return to the pharmacy or destruction; she also stated she was not aware the narcotics box needed to be permanently affixed. In the 3CD medication room, a food refrigerator contained an egg sandwich and a peanut butter sandwich with resident room numbers. On the medication room counter were multiple individually packed shelf-stable fruit smoothies and crackers with resident names and room numbers, along with an open 1-pound package of cream-filled chocolate sandwich cookies that was not effectively sealed. The LPN stated the sandwiches were for resident evening snacks but was unsure why they were kept in the medication room instead of the nourishment refrigerator, and said the smoothies, crackers, and cookies were food items brought in by family for specific residents and kept there for safekeeping. In the 2CD medication room, a black mini refrigerator on a counter contained an unopened 30 mL bottle of morphine oral concentrate 20 mg/5 mL and an unopened 30 mL bottle of lorazepam 2 mg/1 mL oral solution; the refrigerator was not permanently affixed and could be readily moved. The LPN stated the refrigerator did not have a lock box or separate compartment because the whole mini refrigerator was used for narcotics. The DNS later stated the lock box and narcotics refrigerator had been addressed after surveyor observations and that food items, including those belonging to residents, should have been stored in the nourishment room and not in the medication room.
Failure to Honor Resident Meal Choices
Penalty
Summary
The facility failed to support residents in exercising their right to make choices regarding meals by not honoring selected menu items, not informing residents when substitutions were made, and not consistently incorporating food preferences into care planning. Surveyors reviewed observations, clinical records, facility documentation, menu selections, policies, and staff interviews for 10 sampled residents and found repeated breakdowns in how meal choices were collected, entered, communicated, and served. Resident #220 had diagnoses including heart failure, respiratory failure, and lymphedema, and was documented as cognitively intact and independent with feeding and oral hygiene. The resident stated that weekly select menus and daily meal selections were completed, but requested items such as sausage for breakfast, a ham sandwich, a small salad instead of chef salad, and fresh fruit were not provided. Observations showed breakfast trays without sausage, and meal tickets did not reflect the resident’s handwritten requests. Interviews with dietary leadership and the dietitian showed that sausage was not an everyday item, that handwritten requests were not always entered into the meal tracker system, and that the resident had not been notified when requested items could not be filled. The dietitian also confirmed that the resident’s handwritten selections did not match the kitchen menu for at least one meal and would not be served as written. For Resident #238, records showed diagnoses including type 2 diabetes mellitus with circulatory complications, CKD stage 3 with anemia, hypothyroidism, and adjustment disorder with anxiety. The resident was cognitively intact, required assistance with eating and oral hygiene, and had significant weight changes while receiving a therapeutic diet. Documentation showed repeated meal dissatisfaction, including requests for milk with breakfast and dinner, reports that meals were unacceptable, and concerns that preferred items such as grilled cheese sandwiches and salads were no longer appearing on the menu because of renal restrictions. The record did not show that these preferences or communication needs were consistently incorporated into the care plan, and staff interviews confirmed there was no consistent process to notify residents when selections were changed. Additional sampled residents, including #82, #121, #55, #71, #183, #163, #174, and #290, also expressed concerns about menu substitutions, and their records showed inconsistent or absent documentation of discussions about unavailable selections or food preferences.
Failure to Notify Provider of Change in Condition and Late Medication Administration
Penalty
Summary
The facility failed to ensure timely physician notification when Resident #195 experienced a change in cardiac status. Resident #195 had diagnoses including heart failure and atherosclerotic heart disease with angina and had an order for metoprolol succinate extended release 25 mg, 1/2 tablet twice daily, held for systolic blood pressure under 110 or heart rate under 55. On 1/5/2026, vital signs documented a heart rate of 40 beats per minute in the morning and 36 beats per minute in the evening, with an irregular rhythm noted later that day. The clinical record did not reflect notification of the APRN or physician at the time the low heart rate was identified in the morning. Facility interviews showed that LPN #5 recognized the resident was bradycardic and notified RN #2, who assessed the resident and stated she notified APRN #1, although APRN #1 later stated she was not the resident’s provider and that APRN #2 should have been notified. APRN #2 stated she was not notified of the change in cardiac status. The facility’s on-call log showed the first documented call to APRN #4 occurred at 9:24 PM, more than 13 hours after the first episode of bradycardia. The resident was then sent to the emergency room, where hospital documentation showed the resident arrived with a heart rate in the 30s and was found to be in complete heart block, with an elevated NT-proBNP level, and was admitted for treatment and placement of a dual-chamber pacemaker. The facility also failed to ensure physician notification when Resident #227’s scheduled pain medication was not administered timely. Resident #227 had diagnoses including chronic pain and major depressive disorder and received Robaxin 750 mg three times daily for muscle spasms. The facility identified the medication should be administered within a 2-hour window, one hour before or after the scheduled time. The MAR audit showed the 8:00 AM dose was given at 9:32 AM on one day and at 11:10 AM on another day, with the 12:00 noon dose then given at 1:02 PM, and there was no documentation explaining the late administration. Interviews with the DNS, ADNS, LPN #8, and APRN #3 confirmed the doses were late and that the physician/APRN should have been notified. The DNS stated the late administration may have been related to the influenza outbreak and increased medication pass workload, but the record still lacked documentation of notification or explanation for the delayed doses. APRN #3 stated notification was expected when the medication was given outside the allowed time window and that the timing of the remaining doses would have been adjusted.
Failure to Complete Timely Significant Change Assessment After ADL Decline
Penalty
Summary
The facility failed to ensure a significant change in status assessment was completed timely for Resident #10 after the resident experienced a decline in condition. Resident #10 had diagnoses including a neuromuscular disorder, pressure ulcers, and diabetes mellitus. The quarterly MDS assessment dated [DATE] showed the resident was cognitively intact and required varying levels of assistance with ADLs, including set-up and clean-up for eating, superficial touching assistance for personal hygiene, partial moderate assistance for toileting and upper body dressing, dependence for lower body dressing, and supervision/touching assistance for rolling in bed and transfers. That assessment also documented one stage 3 pressure ulcer present on admission and weight loss greater than 5% in the last 30 days or 10% in the last 6 months. The quarterly MDS assessment dated [DATE] later showed further decline, with the resident requiring set-up and clean-up assistance for eating and being dependent for toileting, upper and lower body dressing, bed mobility, transfers, and bathing/showering. It also documented two stage 3 pressure ulcers, reflecting the development of one additional pressure ulcer since the prior assessment on 7/25/2025. The care plan dated 11/06/2025 identified deficits in self-care and included interventions to provide substantial/maximum assist for bathing, dressing, and toileting and to monitor, document, and report changes including declines in function. During interview and record review on 1/22/2026, RN #4 stated Resident #10 should have had a significant change MDS assessment completed in October 2025 because of the ADL declines from the previous assessment and refusals to get out of bed were contributing to the decline, but the decline in ADL status was overlooked.
Care Plan Not Updated for PASRR Status and Contractures
Penalty
Summary
The facility failed to timely review and revise the comprehensive care plan for a resident with diagnoses including anxiety and major depression in relation to PASRR status. The resident’s PASRR Level 1 screen on 8/29/25 approved a 30-day hospital exemption for a suspected or confirmed mental health disability, and the care plan on 9/6/25 identified PASRR as in progress with interventions related to monitoring mental health symptoms and contacting the treating psychiatrist. A social work note on 9/8/25 stated the PASRR Level 2 was completed and that a psychiatry referral had been made, but the care plan was not documented as updated to reflect those results. A later PASRR Level 1 screen on 9/15/25 stated the resident did not require a Level 2 screen and noted the resident had a current diagnosis of major depression but no indicators requiring further evaluation at that time. Despite this change in PASRR status, the care plan dated 12/30/25 still listed PASRR as in progress with the same interventions. During interview and record review on 1/21/26, the Director of Social Services was unable to provide documentation showing the care plan had been updated and revised on 9/15/25 or 12/15/25, and stated she was responsible for tracking PASRRs and updating care plans. The facility also failed to revise the care plan for a resident with contractures and severe mobility limitations. The resident had diagnoses including contracture of the right wrist and elbow, legal blindness, bilateral hearing loss, and dementia, and the admission MDS showed severe cognitive impairment, range-of-motion limitations in all extremities, and dependence on staff for all ADLs. APRN notes documented contracted upper and lower extremities and severe muscle stiffness, and therapy documented that splints were attempted but were not used because of extreme resistance and concern for skin injury. On 1/15/26, the resident was observed asleep in bed with the right hand bent at the wrist and fingers curled inward, with no splints visible, and staff interviews confirmed the care plan did not include directions for the contractures even though the resident’s condition and related care needs had been documented.
Failure to Notify Provider of Bradycardia and Change in Cardiac Status
Penalty
Summary
The nursing facility failed to ensure services were provided in accordance with professional standards for a resident with heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia. The resident had an order for Metoprolol succinate ER 25 mg, 1/2 tablet by mouth twice daily, to be held if systolic blood pressure was under 110 or heart rate was under 55. On 1/5/2026 at 8:20 AM, the resident’s vital signs showed a heart rate of 40 beats per minute with a regular rhythm, and the TAR showed the LPN did not administer the Metoprolol at 9:00 AM. The resident’s record also identified severely impaired cognition on the annual MDS and congestive heart failure on the RCP. Later that day, the resident was sent to the hospital and arrived with a heart rate in the 30s and was found to be in complete heart block. Hospital documentation showed an elevated NT-proBNP level of 2693 pg/ml, and the resident was admitted, treated, and received a dual-chamber pacemaker. Interviews showed the LPN notified the unit manager of the bradycardia, but the APRN who was the resident’s provider was not notified at that time. The unit manager stated she assessed the resident and notified an APRN, but the APRN stated she was not the resident’s provider and that APRN #2 should have been notified. APRN #2 stated she was not notified of the change in cardiac status, and the evening supervisor and charge nurse stated they were not informed during shift report. The facility’s Change in Condition Notification policy stated the licensed nurse will notify the resident, healthcare provider, and family/legal representative when there is a change in condition.
Wander Guard devices not removed after orders discontinued; pain medication given late without provider notification
Penalty
Summary
Resident #49, who had dementia, a non-traumatic subarachnoid hemorrhage, and difficulty walking, was identified as being at risk for elopement and was placed on a secure unit. A physician order dated 1/25/2025 directed discontinuation of checking the expiration date on the Wander Guard, but observations on 1/15/2026, 1/16/2026, and 1/20/2026 showed the Wander Guard still on the resident’s left ankle. Staff interviews confirmed the device remained in place even though the order had been discontinued, and the nurse and DNS stated the device should have been removed when the order ended. Resident #269, who had dementia, traumatic subarachnoid hemorrhage, and difficulty walking, was also identified as at risk for elopement and was on a secure unit. The care plan included elopement precautions and constant supervision outside, but it did not include placement of a Wander Guard. A physician order dated 8/14/2025 directed discontinuation of checking the Wander Guard function, yet observation on 1/16/2026 showed the Wander Guard still on the resident’s right ankle. The LPN stated she was unaware the order had been discontinued, and the DNS stated the device should have been removed on the date the order was discontinued. Resident #227 had chronic pain and major depressive disorder and received scheduled Robaxin 750 mg three times daily for muscle spasms. Review of the MAR showed the 8:00 AM dose was administered at 9:32 AM on 1/1/2026 and at 11:10 AM on 1/2/2026, with the 12:00 noon dose on 1/2/2026 given at 1:02 PM, and there was no documented reason for the late administration. The DNS, ADNS, and APRN stated the physician/APRN should have been notified when the medication was given outside the expected time window, and the APRN stated the remaining dose times would have been adjusted if notified.
Failure to Address Significant Weight Loss
Penalty
Summary
Provide enough food and fluids to maintain a resident’s health was not implemented for a resident with dysphagia, dementia, multiple sclerosis, and feeding difficulties. The resident’s physician ordered a regular, whole texture, thin liquid house diet, and the care plan identified the resident as at risk for weight loss related to inadequate calorie intake and dementia, with interventions to notify the RD, family, and MD of significant weight changes and to obtain and record weights per facility protocol. The resident’s weight decreased from 153.4 lbs. to 140.4 lbs. in one month, then later to 134 lbs., reflecting an 8.5% loss over one month and a 12.8% loss over six months. The clinical record from 10/1/2025 through 1/3/2026 did not reflect additional physician orders for nutritional supplements or other interventions to address the weight loss. RN #2 stated Nutrition was responsible for monitoring residents with weight loss and that Nutrition did not address the resident’s significant losses in October 2025 or January 2026. The Dietitian stated he was aware of the October 2025 weight loss but did not implement interventions because he was thinking about hospice services, and then forgot to follow up; he also stated that an intervention in October 2025 could have slowed the resident’s weight loss.
Incomplete RN Documentation After Bradycardia
Penalty
Summary
The facility failed to ensure the clinical record was complete and accurate by not documenting an RN assessment for Resident #195 after a change in condition. Resident #195 had diagnoses including heart failure, atherosclerotic heart disease with angina, and hypercholesterolemia. The annual MDS identified a BIMS score of 7, indicating severely impaired cognition, and noted the resident required setup assistance with personal hygiene and was independent with bed mobility and transfers. The resident's care plan included interventions to give cardiac medications as ordered, monitor vital signs, notify the medical doctor of significant abnormalities, and provide oxygen as ordered. On 1/5/2026, the vital signs report showed Resident #195 had a heart rate of 40 beats per minute with a regular rhythm in the morning and 36 beats per minute with an irregular rhythm in the evening. An LPN stated she observed the resident was bradycardic with a heart rate between 35 and 40 beats per minute and notified RN #2. RN #2 stated she was told the resident's heart rate was 35 to 40 beats per minute, assessed the resident, and thought the resident seemed okay with a heart rate maybe 60 beats per minute, but she forgot to document the RN assessment in the clinical record. The DNS stated that when a resident experiences a change in condition, an RN assessment is expected to be completed and documented, and the facility's Change in Condition Notification policy required a complete physical and mental evaluation with findings documented in the medical record.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a resident was not protected from physical abuse by another resident following a verbal altercation. The incident involved two residents, both of whom had documented histories of anxiety and mood disorders, and were identified as having the potential for verbal aggression. Both residents were alert, oriented, and independently mobile in wheelchairs. Earlier in the day, a verbal altercation took place between the two residents on one of the facility's units. Later, in a common area near the front lobby, one resident approached the other and initiated a physical assault by punching the resident multiple times in the face. The assault was witnessed by other residents, who notified staff, prompting an in-house emergency response. The assaulted resident sustained significant injuries, including an open fracture of the nasal bone, hematoma of the nasal septum, periorbital hematoma, and an open fracture of the ethmoid bone, and was subsequently transferred to the hospital for treatment. Documentation and interviews confirmed that the physical altercation was preceded by a verbal dispute and that the facility's care plans had identified both residents as having aggressive tendencies. Despite these risk factors, the incident escalated to physical violence, resulting in harm to one resident. The facility's abuse policy states that residents have the right to be free from abuse, including abuse by other residents.
Failure to Timely Reassess Elopement Risk Following Change in Resident Condition
Penalty
Summary
The facility failed to timely reassess a resident's risk for elopement and wandering following significant changes in the resident's condition and mobility status. The resident, who had diagnoses including dementia, psychotic disturbance, mood disturbance, anxiety, and a history of falls, was initially assessed as non-ambulatory and not at risk for elopement. However, subsequent physical therapy assessments documented progressive improvement in ambulation, with the resident eventually able to walk up to 100 feet with minimal assistance. Despite these changes, the resident's elopement risk was not reassessed as required by facility policy. Over several days, nursing notes documented the resident exhibiting agitation, wandering within their room and into other residents' rooms, and difficulty with redirection. The resident was also involved in an incident with a roommate, which led to a temporary hospital transfer. Upon return, the resident continued to display wandering behaviors and increased mobility, but no updated elopement or wander risk assessment was completed during this period. The deficiency culminated when the resident eloped from the facility after being left unattended for a brief period. The resident was found outside the building and returned without injury. Review of facility documentation and interviews confirmed that a reassessment of elopement risk should have been conducted when the resident began exhibiting increased mobility, agitation, and wandering behaviors, but this was not done in a timely manner.
Failure to Revise Care Plan After Suicidal Ideation Incidents
Penalty
Summary
The facility failed to review and revise the care plan with appropriate interventions for a resident with a history of suicidal ideation and multiple psychiatric diagnoses, including paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. Despite physician orders to monitor behavioral occurrences every shift and an existing care plan that addressed general behavioral issues, the care plan did not specifically address the resident's suicidal ideations with intent or include personalized interventions following incidents where the resident expressed intent to self-harm. Notably, after the resident verbalized wanting to harm themselves with a weighted silverware knife and was subsequently transferred to the ER for psychiatric evaluation, there was no documented revision to the care plan upon their return from the hospital. Further, after additional episodes where the resident reported hearing voices instructing them to harm others and was again transferred for psychiatric evaluation, the clinical record still did not reflect any updates or new interventions in the care plan. Interviews with the Director of Nursing confirmed that the care plan was not revised after these incidents, and there was uncertainty about whether updates were necessary. Facility policy required episodic review and revision of the care plan, especially after hospital readmissions, but this was not followed in these instances.
Failure to Remove Environmental Hazards and Implement Safety Interventions for Resident with Suicidal Ideation
Penalty
Summary
A deficiency occurred when the facility failed to remove environmental hazards and implement appropriate safety interventions for a resident with a history of mental disorders, including suicidal ideation, paranoid schizophrenia, bipolar disorder, hallucinations, psychosis, anxiety, and depression. The resident expressed suicidal ideation and intent on multiple occasions, resulting in four transfers to the emergency department over a 38-day period. Despite these incidents, the clinical record showed no timely revisions to the resident's care plan or mitigation of environmental risk factors, such as access to knives and other potentially harmful items. The resident was observed on several occasions with access to silverware, including butter knives, and was seen rubbing a knife against their wrist while expressing intent to self-harm. Staff interviews and documentation revealed that the resident was able to obtain knives from meal trays, and there was a lack of immediate action to restrict access to these items following repeated episodes of suicidal ideation and self-harm attempts. The facility's documentation did not reflect prompt updates to the care plan or consistent removal of environmental hazards, such as corded call lights and phone chargers, even after the resident's behaviors escalated. Multiple staff members, including nursing and medical personnel, indicated that access to knives and metal silverware did not pose a safety risk, despite the resident's documented history and visible evidence of self-harm. Observations confirmed that hazardous items remained accessible in the resident's environment after incidents of suicidal ideation and self-harm. The facility's failure to promptly identify and address these environmental risks contributed to repeated episodes of suicidal behavior and inadequate protection for the resident.
Failure to Provide Required Mealtime Supervision Resulting in Choking Incident
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, dysphagia, aphasia, apraxia, epilepsy, and dementia did not receive the required supervision during mealtime as outlined in their care plan. The resident's care plan specified that all meals and fluid intake should occur under staff supervision due to swallowing difficulties. Despite this, the resident was left unsupervised during lunch, which resulted in a choking incident that required the Heimlich maneuver and emergency intervention. The resident had recently been discharged from speech therapy, which had reiterated the need for mealtime supervision due to swallowing safety concerns. However, the speech therapist did not verbally communicate the supervision requirement to the nursing staff, as the diet remained unchanged and the care plan already indicated supervision was needed. Nursing assistants and other staff members were unaware of the supervision requirement, as the resident's care card only indicated setup assistance for meals, not supervision. This miscommunication and lack of awareness led to the resident being left alone while eating. Interviews with staff revealed that the care plan interventions, including supervision with eating, were not correctly reflected on the quick-reference care cards used by nursing assistants. As a result, multiple staff members believed the resident only required setup assistance and not active supervision. This failure to ensure proper communication and implementation of the care plan directly contributed to the resident's choking incident.
Medication Order Transcription Error Resulting in Incorrect Administration Time
Penalty
Summary
A deficiency occurred when a nurse failed to accurately transcribe a physician's order from a hospital discharge summary into the resident's Medication Administration Record (MAR). The hospital discharge summary specified that Quetiapine 37.5 mg should be administered at night, but the nurse entered the order into the electronic medical record to be given at 9:00 AM. This error was not identified during the transcription process, despite facility policy requiring a double-check of the original order. As a result, the resident received Quetiapine in the morning on two consecutive days. The resident involved had multiple diagnoses, including Parkinson's Disease, vascular dementia, psychotic disturbance, mood disturbance, anxiety, major depressive disorder, and multisystem degeneration of the autonomic nervous system. The resident's care plan included the use of psychotropic medications and required monitoring for side effects and effectiveness. The error was discovered after the resident was evaluated in the emergency department for somnolence, which was attributed to the timing and combination of medications. Interviews with facility staff confirmed that the transcription error occurred and was contrary to facility policy.
Failure to Notify Provider of Repeated Hypoglycemic Episodes
Penalty
Summary
The facility failed to notify the resident's provider in a timely manner when a resident with diabetes and end stage renal disease experienced multiple episodes of low blood sugar. Despite physician orders requiring notification if blood sugar was less than 70 or greater than 400, and further instructions to notify the provider if hypoglycemia persisted or if Glucagon was administered, there was no documentation that the provider was informed of several hypoglycemic events. These events included blood sugar readings as low as 42 mg/dl, repeated administration of Glucose Gel and Glucagon Emergency Injection Kit, and persistent low blood sugar levels over several days. Interviews with facility staff confirmed that the provider should have been notified during these episodes, especially when blood sugar was critically low or when Glucagon was required. However, the provider was not informed of these incidents, and staff were unable to explain the lack of notification. Facility policy also directed staff to notify the provider under these circumstances, but this was not followed, resulting in a failure to communicate significant changes in the resident's condition as required.
Resident Left Unattended on Toilet Due to Staff Failure to Communicate and Assist
Penalty
Summary
A resident with diagnoses including Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration, who was alert and oriented but dependent on staff for activities of daily living and required two staff for toilet transfers, was left on the toilet for an extended period. The resident's care plan specified the need for assistance with toileting and transfers using a Sara lift. On the day of the incident, a nurse aide placed the resident on the toilet and left the room to assist another resident, then left the unit for lunch without notifying any staff that the resident was still on the toilet. Video footage confirmed that the resident remained unattended for approximately one hour and fifteen minutes, during which time other staff entered the room in response to the call light but did not assist or notify anyone about the resident's situation. The incident was reported by the resident to a family member, who then contacted the facility. Interviews confirmed that the resident had asked staff for help during the period but did not receive assistance. The facility's policy defines neglect as the failure to provide necessary goods and services, and the actions of the staff in this case resulted in the resident not receiving timely toileting hygiene and transfer assistance as required by their care plan.
Failure to Timely Respond to Hypoglycemia and Missed Endocrinology Follow-Up
Penalty
Summary
Staff failed to act in a timely manner on multiple low blood sugar test results for a resident with diabetes, IGG4-related disease, and end stage renal disease. The resident's care plan and physician orders required blood sugar checks before meals and at bedtime, with instructions to notify the provider if blood sugar was less than 70 or greater than 400, and to administer glucose gel or glucagon as needed. Despite these orders and facility policy, documentation showed repeated instances where the resident's blood sugar was below 70, and after initial interventions, staff did not consistently recheck blood sugar within the required timeframe or document further actions as directed by protocol. In several cases, blood sugar remained low after treatment, but there was no evidence of additional interventions or provider notification as required. Facility policy specified that after treating hypoglycemia, blood sugar should be rechecked in 15 minutes, and if still low, treatment should be repeated. If glucagon was administered, blood sugar was to be rechecked every 15 minutes until stable, and the provider notified if hypoglycemia persisted after three interventions, if blood sugar was critically low, or if glucagon was used. Interviews with facility staff confirmed that these steps were not always followed, and staff could not explain the lack of timely rechecks or provider notifications. Documentation also failed to show that the resident's blood sugar was monitored according to policy after several hypoglycemic episodes, including instances where blood sugar was critically low. Additionally, the resident was scheduled for regular endocrinology follow-up appointments, but a key appointment was cancelled due to a scheduling conflict and was not rescheduled by the facility. This resulted in a missed endocrinology evaluation for a resident with a known history of low blood sugars, contrary to the recommended follow-up interval. Interviews confirmed that the appointment should have been rebooked, but there was no evidence this occurred.
Failure to Follow Two-Person Transfer Protocol with Mechanical Lift
Penalty
Summary
A deficiency occurred when a resident with diagnoses including Parkinson's Disease, osteoarthritis, chronic kidney disease, and macular degeneration, who required two staff members for transfers using a mechanical lift, was transferred by only one nurse aide. The resident's care plan and physician's order both specified that two staff members were required for transfers with the Sara lift. Documentation and interviews confirmed that the nurse aide was aware of this requirement but proceeded to transfer the resident alone. The facility's Sit to Stand Lift Competency form also directed staff to use two people for such transfers, and the Assistant Director of Nursing confirmed that this protocol was not followed. The incident was identified after the resident reported being left on the toilet for an extended period, and subsequent investigation revealed the improper transfer procedure. There was no facility policy on the use of the Sara lift, but staff training materials clearly required two staff for these transfers.
Failure to Accurately Document and Manage Hypoglycemia Episodes
Penalty
Summary
The facility failed to ensure accurate and complete medical record documentation and physician orders for a resident with diabetes and end stage renal disease who experienced multiple episodes of hypoglycemia. Specifically, the physician order for Glucagon was incorrectly written to indicate administration for blood sugars over 70, rather than under 70, which was confirmed as an error by both the APRN and ADNS. Additionally, the clinical record lacked complete and accurate documentation of nursing actions, including the absence of nursing notes detailing interventions, resident symptoms, provider notifications, and responses to treatment following several low blood sugar events. Review of the Medication Administration Record revealed multiple instances where the resident had blood glucose levels below 70 and received Glucose Gel or Glucagon, but there was no corresponding nursing documentation of the events or follow-up actions. The facility's own Diabetes Management Protocol required documentation of all hypoglycemic episodes, including symptoms, interventions, provider notification, and resident response, but this was not followed. Interviews with facility staff confirmed that nursing notes should have been written for each episode, but they were not, and no explanation was provided for this omission.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 624 citations issued within 25 miles in the last 12 months — including the 8 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.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near East Hartford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Hill Care Center | 3 mi | ★★★★★ | 0 | 0 |
| Chelsea Place Care Center Llc | 3.1 mi | ★★★★★ | 7 | 1 |
| Parkville Care Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Avery Nursing Home/noble Building | 3.9 mi | ★★★★★ | 1 | 0 |
| Civita Care Center At Salmon Brook | 4.1 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.