Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
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 Riverdale Center For Nursing And Healing during CMS and state inspections, most recent first.
Improper Labeling, Dating, and Storage of Opened Food Items: Surveyors found opened dry goods in the storage area without open dates, including grits and potato pearls, and an opened bag of egg noodles that was not properly labeled or dated. An opened, partially used container of cole slaw dressing was also stored on a shelf in the dry storage area instead of being refrigerated. The DM confirmed the items were not handled according to policy.
A resident with bradycardia, epilepsy, and vascular dementia did not receive a required annual comprehensive MDS assessment within the regulatory timeframe. Facility policy required a comprehensive assessment to be completed within a specified ARD window, but the last full comprehensive MDS for this resident was done more than a year before surveyor review. Staff interviews confirmed that the prior MDS coordinator failed to complete the assessment, despite an established process that uses an entry tracking assessment, payor-source–driven scheduling, and an MDS Clinical List to identify due assessments.
Surveyors found that MDS assessments were not accurately completed for two residents. One resident with multiple medical conditions, including epilepsy and vascular dementia, had a quarterly MDS that documented no falls, even though facility incident records and staff interviews confirmed an unwitnessed fall that led to hospital transfer. Another resident with peripheral vascular disease had an MDS indicating daily bed rail use, while observations over several days, the resident’s own statements, the care plan, and physician orders all showed that no bed rails were present or ordered. The MDS Coordinator and unit leadership acknowledged that the MDS coding for both residents was incorrect.
An LPN administered a resident’s metoprolol from another resident’s medication packet after stating the ordered medication was not available on the cart. The MARs showed the two residents had different metoprolol orders, and the Unit Manager and DON stated the medication should have been obtained from the backup medication-dispensing system or the pharmacy instead of another resident’s supply.
A resident with multiple contractures and total dependence for ADLs was not receiving restorative care even though OT discharge documentation recommended it after therapy ended. Interviews showed the therapy team did not complete the required restorative referral process, the resident was never added for discussion in morning meetings, and the ADON, CNA, and charge nurse each described gaps in communication and follow-through regarding the resident’s mobility needs.
A resident receiving hospice care had no hospice plan of care or documented communication process available in the facility record. Staff stated they relied on verbal updates from hospice, but an LPN, RN, DON, and NHA confirmed the EMR did not show hospice interventions or services and the facility had not maintained the required coordination documents. The resident had advanced cognitive impairment, was nonverbal, and was receiving hospice for senile degeneration of the brain.
Infection control failed during catheter care for a resident with a suprapubic catheter and EBP in place. An LPN did not wear a gown, placed uncleaned scissors into her pocket after cutting the dressing, and did not sanitize the bedside table after using a wash basin. The DON and IP stated gowns, table sanitizing, and cleaning scissors were expected during catheter care.
The facility's kitchen had several sanitation and safety deficiencies, including a soiled ceiling vent, an exposed electrical outlet, peeling paint, warped food trays, and a dirty eyewash sink. Interviews revealed a lack of awareness and timely action regarding these issues, indicating gaps in communication and oversight within the facility's maintenance processes.
A nonverbal resident with multiple medical conditions was found to have the call light out of reach on several occasions. Staff interviews confirmed the resident's inability to use the call light, and the care plan lacked interventions for this issue. The facility's policy requires accommodating individual needs, but no alternative alert system was in place for the resident.
A facility failed to implement a comprehensive oxygen care plan for a resident, resulting in the resident not receiving the prescribed oxygen therapy. The care plan indicated the need for oxygen due to ineffective gas exchange, but observations showed the resident with oxygen tubing on her forehead and the flow set incorrectly. Staff interviews confirmed the care plan did not reflect the physician's orders, and the DON and Administrator acknowledged the inconsistency and lack of adherence to the physician's recommendations.
The facility failed to update care plans for three residents, leading to potential care discrepancies. One resident with COPD frequently removed her prescribed continuous oxygen, which was not documented in her care plan. Another resident's care plan lacked a physician's order for continuous oxygen, and the flow was incorrectly set. A third resident's care plan was not updated after an incident of inappropriate touching, leaving her vulnerable. Staff interviews confirmed these deficiencies, and the DON acknowledged the need for accurate care plans.
A resident with severe cognitive impairment and dependent on staff for ADLs was not provided necessary grooming care, specifically shaving, despite multiple requests. Observations confirmed the resident needed a shave, and interviews with staff revealed a lack of documentation and adherence to the facility's grooming policy.
The facility failed to administer oxygen therapy according to physician orders for two residents. One resident's oxygen was not attached and set at a lower flow rate than prescribed, while another resident was observed without oxygen during an activity, despite a continuous oxygen order. Staff interviews confirmed the discrepancies and lack of adherence to care plans.
Improper Labeling, Dating, and Storage of Opened Food Items
Penalty
Summary
The facility failed to ensure that opened food items in the dry storage area were properly labeled and dated, and dietary staff also failed to ensure that an opened food item was properly refrigerated. Review of the facility policy titled Food Receiving and Storage stated that dry foods stored in bins are to be removed from original packing, labeled, and dated, and that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated. During observation of the dry storage area, surveyors found a five-pound bag of grits that had been opened with no date and a three-pound box of potato pearls that had been opened with no open date. The Dietary Manager confirmed that both items lacked an open date and stated that dietary staff are to date opened or used food items before placing them in storage. Later observations in the dry storage area found a large clear resealable plastic bag containing egg noodles that had been removed from its original packaging, but the bag had no label and had a date written on it that the Dietary Manager identified as the use-by date rather than an open date. Surveyors also observed a one-gallon container of cole slaw dressing that had been opened and partially used, stored on the shelf in the dry storage area instead of being refrigerated, and it also lacked an open date. The Dietary Manager confirmed that the egg noodles were not properly labeled or dated and that the opened cole slaw dressing should have been stored in the refrigerator, not the dry storage area.
Failure to Complete Required Annual Comprehensive MDS Assessment
Penalty
Summary
The facility failed to complete a timely comprehensive Minimum Data Set (MDS) assessment for one resident, resulting in noncompliance with required assessment timeframes. Facility policy titled "MDS 3.0 Completion" stated that an annual comprehensive assessment must be completed using an Assessment Reference Date (ARD) no more than 366 days from the most recent prior comprehensive assessment and no more than 92 days from the most recent quarterly assessment. The resident’s electronic medical record showed an admission date of 02/18/2024 with diagnoses including bradycardia, epilepsy, and vascular dementia. Record review revealed that the last full comprehensive MDS assessment for this resident was completed on 01/24/2025, and no subsequent comprehensive assessment was completed within the required annual timeframe. During interviews, the MDS Coordinator II confirmed that a comprehensive assessment was not completed for this resident in February 2026, as required, and attributed the missed assessment to the previous MDS Coordinator’s failure to complete it. The Administrator stated that the MDS department should follow the Resident Assessment Instrument (RAI) Manual for guidance. The MDS Coordinator II further explained that the facility’s system for ensuring timely assessments involves completing an entry tracking assessment upon admission and then scheduling further MDS assessments based on the resident’s payor source, using the MDS Clinical List and the MDS tab to identify which assessment is due and when. Despite this system, the required annual comprehensive MDS assessment for this resident was not completed within the regulatory timeframe.
Inaccurate MDS Coding for Falls and Bed Rail Use
Penalty
Summary
The deficiency involves the facility’s failure to ensure accurate completion of MDS assessments for two residents. For one resident with diagnoses including bradycardia, epilepsy, and vascular dementia, the quarterly MDS dated 01/19/2026 documented no falls in Section J, despite facility incident records showing the resident sustained a substantiated unwitnessed fall on 12/06/2025, during which the resident was unresponsive, did not respond to commands, and was transported to the hospital via 911. The resident later stated he had fallen in the past and gone to the hospital once, and an LPN reported the resident had two unwitnessed falls and was sent to the hospital in December 2025 for a fall with possible seizure activity. The MDS Coordinator confirmed that the fall on 12/06/2025 should have been coded on the 01/19/2026 quarterly MDS and that Section J was not accurately completed. For another resident admitted and readmitted with diagnoses including peripheral vascular disease, the quarterly MDS dated 12/18/2025 documented a BIMS score of 15 in Section C and indicated daily use of bed rails in Section P. However, the resident’s care plan dated 12/21/2025 contained no focus area for restraint use, and the physician’s orders contained no order for restraints. Multiple observations over several days showed the resident in bed or in the room without any bed rails on the bed. The resident stated he did not have bed rails and could transfer without them. The MDS Coordinator confirmed that the MDS incorrectly documented bed rail use, and the Unit Manager stated the resident did not use bed rails, there were no physician’s orders for bed rails, and an audit of bed rail use had been provided to the MDS Coordinator for updating MDS assessments.
Medication Given From Another Resident’s Supply
Penalty
Summary
The facility failed to ensure that residents' medications were free from misappropriation by licensed nursing staff during medication administration observations. The facility's Medication Administration policy, revised 04/2025, stated that medication source should be compared with the MAR to verify the resident name, medication name, form, dose, route, and time. The MAR for one resident showed an order for metoprolol succinate ER 25 mg by mouth daily for hypertension, while another resident's MAR showed an order for metoprolol tartrate 25 mg by mouth twice daily. During medication administration observation, an LPN stated that the first resident's metoprolol ER 25 mg was not available on the medication cart and said she would obtain it from the second resident's medication packet because it was the same medication. The LPN removed the medication from the second resident's pill card and administered metoprolol tartrate 25 mg from that resident's supply to the first resident. The Unit Manager stated the LPN should not have administered medication to one resident from another resident's medication card and that the correct medication should have been obtained from the backup medication dispensing system. The DON stated that if a resident's medication was not available, the nurse should obtain it from the facility's backup medication-dispensing system, and if it was not available there, the nurse should call the pharmacy.
Failure to Provide Recommended Restorative Care
Penalty
Summary
The facility failed to ensure that one resident with contractures of the right and left hands, knees, ankles, and feet received restorative care services as recommended by therapy staff. The resident’s significant change MDS documented that the resident was dependent on staff for all ADLs. OT discharge documentation stated that restorative services were recommended after therapy discharge, but the resident was not receiving restorative care at the time of review. Interviews showed breakdowns in the facility’s process for identifying and initiating restorative services. The ADON stated she was responsible for the restorative care program and confirmed the resident was not receiving restorative care. The DT stated that therapy staff were supposed to complete a paper form when restorative services were recommended, but she could not locate the form for this resident and stated therapy staff did not follow the proper process to ensure the resident was placed on the restorative list. The ADON also stated the resident had not been discussed in morning meetings for restorative services. A CNA stated she had notified the charge nurse about the resident’s mobility issues, while the charge nurse stated she assumed the resident was receiving restorative services and did not recall being notified of the decrease in mobility.
Failure to Coordinate Hospice Care and Communication
Penalty
Summary
The facility failed to maintain communication and coordination of care with hospice for one resident receiving hospice palliative care services. The resident was admitted to the facility with multiple diagnoses including senile degeneration of the brain, vascular dementia, depression, diabetes mellitus type 2, hypertension, contractures, and a history of venous thrombosis and embolism. The resident was admitted to hospice for senile degeneration of the brain and had an MDS assessment showing a BIMS score of zero, indicating the resident was rarely or never understood and was receiving hospice care. Review of the facility’s hospice care plan showed that the resident began receiving hospice services and that facility staff were to notify hospice of significant changes, clinical complications, transfer needs, and death, while also assessing symptoms such as pain, restlessness, agitation, constipation, and other discomfort. The facility’s hospice and nursing facility services agreement also required a communication process documenting how communication between the facility and hospice provider would occur to ensure the resident’s needs were met 24 hours per day. The facility policy stated that the DON was responsible for coordinating care with hospice representatives and obtaining the most recent hospice plan of care for each resident. During observations and interviews, staff members stated they did not have a hospice care plan, hospice communication book, or documentation in the EMR showing the interventions or services hospice provided for the resident. An LPN stated the facility only had its own care plan and no hospice plan of care was available. An RN stated she could not determine what hospice did or was responsible for because there was no documentation of hospice services in the EMR. The DON confirmed there was no hospice care plan or communication book and said hospice staff only verbally reported to nursing staff. The NHA later confirmed the hospice plan of care and coordination documents were not obtained until after the issue was identified, and the DON stated she had not read the hospice policy and was not involved in care planning for residents receiving hospice services.
Infection Control Failure During Catheter Care
Penalty
Summary
The facility failed to follow its infection control process during indwelling catheter care for one resident with a suprapubic catheter. The resident was admitted and later readmitted with diagnoses including retention of urine, and the quarterly MDS documented an indwelling catheter. The care plan identified a suprapubic catheter related to neurogenic bladder, retention of urine, bilateral hydronephrosis, obstructive and reflux uropathy, and benign prostatic hypertrophy, with interventions that included cleaning the catheter stoma site as ordered and maintaining enhanced barrier precautions. During observed catheter care, the LPN did not wear a gown even though enhanced barrier precautions were in place and PPE was available in the hallway near the room. The LPN also used a pair of scissors to cut the old dressing from the catheter, placed the scissors into her uniform pocket without cleaning them, and did not clean the resident's bedside table after removing the wash basin used during the procedure. Personal items were observed on the bedside table used for the catheter care. In interview, the LPN stated she should have worn a gown because the resident was on enhanced barrier precautions and catheter care was a high-contact procedure. She also stated the bedside table should have been cleaned after the wash basin was removed and the scissors should have been cleaned before being placed in her pocket because of cross-contamination and infection concerns. The DON and Infection Preventionist both stated that gowns and gloves were expected for catheter care, that bedside tables used during the procedure should be sanitized, and that scissors should be cleaned after use rather than placed in a pocket uncleaned.
Kitchen Sanitation and Safety Deficiencies
Penalty
Summary
The facility failed to maintain a safe and sanitary kitchen environment, which posed potential safety and sanitation hazards to all 121 residents receiving an oral diet. Observations revealed several deficiencies, including a ceiling vent in the dietary hallway that was soiled with dust and debris, an exposed electrical outlet in the dishwashing room, peeling paint above the stove and oven area, and numerous metal food trays that were warped and unserviceable. Additionally, the eyewash sink was found with a visible brown substance pooled in it, covered by a tray. Interviews with the Dietary Services Manager (DSM) and the Maintenance Director (MD) indicated that the facility had an electronic work order system for repairs, but there was a lack of awareness and timely action regarding the identified issues. The DSM was unaware of the dirty vent and the missing faceplate on the electrical outlet, while the MD confirmed the need for cleaning and repairs. The Administrator also expressed unawareness of the deficiencies, highlighting a gap in communication and oversight within the facility's maintenance and sanitation processes.
Failure to Ensure Call Light Accessibility for Nonverbal Resident
Penalty
Summary
The facility failed to accommodate the needs of a resident, identified as R60, by not ensuring that the call light was within reach. Observations on multiple occasions revealed that R60, who is nonverbal and has several medical conditions including dysphagia, muscle weakness, and cerebral palsy, was lying in bed with the call light out of reach. The facility's policy on Accommodation of Needs requires that residents' individual needs and preferences be reasonably accommodated, yet R60's care plan did not include goals or interventions related to the accessibility of the call light. Interviews with staff, including an LPN and the Unit Manager, confirmed that R60 could not use the call light and that staff checks on her frequently. However, the Unit Manager acknowledged that an alternative method should be in place for R60 to alert staff in case of distress. The Administrator was unaware of R60's inability to use the call light and confirmed the need for an emergency alert system for R60, as she cannot rely on her roommate for assistance.
Failure to Implement Oxygen Care Plan for Resident
Penalty
Summary
The facility failed to implement a comprehensive oxygen care plan for a resident, identified as R60, which resulted in the resident not receiving the prescribed oxygen therapy. The care plan for R60, dated December 26, 2024, indicated that the resident required oxygen therapy due to ineffective gas exchange and had a tendency to remove the oxygen from her nose. Despite this, observations on March 17, 2025, revealed that R60 was nonverbal and lying in bed with the oxygen tubing on her forehead and the oxygen flow set at 2.5 LPM, contrary to the physician's order of 3.5 LPM. Interviews with staff, including an LPN and the Unit Manager, confirmed that the oxygen was not attached as required and that the care plan did not reflect the physician's orders. Further interviews with the Director of Nursing (DON) and the Administrator highlighted that there was no documentation in the care plan for R60's oxygen orders, and staff were not following the physician's recommendations. The DON acknowledged that the care plan, physician's orders, and oxygen flow should be consistent, and staff should visit the resident more frequently if she was known to remove her oxygen. The Administrator confirmed that all orders, including those for oxygen, should be followed according to the physician's recommendations, but this was not being done for R60.
Failure to Revise Care Plans for Residents
Penalty
Summary
The facility failed to revise care plans for three residents, leading to potential discrepancies in the care provided. For one resident with chronic respiratory failure and COPD, the care plan did not reflect the resident's behavior of removing her oxygen, which was prescribed to be worn continuously. Observations showed the resident frequently without her oxygen, and interviews with staff confirmed the lack of documentation allowing this behavior. The Director of Nursing (DON) acknowledged the inconsistency between the care plan and the physician's orders, emphasizing the need for staff to follow the prescribed orders. Another resident's care plan did not include the physician's order for continuous oxygen at 3.5 LPM. Observations revealed the resident's oxygen was not attached, and the flow was set at 2.5 LPM, contrary to the physician's order. Interviews with staff confirmed the omission of the oxygen order in the care plan and the incorrect flow setting. The Respiratory Therapist admitted to attempting to wean the resident off oxygen without documenting or consulting the physician, further contributing to the care plan's inadequacy. The third resident's care plan was not updated to address an incident of inappropriate touching, leaving the resident vulnerable. Interviews with the MDS Coordinator and Social Services Director confirmed the absence of an updated care plan to reflect the incident. The DON and Administrator acknowledged the need for the care plan to include measures addressing the resident's vulnerability following the incident.
Failure to Provide Grooming Care for Resident
Penalty
Summary
The facility failed to provide necessary grooming care for a resident, identified as R70, who was dependent on staff for assistance with activities of daily living (ADLs). R70, who had severe cognitive impairment and required assistance with ADLs, was observed on multiple occasions needing a shave, which was not provided despite his requests. Interviews with R70 revealed that he had asked for a shave several times but was told by staff that they did not have time. Observations confirmed that R70 had facial hair and needed grooming. The facility's policy on ADLs, which was revised in January 2024, mandates that residents unable to perform ADLs should receive necessary services to maintain grooming and personal hygiene. However, interviews with staff, including a Licensed Practical Nurse (LPN) and the Director of Nursing (DON), revealed that the facility did not maintain a grooming log, and there was no documentation of resident grooming. The DON confirmed that residents should not have to wait days for grooming if requested, and the Administrator acknowledged that residents' grooming requests should be honored.
Failure to Administer Oxygen Therapy as Prescribed
Penalty
Summary
The facility failed to administer oxygen therapy in accordance with physician orders for two residents, R60 and R17. R60, who was admitted with multiple diagnoses including dysphagia, muscle weakness, and shortness of breath, had a physician's order for oxygen at 3.5 liters per minute (LPM) via nasal cannula continuously. However, observations revealed that R60's oxygen was not attached, and the flow was set at 2.5 LPM instead of the prescribed 3.5 LPM. The care plan for R60 did not include goals and interventions for oxygen therapy, and the respiratory therapist attempted to wean R60 off oxygen without documenting or consulting the physician. R17, diagnosed with chronic respiratory failure with hypoxia and COPD, had a physician's order for continuous oxygen at 3 LPM via nasal cannula. Observations showed that R17 was not wearing her oxygen while participating in an activity in the dining area, contrary to the continuous oxygen order. The care plan for R17 included interventions for managing her respiratory condition, but the prescribed oxygen therapy was not adhered to during the observed period. Interviews with facility staff, including the Unit Manager, Respiratory Therapist, Director of Nursing, and Administrator, confirmed the discrepancies between the physician's orders and the actual administration of oxygen therapy. The staff acknowledged that the orders were not followed as prescribed, and the care plans did not reflect the necessary interventions for oxygen management, leading to a deficiency in providing safe and appropriate respiratory care for the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Riverdale
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Arrowhead Post Acute Llc | 1.1 mi | ★★★★★ | 0 | 0 |
| Lake City Center For Nursing And Healing Llc | 4.9 mi | ★★★★★ | 15 | 0 |
| Jonesboro Center For Nursing And Healing Llc | 6.1 mi | ★★★★★ | 16 | 0 |
| Healthcare At College Park, Llc | 6.2 mi | ★★★★★ | 0 | 0 |
| Fulton Center For Rehabilitation Llc | 7.2 mi | ★★★★★ | 0 | 0 |
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