Average — CMS composite of the measures below.
The next survey window likely opens around January 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 Riverside Health And Rehabilitation during CMS and state inspections, most recent first.
The facility failed to follow infection control practices in the laundry area and during perineal care. In the laundry department, dirty and clean linen were observed in the same spaces, clean linen was uncovered, personal drinking cups and a bottle of hot sauce were present in the clean area, and a soiled pillow was found on clean linen. During perineal care for a resident with spastic quadriplegic cerebral palsy and severe cognitive impairment, one CNA kept gloves in her pocket with personal items and another CNA did not perform hand hygiene between glove changes.
A resident with ataxic cerebral palsy, COPD, SOB, and hypoxemia was ordered oxygen by NC at 3 LPM PRN, but surveyors observed the resident receiving oxygen at 2 LPM on two occasions. A CMA said she was not assigned to check the oxygen level, an LPN confirmed the resident was on 2 LPM despite the 3 LPM order, and the DON later confirmed the ordered flow rate before changing it to 3 LPM.
Expired Arginine Powder was found in a medication room, and an LPN confirmed it should have been removed from stock. In two medication carts, an opened bottle of Latanoprost Ophthalmic Solution and three vials of blood sugar test strips lacked open dates; the LPN, DON, and CMA confirmed these items should be dated when opened so staff know when to discard them.
The facility failed to maintain proper storage temperatures for medications in the medication storage refrigerator, which was observed to be at 51°F, above the recommended range. An LPN confirmed the issue and contacted maintenance, while the DON was informed of potential refrigerator or thermostat problems.
The facility failed to protect two residents from sexual abuse by another resident, R632, who has severe cognitive impairment and a history of inappropriate sexual conduct. Despite incidents being reported, the facility's interventions were insufficient, leading to repeated inappropriate interactions. The facility's policy on abuse prohibition was not effectively implemented, resulting in a deficiency in ensuring resident safety.
A facility failed to report an incident involving a resident found in bed with another unclothed resident within the required timeframe. The incident was not reported to the SSA until weeks later due to uncertainty about its reportability, despite facility policy requiring prompt reporting of such incidents.
A resident with vascular dementia and hallucinations did not have a comprehensive care plan addressing her refusal of care and medications, despite facility policy requiring such plans. Staff interviews confirmed the resident's frequent refusals, but the care plan lacked necessary interventions.
A resident's discharge documentation was incomplete, failing to include a recapitulation of stay and discharge instructions as required by facility policy. The interdisciplinary team, including the DON, ADON, Nurse Supervisor, and Wound Care Nurse, did not complete the necessary sections of the discharge summary. Interviews with staff confirmed the oversight, with the Social Worker and Medical Records being identified as responsible for ensuring the completion of the discharge documentation.
The facility failed to follow proper hand hygiene and equipment sanitization practices during medication pass observations. A CMT did not clean a blood pressure monitor before or after use, and an LPN did not sanitize her hands between resident interactions. Interviews with the DON and IC Nurse confirmed that these actions were against facility policy.
Infection Control Lapses in Laundry and Perineal Care
Penalty
Summary
The facility failed to use effective infection control protocols in the laundry department and during perineal care for one resident. Facility policies reviewed for Laundry Services, Infection Prevention Plan, and Hand Hygiene stated that standard precautions were to be used when handling linen, clean linen was not to come in contact with dirty linen, gloves did not replace hand hygiene, and hand hygiene was to be performed before donning gloves and immediately after removing them. In the laundry department, observations showed dirty laundry, a washing machine, and a dryer on one side of the room, with clean laundry on the other side. Clean laundry was observed on shelves and a table in a second room, but drinking cups and a bottle of hot sauce were also present in the clean laundry area. Laundry staff was observed placing dirty linen into the washing machine while wearing gloves but no gown or apron. Pillows in a plastic bag were observed on the floor beside the dryer, and a container of linen was observed on the floor in the clean linen room. Later observation showed a soiled pillow lying on top of clean linen, personal drinking cups in the clean room, and uncovered clean linen in the room with dirty items. The Infection Control Nurse stated staff should have gloves and a gown when handling dirty linen, linen should not be on the floor, and personal drinking cups should not be in the clean area. For the resident care observation, the resident had spastic quadriplegic cerebral palsy, severely impaired cognition with a BIMS score of 5, functional limitations, and required substantial to maximal assistance. The care plan documented a self-care deficit and need for assistance with toileting hygiene. During observed perineal care, one CNA removed gloves from her pocket and put them on to provide care, and she stated she kept gloves in her pocket with her wallet, house keys, and other items. Another CNA did not perform hand hygiene between glove changes. Both CNAs acknowledged that hand hygiene should have been performed between glove changes and that failure to do so could spread germs or cause infection.
Oxygen Flow Rate Not Given as Ordered
Penalty
Summary
The facility failed to ensure oxygen was administered at the prescribed rate for one resident receiving oxygen therapy. The resident had diagnoses of ataxic cerebral palsy, COPD, shortness of breath, and hypoxemia, and the care plan identified respiratory difficulties/risk for further decline with oxygen as ordered and physician notification for changes. The physician's order was for oxygen by nasal cannula at 3 LPM as needed. Observations showed the resident receiving oxygen by nasal cannula at 2 LPM on 02/14/2026 at 9:18 AM and again on 02/15/2026 at 8:30 AM. During interview, a CMA stated she was not assigned to check the resident's oxygen levels and that the nurse checks the oxygen flow rate. An LPN confirmed the resident was receiving oxygen at 2 LPM and verified the order was for 3 LPM. The DON later stated the respiratory therapist visits quarterly, reviews the EMR, and assesses residents, and she confirmed the order was for 3 LPM before changing the oxygen level from 2 to 3 LPM.
Expired Medications and Missing Open Dates in Medication Storage
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with facility policy and accepted medication storage practices. During review of the medication room, four boxes of Arginine Powder dietary supplement were found with expired dates still in stock. An LPN confirmed the expired supplements were present in the medication room and stated they should have been removed by nursing staff or central supply staff who stocked the room. The facility policy reviewed stated that outdated, contaminated, or deteriorated medications are to be promptly removed from stock. During review of two medication carts, one bottle of Latanoprost Ophthalmic Solution and three vials of EvenCare ProView blood sugar test strips were found opened without open dates. The LPN confirmed the eye drops and test strips had been opened and lacked dates, and stated the eye drops should not be used after 42 days and the test strips should be discarded 3 months after opening. The DON stated nurses were expected to place open dates on eye drops and blood sugar test strips when first opened, and a CMA also confirmed that open dates should be present because no one would otherwise know when to discard them.
Improper Medication Storage Temperature
Penalty
Summary
The facility failed to store medications and biologicals at the proper temperatures, as required by their policy, in the medication storage refrigerator. During an observation, the refrigerator's temperature was found to be 51 degrees Fahrenheit, which is above the recommended range of 36 to 46 degrees Fahrenheit. This discrepancy was confirmed by an LPN who was unsure about the frequency of temperature checks and documentation. Further observation confirmed the same temperature issue, and another LPN acknowledged the problem and contacted maintenance for investigation. The Director of Nursing was informed of the issue later and mentioned that there were problems with the refrigerator or thermostat. The facility had an extra refrigerator available and replaced the malfunctioning one.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect the rights of two residents, R58 and R73, from sexual abuse by another resident, R632. R58, who has a history of PTSD and inappropriate sexual behaviors, reported that R632 had kissed and rubbed on him without consent. Despite the incident being reported to law enforcement, the facility did not adequately separate the residents, leading to further inappropriate interactions, including R58 exposing himself to R632. Interviews with staff revealed that the residents were initially allowed to interact in common areas, which led to repeated incidents of inappropriate behavior. R632, who has severe cognitive impairment and a history of inappropriate sexual conduct, was also involved in an incident with R73, where he exposed himself to her. R73, who has intact cognition, reported the incident to the staff, and an investigation was conducted. Despite these incidents, the facility's interventions were limited to monitoring resident behavior and keeping them in common areas, which proved insufficient in preventing further occurrences. The facility's policy on abuse prohibition was not effectively implemented, as evidenced by the repeated incidents involving R58 and R632. Interviews with the Director of Nursing and other staff members indicated that while some actions were taken, such as separating the residents and involving law enforcement, these measures were not enough to prevent further incidents. The facility's failure to adequately protect residents from abuse highlights a deficiency in their ability to ensure a safe environment for all residents.
Delayed Reporting of Inappropriate Resident Behavior
Penalty
Summary
The facility failed to report an incident of inappropriate behavior to the State Survey Agency (SSA) within the required time frame. The incident involved a resident, R26, who was found in the room of a male resident, lying in bed with him. The male resident was unclothed and lying on his stomach, while R26 had pants on but no shirt. The staff discovered the residents in this state but noted that they were not engaged in any activity. The incident occurred on October 16, 2024, but was not reported to the SSA until November 1, 2024, which was beyond the required reporting timeframe. The facility's policy on Abuse Prohibition-Reporting and Investigating mandates that all allegations of abuse or those involving serious bodily injury must be reported immediately, but no later than two hours, and other allegations must be reported within 24 hours. Despite this policy, the incident was not reported promptly. The Social Service Director (SSD) was informed of the incident on the day it occurred, and a note was made, but the report to the SSA was delayed. The Administrator stated that the delay was due to uncertainty from the Regional Nurse Consultant about whether the incident needed to be reported, as no activity was observed. The report was eventually submitted after a complaint about a rape at the facility, prompting the Administrator to report the incident as it was the closest related event.
Failure to Develop Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop a person-centered comprehensive care plan for a resident identified as R68, who was admitted with diagnoses including vascular dementia, depression, and hallucinations. The facility's policy on patient care plans emphasizes the need for a comprehensive approach that addresses medical, physical, mental, and psychosocial needs. However, upon review, it was found that R68's care plan lacked specific areas, goals, or interventions related to her refusal of care and medications, despite documentation in her medical records and medication administration record (MAR) indicating such refusals. Interviews with facility staff, including a Certified Nursing Assistant (CNA), Certified Medication Technician (CMT), and the Director of Nursing (DON), confirmed that R68 frequently refused care and medications. The Assessment Coordinator acknowledged that care plans should be updated to reflect such behaviors and interventions should be in place. Despite these acknowledgments, the care plan for R68 did not include necessary interventions for her refusal of care and medications, highlighting a gap in the facility's adherence to its own care planning policy.
Incomplete Discharge Documentation for a Resident
Penalty
Summary
The facility failed to complete a recapitulation of stay and discharge instructions for a discharged resident, identified as R73. The facility's policy, titled Discharge Recapitulation Summary, mandates that a recapitulation summary should be completed for patients discharged from the center, including a service summary by each discipline. However, upon review, it was found that R73's Interdisciplinary Discharge Summary was incomplete. The Follow-Up Physician Care section of the Discharge Instruction for Care was not filled out, and the interdisciplinary sections, including the Recapitulation of Resident's Stay, were left incomplete. Interviews with facility staff, including the Director of Nursing (DON), Social Worker (SW), and the Administrator, confirmed the incomplete status of R73's discharge documentation. The DON acknowledged that the interdisciplinary team, including herself, the Assistant Director of Nursing (ADON), the Nurse Supervisor, and the Wound Care Nurse, were responsible for completing the discharge summary. The SW was unsure why the form was incomplete and indicated that Medical Records was responsible for ensuring its completion. The Administrator confirmed that the Social Worker initiated the discharge and that Medical Records was tasked with completing the summary recapitulation.
Deficient Hand Hygiene and Equipment Sanitization Practices
Penalty
Summary
The facility failed to adhere to proper hand hygiene practices and the sanitization of shared medical equipment during two of five medication pass observations. During one observation, a Certified Medical Technician (CMT) did not clean the blood pressure monitor before or after using it on a resident. The CMT acknowledged the oversight in an interview following the observation. In another instance, a Licensed Practical Nurse (LPN) was observed not sanitizing her hands after exiting a resident's room and before preparing medication for another resident. The LPN confirmed that she should have re-sanitized her hands between residents. Interviews with the Director of Nursing (DON) and the Infection Control (IC) Nurse revealed that the facility's expectations were for staff to perform hand hygiene before and after contact with each resident and to sanitize shared medical equipment between uses. The IC Nurse specified that hand sanitizer was appropriate unless hands were visibly soiled or the resident was in isolation, in which case hand washing was required. The IC Nurse also stated that medical equipment, such as blood pressure cuffs, should be cleaned with approved sanitizing wipes between each resident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 23 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Thomaston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Healthcare | 0.4 mi | ★★★★★ | 4 | 0 |
| Harborview Health Systems Thomaston | 2.1 mi | ★★★★★ | 0 | 0 |
| Heritage Inn Of Barnesville Health And Rehab | 16.6 mi | ★★★★★ | 0 | 0 |
| Warm Springs Medical Center Nursing Home | 20.2 mi | ★★★★★ | 4 | 0 |
| Roberta Trails Of Journey Llc | 21.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverside Health And Rehabilitation.
100% money-back within 48 hours.
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.