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 July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Bend Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident was subjected to verbal abuse when a CNA used inappropriate language during care, in violation of the facility’s abuse policy that requires residents be free from verbal, mental, sexual, and physical abuse and be treated with respect and dignity. The incident was investigated and determined to meet the facility’s definition of verbal abuse, which includes intimidation or punishment causing mental anguish.
The facility failed to maintain complete and timely documentation for several residents, including missing or retroactively entered care conference notes for a resident with multiple sclerosis and another with severe cognitive impairment, where quarterly care plan conferences were not documented until much later. A resident with chronic kidney disease and diabetes had large gaps in recorded weights despite orders for monthly and then weekly weights, and the DON reported the resident refused weights but staff did not document refusals. For a resident with COPD and an indwelling catheter, the eMAR/eTAR showed multiple undocumented administrations of Lyrica, blood glucose checks, BIPAP care, and ordered small frequent meals, with the DON stating staff said they provided the care but failed to chart it. Another resident with congestive heart failure and an insulin lispro sliding scale had numerous early-morning insulin doses not documented as given, with the DON indicating that insulin administration at breakfast was sometimes missed in documentation.
Surveyors identified a failure to maintain a safe, sanitary environment when strong, persistent odors were observed in multiple common areas and units, including hallways, the main lobby, and an area outside a conference room. Odors noted included urine, sewer gas, and bowel movement smells. During an interview, the Administrator stated that odors should be controlled through routine cleaning and increased cleaning in odor-prone areas. The facility’s Environmental policy requires staff and management to promote pleasant, neutral scents and minimize institutional odors, but the observed conditions did not meet these standards.
Improper Medication Labeling and Storage: Loose pills and capsules were found in medication carts, several resident-labeled items were missing names or dates, and an insulin cart contained pens without open or expiration dates. An unopened insulin pen was kept in the cart instead of refrigerated, and a resident glucometer had visible blood spots. Staff interviews confirmed that pills should not remain in carts, insulin pens should be dated, and glucometers should be cleaned between uses.
Missing Dementia Care Training for Nursing Staff: The facility failed to ensure required dementia-related in-services were completed for 4 of 5 reviewed staff members, including a QMA, RN, CNA, and LPN. Employee file review showed each was missing required hours of dementia management training, and requested additional in-service trainings were not provided. The regional clinical support nurse stated staff should receive six hours in the first year and three hours annually of dementia-related in-services.
Surveyors found that the facility failed to consistently implement care plan interventions for two residents, one at high risk for falls and one with a pressure ulcer and continuous tube feeding. A resident with cognitive impairment and a history of multiple falls was observed without required nonskid socks and with the call light out of reach, while the wheelchair was placed in the resident’s line of sight despite prior falls during self-transfer attempts. Another resident with a coccyx wound and PEG tube feeding did not receive wound care as ordered, as an RN applied triad and collagen without cleansing the area first and laid the resident flat without pausing continuous tube feeding, contrary to care plan aspiration precautions requiring head-of-bed elevation during feedings.
A resident receiving O2 therapy was observed with undated O2 tubing, water bottle, and nebulizer equipment, and without an “Oxygen in Use” sign posted on the room door. On another observation, the resident was in bed without O2, and the nebulizer mask was on the floor with undated tubing. Record review showed no physician order for O2 and no care plan addressing O2 use. In interviews, a hospice provider and an RN stated that residents on O2 should have an order with the facility, and the facility’s O2 administration policy requires a physician’s order, review of the care plan, and an O2-in-use sign, which were not in place for this resident.
Surveyors observed failures in infection prevention practices, including a glucometer on the insulin cart with visible blood spots that had not been cleaned between uses, and improper PPE and hand hygiene during tracheostomy suctioning for a resident on Enhanced Barrier Protocol. An RN did not perform hand hygiene before donning gloves, did not wear a gown, used the same gloves to open a trach care kit and sterile water, contaminated a sterile glove by touching the trach collar, and then handled the suction catheter without changing gloves or re-washing hands, while two CNAs assisted in the room without gowns. Staff interviews confirmed that gowns should have been worn for EBP, gloves changed when moving from dirty to clean tasks, and glucometers cleaned after each use, consistent with facility policies on hand hygiene, PPE, and glucometer disinfection.
The facility failed to complete quarterly care conferences for 3 residents. One resident with schizophrenia and anxiety had no documented conference after a social worker left a message for the guardian, and two other residents with significant dependence and cognitive impairment also had no care conference documentation since their last meetings. The SSD stated conferences were to be held every 3 months, but the records showed they were overdue.
A facility failed to ensure that two residents with meds at bedside had physician orders, self-administration assessments, and care plans for self-administration. One resident with DM2, dialysis, and CVA was found with unlabeled pills at the bedside, and another resident with acute pulmonary edema and dysphagia was found with a pill on the over-bed table. Records for both residents lacked the required orders, assessments, and care plans, and staff reported finding meds at bedside at times.
A resident with end stage renal disease was coded on the Quarterly MDS as having received an antianxiety medication during the 7-day lookback, but the eMAR showed zero doses of hydroxyzine were given. The Regional Clinical Support Nurse stated the resident did not receive an antianxiety medication during the lookback period and was marked in error on the MDS.
Care plans were not revised to reflect changes in condition for two residents. One resident’s advanced directive care plan still listed DNR even though records, a care conference, and staff confirmed full code status. Another resident’s fall care plan still included bright tape on a call light even after the call light was changed to a pressure-sensitive pad, and the DON stated the intervention should have been removed.
A resident with dementia and muscle weakness was at high fall risk and had a care plan requiring wheelchair safety devices such as anti-rollbacks and anti-tippers. The record showed repeated falls, including head injuries and an ER visit, while hospice and facility staff had ongoing communication problems about DME, labeling, and installation. The hospice-issued wheelchair did not contain the resident’s individualized fall interventions, and the chart lacked clear orders and documentation showing hospice care changes and ongoing coordination.
Failure to notify emergency contact of injury and x-ray order: A resident with dementia, osteoporosis, and malnutrition was found on the floor, later developed swelling and tenderness near the R knee, and had a 4-view x-ray ordered and completed. The record lacked documentation that the resident’s emergency contact was notified of the injury or the x-ray order, and the family member stated he was not informed until after an ER transfer order was made.
A resident with dementia, osteoporosis, and protein-calorie malnutrition had a fall, later developed swelling and bruising to the right leg, and a STAT x-ray order for the knee was not entered or completed promptly; the x-ray was delayed until the next day, when a broken femur was found and the resident was sent to the hospital. The facility also failed to document ordered weekly weights for the resident despite a history of significant weight loss and care plans addressing nutritional risk.
Failure to provide an appropriate supplement for a resident with a milk allergy. A resident with Type 2 DM, severe cognitive impairment, and total dependence for ADLs was ordered MedPass 2.0 daily, even though the allergy list and RD note identified a true milk protein allergy with hives. An LPN observed the resident receiving the supplement, and the carton listed milk as the first ingredient with a contains milk warning; the DON stated the resident should not be receiving it.
The facility failed to notify residents or their representatives of the bed hold policy during hospital transfers. A resident with a fractured neck, another with multiple hospitalizations, and others requiring substantial assistance were not provided with the necessary documentation. The DON confirmed the absence of transfer paperwork and bed hold policies.
The facility failed to properly store medications, as loose pills were found in medication carts across three halls. Despite a policy requiring drugs to be stored in their original packaging, numerous loose pills with various markings were observed. An RN noted that carts are cleaned bi-weekly, but the presence of loose pills indicates non-compliance with the storage policy.
The facility failed to serve food at appropriate temperatures, with a test tray showing a grilled cheese at 117°F and fruit cocktail at 60.2°F, both cooler than required. Residents reported the food as unappetizing and repetitive, and the Ombudsman noted several complaints. The facility's policy requires hot food to be at least 135°F and cold food at or below 41°F.
The facility failed to properly store, label, and date food items, as observed during multiple kitchen inspections. Items such as onions, lettuce, tea, and various sauces were found without proper dates, and temperature logs were incomplete. The Interim Dietary Manager confirmed that open lettuce should be dated and temperatures recorded twice daily. Further inspections revealed additional items without dates, and inconsistencies in temperature logs were noted, with housekeeping responsible for checks.
The facility was found to have a persistent urine odor in several areas, including hallways and a conference room, over six days. Staff interviews confirmed awareness of the issue, attributing it to a resident urinating on the floor. Additionally, air conditioning units in resident rooms were observed with flaking paint and rust, indicating poor maintenance. The facility's maintenance policy requires documentation of compliance, but the observed conditions suggest non-adherence.
The facility failed to provide SNF-ABN and NOMNC forms to two residents who remained in the facility after their Medicare services ended. One resident did not receive a SNF-ABN form despite being notified of the end of coverage, while another did not receive either form due to a discharge from therapy. The Social Services Director acknowledged the oversight and a lack of understanding of the Medicare coverage process.
A facility failed to provide necessary transfer documentation for a resident who was emergently sent to the hospital after a fall resulting in a fractured neck. The resident's clinical record lacked any transfer paperwork, which was confirmed by the DON during interviews. The DON acknowledged that essential documents like the face sheet and bed hold policy should have been sent with the resident.
A facility failed to notify the Ombudsman office about an emergency hospital transfer of a resident with a fractured neck. The resident, who is moderately cognitively impaired, was transferred without the necessary paperwork or notification to the Ombudsman. Interviews revealed that the required transfer forms were missing, and the Social Service Director acknowledged the oversight.
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing behaviors, accidents, and nutrition. A resident with dementia was observed eating non-food items without a behavior-focused care plan. Another resident involved in an altercation lacked documentation and a care plan for the incident. A third resident experienced significant weight loss without an updated intervention plan, despite being on nutritional supplements.
The facility failed to conduct quarterly care plan conferences for two residents, one with dementia and anxiety, and another with multiple sclerosis and other conditions. Both residents were dependent on staff for daily activities, and the required care plan conferences were not held within the specified periods. The Social Services Director and DON confirmed the necessity of these quarterly reviews.
A facility failed to provide person-centered activities for a resident with dementia and anxiety. The resident was often positioned in a way that obstructed her view of the television and was not invited to group activities. Despite a care plan emphasizing engagement, there was no documentation of activity participation, and a CNA noted restrictions in assisting residents to activities.
A resident with multiple sclerosis and vision impairments was not assessed by vision services for over a year, despite wearing cloudy glasses and having difficulty with her prescription. The facility's policy requires assistance in arranging such services, but the resident's clinical record lacked documentation of evaluations or transportation offers since April 2023. Interviews revealed a gap in the process for arranging vision services.
A resident with a suprapubic catheter experienced infections due to inadequate care and maintenance by the facility. The catheter was not changed or documented as required, and staff failed to follow enhanced barrier precautions. Observations showed improper placement of the catheter bag and lack of training for CNAs on catheter care. Interviews revealed confusion among staff about care responsibilities, contributing to the resident's infections.
A facility failed to provide sufficient fluid intake to a resident, who was found with an empty cup and an unreachable call light. The resident, dependent on staff for daily activities and on diuretic medication, expressed concerns about inadequate fluid intake. Despite being at risk for dehydration due to medical conditions and diuretic use, the facility did not closely monitor fluid intake, contrary to their hydration policy.
The facility failed to provide and dispense medications as ordered for two residents. A resident did not receive their prescribed ProStat supplement due to unavailability, and another resident's ProStat AWC SF was inconsistently administered, with doses missed or incorrectly given. The facility's medication management practices were inadequate, impacting residents with significant medical needs.
The facility exceeded the acceptable medication error rate with an 8% error rate during a medication pass. An LPN failed to prime insulin pens before administering insulin to two residents, contrary to manufacturer instructions. This resulted in incorrect dosing for both residents, as the facility's policy requiring adherence to manufacturer guidelines was not followed.
A facility failed to consistently document wound care treatments for a resident with pressure injuries on the right buttock and heel. Despite specific orders for wound care, records showed incomplete documentation on several dates. The DON could not explain the inconsistency, and the staff nurse's job description included responsibilities for ensuring proper care and treatment administration.
The facility failed to follow infection control practices for three residents, including improper use of mechanical lift slings, inadequate hand hygiene during incontinence care, and inconsistent use of gowns and masks during catheter care. These actions were contrary to the facility's infection control policies.
The facility failed to maintain a pest-free environment, with flies and gnats observed in a resident's room and the Second Floor Nurse's Station. A resident reported previous pest issues, and the Administrator was unaware of the problem. The facility's pest control policy requires a clean environment and an active pest control contract.
A resident sustained fractures to both ankles due to inadequate safety measures during transport. In one incident, the resident's foot was caught under the wheelchair due to missing footrests, and in another, the resident slid out of the wheelchair because the seatbelt was not properly secured. The resident, who had a history of mobility issues, required medical intervention for her injuries.
The facility failed to properly dispose of and store medications for discharged and deceased residents, with controlled medications not double locked and improper temperature controls. Medications for residents who had expired or been discharged were not disposed of timely, and there was inadequate documentation for non-narcotic medication disposition.
The facility failed to develop and implement a timely care plan for a resident with an enteral feeding tube. Despite physician orders, the care plan did not include a focus on the feeding tube until much later, and observations revealed that the enteral feeding pump was not running as ordered. Staff interviews and record reviews indicated a lack of documentation and adherence to facility policies.
A resident with a history of inappropriate sexual behavior inappropriately touched another resident, who has a history of mental health issues, in a common area of the facility. The incident was observed by staff, and the residents were separated immediately. Despite the facility's awareness of the perpetrator's behavior, the incident occurred, indicating a failure in monitoring or intervention strategies.
Failure to Protect a Resident From Verbal Abuse by CNA
Penalty
Summary
The deficiency involves a failure to protect a resident from verbal abuse by facility staff. On 4/9/26 at 8:32 a.m., a CNA (CNA 2) used inappropriate language toward Resident B during the provision of care. This conduct was documented in a state reportable incident reviewed on 4/28/26 at 9:00 a.m., which identified the event as verbal abuse. The facility’s own abuse policy, revised in 9/22 and provided by the Administrator, states that residents have the right to be free from abuse, including verbal, mental, sexual, or physical abuse, and that residents must be treated with respect and dignity. The policy further defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting harm, pain, or mental anguish, and includes verbal abuse and mental abuse. Despite this policy, the interaction between CNA 2 and Resident B during care involved inappropriate language that met the facility’s definition of verbal abuse. The Administrator later confirmed that verbal abuse was substantiated following an investigation. This constituted a failure to ensure that Resident B was free from verbal abuse as required by facility policy and regulatory standards.
Incomplete and Late Clinical Documentation for Care Conferences, Weights, and Medication Administration
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical documentation and care conference records for multiple residents. For one resident with multiple sclerosis and quadriplegia who was cognitively intact and dependent on staff for all ADLs, the record showed the most recent completed care conference on one date, with a later care conference note marked as “in progress” and not completed. The Social Services Director later produced several care conference notes for this resident that were all created and signed in the EHR on the same later date, despite being dated for earlier months, and stated she took notes in a notebook and entered them into the EHR whenever she had the chance, acknowledging she had fallen behind on documentation. Another resident with congestive heart failure and severe cognitive impairment had no quarterly care plan conferences documented since admission, and the record later showed multiple quarterly care plan conferences that were all created on the same later date, although they were dated for earlier months. The facility also failed to accurately document weights and refusals for a resident with chronic kidney disease and diabetes mellitus who was cognitively intact and dependent on staff for toileting. The care plan included monitoring weight and intake and educating and documenting refusals, and physician orders required monthly weights and then weekly weights. The weight summary showed only a single weight in October and then weights in January, with a significant decrease, and an IDT note referenced a three percent weight decrease and missing weights from October to January. The TAR for November and December had blank monthly weight entries with no staff signatures, and the DON reported the resident was noncompliant and refused to be weighed in those months, but staff did not document the refusals. Additional documentation deficiencies were identified in medication and treatment administration records for residents with chronic obstructive pulmonary disease and congestive heart failure who required insulin and other treatments. For one resident with COPD, oxygen therapy, and an indwelling catheter, the eMAR/eTAR showed multiple dates when Lyrica, blood sugar checks, BIPAP-related tasks, and ordered small frequent meals were not documented as administered or refused; the DON reported that staff working those shifts stated they had provided the medications and treatments but missed the documentation. For another resident with congestive heart failure and an insulin lispro sliding scale order, the eMAR showed numerous early-morning doses not administered, and the DON explained that night shift nurses obtained blood sugars and relayed results to day shift nurses, who then gave insulin at breakfast, but documentation sometimes was missed.
Failure to Maintain Odor-Free, Sanitary Environment in Common Areas and Units
Penalty
Summary
The facility failed to provide a safe and sanitary environment by not maintaining pleasant, neutral scents and minimizing institutional odors as required by its Environmental policy. During multiple observations, surveyors noted strong, persistent odors in several areas of the building. On 1/22/26 at 9:40 A.M., the hallways on Stocker Unit 1 and Stocker Unit 2 had a strong smell of urine. On 1/23/26 at 8:56 A.M., the main lobby, Stocker Unit 1, and Stocker Unit 2 had a strong, pungent odor consistent with sewer gas. On 1/28/26 at 9:05 A.M., the hallway outside of the conference room had an odor consistent with bowel movement. In an interview, the Administrator stated that odors in the facility should be controlled by general routine cleaning and that staff should increase cleaning in areas prone to odors. The facility’s written Environmental policy, dated 5/17 and provided by the Administrator, states that staff and management shall maximize pleasant, neutral scents and minimize institutional odors, but the observed conditions did not align with these policy expectations. No specific residents or their medical conditions were identified in the report; the deficiency was based on environmental observations in common areas and units accessible to residents, staff, and the public.
Improper Medication Labeling and Storage
Penalty
Summary
Drugs and biologicals were not properly labeled, dated, stored, or discarded in multiple medication areas. During observation of the North Hall medication cart, several loose pills and a capsule were found in the cart. In the South Hall medication cart, a container of pudding dated 1/19/26 was observed along with multiple loose pills and capsules. In the Stocker 1 medication cart, bottles of Magnesium, Vitamin C 250 mg, and Lutein 20 were observed with no names on them. The insulin cart also contained multiple storage and labeling problems. A Lantus pen for Resident 13 had an open date of 12/19/25 but no expiration date. A Lantus pen for Resident W had no open date or expiration date, and two Lispro pens for Resident W had no open date or expiration date, while another Lispro pen for Resident W had no open date. An unopened Lantus pen for Resident 45 was also observed in the insulin cart. In addition, the glucometer for Resident 45 had two spots of blood on it. During interview, the QMA stated there should be no pills in the medication carts and that pills are placed in a drug buster solution and reported to the DON. The RN stated insulin pens should have open and expiration dates and unopened insulin pens should be refrigerated until needed. The Infection Preventionist stated each resident has their own glucometer that should be cleaned in between use.
Missing Dementia Care Training for Nursing Staff
Penalty
Summary
The facility failed to ensure staff completed required dementia management training for 4 of 5 staff employed longer than one year who were reviewed. During employee file review on 1/28/26, QMA 6, who started employment on 9/6/24, was missing two of three hours of dementia management in-services required since 2024. RN 14, who started employment on 11/3/24, was missing two of three hours required since 2024. CNA 15, who started employment on 8/3/23, was missing three of three hours required since 2024. LPN 16, who started employment on 8/26/24, was missing one of three hours required since 2024. Additional in-service trainings were requested but not provided. During interview, the regional clinical support nurse stated staff should have six hours in the first year and three hours annually of dementia-related in-services. The Administrator provided a policy stating competency requirements and training for nursing staff are established and monitored by nursing leadership to ensure nursing competency and that gaps in education are identified and addressed.
Failure to Implement Care Plan Interventions for Falls and Pressure Ulcer Management
Penalty
Summary
Surveyors identified that the facility did not fully implement and maintain care plan interventions for a resident at high risk for falls. One resident with senile degeneration of the brain, muscle weakness, impaired cognition, and a documented high fall risk had a care plan that required a safe environment, call light within reach, and nonskid socks at all times as the resident allowed. Despite multiple prior falls related to self-transfers and added interventions such as nonskid socks, alarms, and safe storage of assistive devices, the resident was observed sitting in a wheelchair wearing plain white socks without nonskid tread. On another occasion, the resident was observed in bed with the call light under the bed and the wheelchair positioned in the resident’s line of sight, contrary to staff’s stated practice of storing the wheelchair out of sight to reduce self-transfer attempts. Surveyors also found that the facility failed to follow physician orders for wound care for a resident with a coccyx wound. The resident, who had chronic respiratory failure, was rarely or never understood, and was dependent on staff for all ADLs, had a physician order directing staff to cleanse the coccyx wound with wound cleanser, pat dry, then apply a mixture of triad and collagen particles to the wound bed and leave it open to air once per day on the day shift. During an observed treatment, an RN entered the room, turned the resident, laid the bed down, removed existing paste from the coccyx area using the pad under the resident, changed gloves, and applied a mixture of collagen and triad with a cotton swab. The RN did not cleanse the wound area before applying the new paste, contrary to the physician’s order. In addition, the facility did not adhere to care plan interventions related to aspiration precautions for the same resident receiving continuous tube feeding. The resident’s care plan required keeping the head of the bed elevated 45 degrees during tube feeding and for one hour after completion. During the observed wound treatment, the RN used the bed remote to lay the bed down without pausing the resident’s continuous PEG tube feeding. The Infection Prevention Nurse later stated that a resident receiving continuous tube feeding should not be laid flat and that staff should follow treatment orders as written by the physician. These observations demonstrated that care plan and physician-ordered interventions for both fall prevention and pressure ulcer management were not consistently implemented as planned.
Failure to Ensure Ordered and Properly Managed Oxygen Therapy
Penalty
Summary
The deficiency involves the facility’s failure to provide safe and appropriate respiratory care for a resident receiving oxygen therapy by not ensuring required orders, care planning, equipment dating, and signage were in place. During an observation, the resident was found in bed with oxygen tubing connected to a concentrator, but the tubing and water bottle, as well as the nebulizer, were not dated, and there was no oxygen administration sign posted on the door. On a later observation, the same resident was in bed without oxygen in use, and the nebulizer face mask was on the floor with tubing that also lacked a date. Review of the physician orders showed there was no documented order for oxygen, and the clinical record did not contain a care plan addressing oxygen use. In interviews, a hospice provider stated that residents on oxygen should have an order with the facility, and an RN confirmed there should be an oxygen order for anyone utilizing it. The facility’s own oxygen administration policy, provided by the Administrator, requires verification of a physician’s order, review of the resident’s care plan for special needs, and placement of an “Oxygen in Use” sign on the room entrance door, all of which were not followed for this resident.
Failure to Follow Infection Control Practices for Tracheostomy Care and Glucometer Cleaning
Penalty
Summary
Surveyors identified a failure to follow infection prevention and control practices related to glucometer cleaning and use of personal protective equipment (PPE) and hand hygiene. During a random observation of the insulin cart, a glucometer was found with two visible spots of blood on the machine, despite facility policy stating that glucometers must be cleaned and disinfected after each use on each patient. In an interview, a registered nurse confirmed there should be no blood on glucometers and that they are to be cleaned between each use. In a separate observation of tracheal suctioning for a resident on Enhanced Barrier Protocol (EBP) due to a tracheostomy, multiple infection control breaches were observed. The RN performing the procedure did not wash hands before donning gloves and did not wear a gown, and two CNAs who entered the room to assist with repositioning the resident also did not don gowns, although they wore gloves. The RN used the same gloves to open the tracheostomy care kit and sterile water, then removed gloves and washed hands before donning a single sterile glove on the right hand. The RN then touched the trach collar with the sterile gloved hand, did not remove the glove or perform hand hygiene, and subsequently touched the suction catheter with a now-contaminated glove without changing to a new sterile glove or washing hands. The RN proceeded to perform multiple suction passes, cleared the catheter with sterile water, placed the catheter into a container uncurled, reattached the trach collar, and then removed gloves and discarded the suction catheter. In interviews, the RN, CNAs, and Infection Preventionist acknowledged that gowns should have been worn for EBP and that gloves should be changed when moving from dirty to clean tasks, and that glucometers should be cleaned after each use. Facility policies on hand hygiene, PPE, and glucometer cleaning supported these requirements.
Missed Quarterly Care Conferences
Penalty
Summary
The facility failed to ensure that care conferences were conducted every 3 months for 3 of 18 residents reviewed. Resident 26 had diagnoses including undifferentiated schizophrenia and generalized anxiety disorder, and the current Annual MDS indicated mild cognitive intactness with assistance needs for eating, transfers, hygiene, dressing, and toileting. The clinical record showed a social service note on 4/29/25 stating the social worker contacted the resident’s guardian to schedule a care conference and left a message, but there was no further documentation of any care conference being completed. During interview, the Social Services Director stated the previous director was behind with conferences and the facility was still trying to catch up, and this resident was one of those not completed. Resident N was admitted with chronic respiratory failure and the most recent Quarterly MDS indicated the resident was rarely or never understood and was dependent on staff for eating, toileting, bathing, and transfers. The record lacked quarterly care plan conferences since 6/26/25. Resident 7 had vascular dementia, was unable to complete the cognitive interview on the most current Quarterly MDS, and was dependent on staff for all ADLs. A care conference had been completed on 6/24/25 with a family member participating by phone, but the record lacked documentation of any care conference since that date. The Social Services Director stated the last care conference for Resident 7 was on 6/24/25 and that care conferences were to be completed every three months.
Bedside Medications Without Orders or Self-Administration Assessments
Penalty
Summary
The facility failed to ensure that residents who had medication at bedside had a physician order for bedside storage and self-administration, a completed self-administration assessment, and a care plan for self-administration. During observation, Resident 62 was found lying in bed with a medication cup containing unlabeled pills on the over-bed table, and the resident stated the pills were morning medicines but did not know how long they had been there. Review of the record showed diagnoses including type 2 diabetes, dialysis, and cerebral infarction; the resident was cognitively intact and required varying levels of assistance with eating, hygiene, dressing, and transferring. The chart lacked an order for self-administration, a self-administration assessment, and a care plan for self-administration. Resident W was also observed lying in bed with a medication cup containing one large white pill on the over-bed table. Record review showed diagnoses including acute pulmonary edema and dysphagia, oropharyngeal phase, and the resident was cognitively intact but needed set-up help with eating, dressing, hygiene, and transferring. The clinical record lacked an order for self-administration of medications, a care plan for self-administration, and an assessment for self-administration. Staff interviews indicated medications were found at bedside at times, with one housekeeper aide stating she found medications at bedside several times and immediately told the nurse, while a QMA stated no medication should be left at bedside and unauthorized medications should be destroyed and the nurse notified.
Inaccurate MDS Coding for Antianxiety Medication Use
Penalty
Summary
The facility failed to ensure the MDS Assessment was completed accurately for one resident reviewed for unnecessary medications. The resident was admitted with diagnoses including end stage renal disease and, on the most recent Quarterly MDS dated 12/29/25, was coded as cognitively intact, dependent on staff for toileting, bathing, and transfers, and as having received an antianxiety medication during the 7-day lookback period. The physician order was for hydroxyzine HCl 25 mg by mouth every 8 hours as needed for itching, starting 12/23/25, but the eMAR showed zero doses of hydroxyzine were administered during December 2025. During interview, the Regional Clinical Support Nurse stated the resident did not receive an antianxiety medication during the 7-day lookback and was marked in error on the MDS assessment. The Administrator also provided a policy stating that anyone completing any portion of the MDS must certify the accuracy of that portion and that the assessment reflects the resident's status during the observation period.
Care plans not revised for code status and fall intervention changes
Penalty
Summary
The facility failed to revise care plans to reflect changes in residents’ conditions for 1 of 2 residents reviewed for advanced directives and 1 of 2 residents reviewed for falls. Resident 18, who had diagnoses including chronic pain syndrome and peripheral vascular disease, had a quarterly MDS dated 12/1/25 showing cognitive intactness and independence in ADLs. A care conference on 12/23/25 documented that the resident was a full code and wished to remain that way, and current physician orders and a POST form also indicated full code status. However, the resident’s care plan still listed an advanced directive of DNR and had last been revised on 7/25/24. Staff interviews confirmed the resident was full code, and the SSD stated the MDS Coordinator revised care plans as needed, but the advanced directives care plan had not been updated to reflect the resident’s current code status. Resident 29, who had diagnoses including fracture of the lower end of the right tibia, osteoarthritis, and muscle wasting and atrophy, had a quarterly MDS dated 11/18/25 showing severe cognitive impairment, dependence on staff for eating, toileting, and bathing, and no falls since the prior assessment. A fall risk assessment dated 11/14/25 identified the resident as high risk for falls, and a care conference on 12/30/25 noted the care plan was reviewed. The current high-risk-for-falls care plan included an intervention for bright colored tape on the call light, but on 1/29/26 a pressure-sensitive pad call light was observed in use and there was no bright tape on it. The DON stated the bright tape intervention was for the old standard call light and should have been removed when the call light was changed to the pressure-sensitive pad, but the care plan had not been revised to match the equipment change.
Hospice coordination failures left fall interventions inconsistently implemented
Penalty
Summary
The facility failed to consistently coordinate with hospice staff to meet a resident’s nursing needs related to fall prevention. The resident had diagnoses including senile degeneration of the brain and muscle weakness, was assessed as high risk for falls, and had a care plan that included wheelchair safety interventions such as anti-rollbacks and anti-tippers. The record also showed that the resident had been admitted to hospice services, with hospice responsible for DME and for communicating changes and care information to the facility. The resident experienced multiple falls over the course of the record, including an unwitnessed fall with head injuries, a witnessed fall, another unwitnessed fall in the room, a fall in the common room with scalp bleeding and a skin tear that required ER evaluation, and later unwitnessed falls while attempting to self-transfer. IDT notes repeatedly identified unassisted transfer and weakness as root causes and added interventions to the care plan. One note stated that the hospice-issued wheelchair did not contain the individualized fall interventions previously in place on facility-issued equipment, and hospice staff acknowledged the concern and said they would address it. The record showed ongoing communication problems between the facility and Hospice Provider 1 regarding equipment and care coordination. A social services note stated that DME was not being delivered appropriately, installed appropriately, or labeled appropriately, and that the hospice company had ordered DME multiple times but it was not being found in the facility. The clinical record lacked a physician order showing the resident changed hospice providers and lacked care plans reflecting that change. Hospice documentation in the facility binder was limited, and the record lacked documentation of care plan updates, medication changes, physician notes, care provided, fall interventions installed, DME ordered and installed, and changes in condition from the hospice provider.
Failure to Notify Emergency Contact of Injury and X-Ray Order
Penalty
Summary
The facility failed to notify a resident’s emergency contact of a new injury and the subsequent x-ray order. Resident B had diagnoses including dementia, age-related osteoporosis, and protein-calorie malnutrition, and was dependent on staff for transfers and toileting. After being found on the floor on her fall mat, she was assessed with no injuries noted. Several days later, she was noted to have swelling and tenderness to the inner right thigh just above the knee, and Nursing Home Triage was notified. A physician order was then received for a 4-view x-ray of Resident B’s right knee, and a mobile x-ray company came to the facility to obtain the study. The clinical record from the time the swelling and tenderness were identified through the x-ray event lacked documentation that the resident’s emergency contact was notified of the injury or that an x-ray had been ordered. During interview, the family member stated he was not notified of the injury or x-ray order until after the resident had an order to be sent to the ER, and the DON stated the emergency contact should have been notified about the initial x-ray order.
Delayed X-ray and Missed Weekly Weights
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident B, who had diagnoses including dementia, age-related osteoporosis, and protein-calorie malnutrition. After Resident B was found on the floor on a fall mat, follow-up assessments initially noted no injury or pain. Later, the resident was noted to have swelling and tenderness to the inner right thigh above the knee, and Nursing Home Triage was notified. Orders were given for a 4-view x-ray of the right knee, including a STAT order, but the mobile x-ray was not obtained until the next day, when the resident’s right femur was found to be broken and the resident was sent to the hospital for evaluation and treatment. Record review showed that the x-ray order was not entered and communicated promptly after it was received. A nursing note documented that the order was received and called in to the mobile x-ray company in the late afternoon, while NHT call logs showed the order had been given earlier that morning and again later that morning. The DON stated she was unsure why the LPN waited eight hours to enter the order and notify the mobile x-ray company, and said orders should be entered upon receipt. The DON also provided a nursing meeting agenda stating that x-ray orders are to be written when received and the mobile x-ray company notified, and if the x-ray cannot be obtained in a timely manner, NHT should be called for transfer orders to the hospital. The facility also failed to complete weekly weights as ordered for Resident B, who had a history of significant weight loss and was on care plans for altered nutritional/hydration status and nutritional risk. A physician order required weekly weights every Tuesday, and the TAR indicated weights were completed, but the Weights and Vitals Summary lacked documentation for multiple scheduled dates across several months. The DON stated that weights should be entered into the EMR Weights and Vitals section and that if they were not there, they were not done. The Weight Assessment and Intervention policy stated that weights will be recorded in each individual's medical record.
Failure to Provide Milk-Free Supplement for Resident with Milk Allergy
Penalty
Summary
The facility failed to ensure alternative supplements were provided to accommodate a resident's allergies. Resident D was admitted with diagnoses including Type 2 Diabetes Mellitus and, on the most recent Quarterly MDS assessment, was described as severely cognitively impaired and completely dependent on staff for eating, bathing, toileting, and transfers. The resident's allergy list included milk and milk related products. The resident's record included a physician order for MedPass 2.0 once daily for weight, and a dietitian note stated the resident should not consume milk or milk related compounds due to a hives reaction, identified this as a true milk protein allergy, and directed dietary staff to make the resident's tray separately. During observation, an LPN indicated the resident received MedPass 2.0 daily with morning medications and showed the carton. The supplement's label listed milk as the first ingredient and included a bold warning that it contains milk. The DON stated the resident should not be receiving a supplement that contained milk.
Failure to Provide Bed Hold Policy Notification
Penalty
Summary
The facility failed to provide notification of transfer and bed hold policy to residents or their representatives in cases of hospitalization. This deficiency was identified in the records of four residents who were reviewed for hospitalizations. Resident 7, who was moderately cognitively impaired, was emergently transferred to the hospital after a fall resulting in a fractured neck, but the clinical record lacked any transfer paperwork and bed hold policy. The Director of Nursing (DON) confirmed the absence of these documents during an interview. Similarly, Resident 51, who was cognitively intact and had multiple hospitalizations, did not receive a bed hold policy for any of the transfers. Resident 53, who required substantial assistance and had been hospitalized twice, also lacked documentation of a bed hold policy. Lastly, Resident 57, who was not cognitively intact and under hospice care, was hospitalized without receiving a bed hold policy. The facility's policy on changes in resident condition or status was provided by the DON, but it was non-dated and did not ensure compliance with the notification requirements.
Improper Storage of Medications in Facility
Penalty
Summary
The facility failed to ensure proper storage of medications, as evidenced by the presence of loose pills in the medication carts across three different halls. On November 7, 2024, during a review of the medication cart for rooms 310 to 317, several loose pills were found in the bottom of the drawers, including a blue oval capsule, red circle pills, light blue circle pills, and others with various markings. Similar observations were made in the 400 hall medication cart and the upstairs medication cart, where numerous loose pills with different markings were found scattered in the drawers. Registered Nurse 5 indicated that medication carts were cleaned out every two weeks during the night shift, and loose pills were disposed of in the drug buster or sharps container. The facility's current Storage of Medications policy, revised in April 2007, states that drugs and biologicals should be stored in the packaging, containers, or other dispensing systems in which they are received. However, the presence of loose pills in the medication carts indicates a failure to adhere to this policy, leading to the deficiency noted in the report.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that food was served at palatable temperatures and taste, as evidenced by a test tray from the 200 Hall. The grilled cheese sandwich was served at 117 degrees Fahrenheit, and the fruit cocktail was at 60.2 degrees Fahrenheit, both of which were cool to taste. According to the Interim Dietary Manager, hot food should be served at a minimum of 155 degrees Fahrenheit, and cold food should be served at a minimum of 41 degrees Fahrenheit. Additionally, Resident 6 expressed that the food was not appetizing and often repetitive, while Resident 15 mentioned receiving a lot of sandwiches. The Ombudsman reported several anonymous complaints about food and meals after a resident council meeting. The facility's current policy, dated July 2023, states that foods should be transported and delivered to maintain temperatures at or below 41 degrees Fahrenheit for cold items and at or above 135 degrees Fahrenheit for hot items.
Deficiencies in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to ensure proper storage, labeling, and dating of food items in accordance with professional standards during multiple kitchen observations. During an initial tour of the kitchen, several items were found improperly stored or labeled, including a box of onions with a sprouted onion, bags of lettuce, pitchers of tea, and various other food items without dates. The temperature log for the drink refrigerator was incomplete, missing entries for specific shifts. The Interim Dietary Manager acknowledged that open lettuce should be dated and is typically good for only three days, and that temperatures should be recorded twice daily. Further observations revealed additional issues, such as an open bag of biscuits without an open date, and spices and sauces without proper labeling. A second walkthrough found more items without dates, including Worcestershire sauce and cottage cheese. The kitchenette nutrition refrigerator on the first floor lacked a temperature log and contained several items without names or open dates. The administrator indicated that housekeeping was responsible for temperature checks, but inconsistencies were noted in the logs. The facility's policies on storage and food from outside sources were provided, but no specific policy for the kitchenette refrigerator was produced.
Facility Fails to Maintain Sanitary Environment and Equipment
Penalty
Summary
The facility failed to maintain a safe and sanitary environment for residents, staff, and the public, as evidenced by multiple observations of strong urine odors and deteriorating conditions of air conditioning units. Over a period of six days, surveyors noted a persistent smell of urine in various areas, including the conference room, the 400 Unit Nurse's Station Hallway, and the 400 Unit Hallway. Interviews with staff, including an LPN and the Administrator, confirmed awareness of the odor issue, attributing it to a resident urinating on the floor. Despite this acknowledgment, the problem persisted across multiple days and locations. Additionally, the facility's maintenance of heating and air conditioning units was found lacking, with observations of paint flaking and rust on units in resident rooms. The facility's current maintenance policy, dated March 2015, was provided by the DON, indicating a requirement for documentation of functional compliance for heating and cooling systems. However, the observed conditions suggest a failure to adhere to these standards, contributing to an unsanitary and potentially unsafe environment for residents.
Failure to Provide Required Medicare Coverage Notices
Penalty
Summary
The facility failed to provide the necessary SNF-ABN (Skilled Nursing Facility-Advanced Beneficiary Notice) and NOMNC (Notice of Medicare Non-Coverage) forms to two residents who were discharged from Medicare services but remained in the facility. Resident 9, who began receiving Medicare Part A Skilled Services on August 26, 2024, had her last covered day on October 18, 2024. Although she received a NOMNC form indicating the end of her Medicare coverage, she did not receive the required SNF-ABN form. The Social Services Director confirmed that Resident 9 remained in the facility and acknowledged the oversight in not providing the SNF-ABN form. Similarly, Resident 215, who started receiving Medicare Part A Skilled Services on June 24, 2024, had her last covered day on July 31, 2024. She did not receive either the SNF-ABN or NOMNC forms because she was discharged from therapy before the end of her covered days. The Social Services Director admitted that Resident 215 remained in the facility and had not received the necessary forms since 2022. The Director also indicated a lack of understanding of the Medicare Part A coverage process, which contributed to the failure in providing the required notifications.
Failure to Provide Transfer Documentation for Hospitalized Resident
Penalty
Summary
The facility failed to provide the necessary documentation for a resident who was emergently transferred to the hospital. The incident involved a resident with diagnoses including a fracture of the neck and disorders of bone density. Upon review of the clinical record, it was found that there was no transfer paperwork accompanying the resident when they were sent to the hospital following a fall that resulted in a fractured neck. During interviews, the Director of Nursing (DON) confirmed the absence of transfer forms and acknowledged that documents such as the face sheet and bed hold policy should have been sent with the resident to the hospital.
Failure to Notify Ombudsman of Emergency Hospital Transfer
Penalty
Summary
The facility failed to notify the Ombudsman office regarding the emergency transfer of a resident to the hospital. Resident 7, who is moderately cognitively impaired and has diagnoses including a fracture of the neck and disorders of bone density, was emergently transferred to the hospital after a fall resulting in a fractured neck. The clinical record lacked any transfer paperwork or information sent to the Ombudsman for this hospitalization. Interviews with the Director of Nursing and the Social Service Director revealed that there were no transfer forms located, and the Social Service Director acknowledged the absence of the required notification to the Ombudsman. An email from the Ombudsman Office indicated that information regarding emergency transfers expected to return can be provided in a monthly list to the State LTC Ombudsman portal.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, leading to deficiencies in addressing behaviors, accidents, and nutrition. Resident 39, who has unspecified dementia and cognitive communication deficits, was observed eating puzzle pieces, indicating a need for a behavior-focused care plan. Despite discussions between the Social Service Director and the family about the resident's behaviors, the care plan lacked specific interventions for these behaviors. Resident 58, diagnosed with dysphagia and PTSD, was involved in an altercation with a roommate, resulting in a room transfer. However, there was no documentation of the incident or a care plan addressing the retaliatory behavior that led to the room change. The Social Services Director acknowledged the oversight in documentation and care planning. Resident 15 experienced significant weight loss, dropping from 200.1 lbs to 164.6 lbs over several months. Despite being on nutritional supplements and having a care plan indicating a risk for weight loss, there was no updated intervention plan to address the ongoing weight loss. The facility's policy required monthly weight monitoring, but the care plan was not revised to reflect the resident's nutritional needs adequately.
Failure to Conduct Quarterly Care Plan Conferences
Penalty
Summary
The facility failed to conduct quarterly care plan conferences for two residents, Resident 13 and Resident 29, as required. Resident 13, who has diagnoses including dementia and anxiety, did not have a quarterly care plan conference between March 20, 2024, and September 25, 2024. A significant change MDS assessment dated October 8, 2024, indicated that Resident 13's cognition level was not assessed due to diminished cognition, and the resident was dependent on staff for toileting, bathing, and transfers. Similarly, Resident 29, diagnosed with multiple sclerosis, involuntary eye movements, and kidney calculus, did not have a quarterly care plan conference between April 4, 2024, and August 21, 2024, through November 14, 2024. An annual MDS assessment dated August 13, 2024, showed that Resident 29 was cognitively intact but dependent on staff for eating, toileting, bathing, and transfers. The Social Services Director confirmed that care plan conferences should occur at least quarterly, and the Director of Nursing provided documentation indicating that the interdisciplinary team must review and update the care plan quarterly in conjunction with the required MDS assessment.
Failure to Provide Person-Centered Activities for Resident with Dementia
Penalty
Summary
The facility failed to provide person-centered engagement activities for a resident with dementia and anxiety. Observations over several days revealed that the resident was consistently positioned in her wheelchair in a way that obstructed her view of the television, either by a large plant or by facing away from the screen. On multiple occasions, the television was on a menu screen, indicating a lack of engagement. Additionally, the resident was not offered the opportunity to attend group activities, such as bingo, despite being in the common area during these events. The resident's care plan emphasized the importance of involving her in daily activities, encouraging socialization, and providing one-on-one conversations. However, there was a lack of documentation in the clinical record regarding invitations to or participation in activities since the last care plan revision. A CNA indicated that the resident would participate in group activities if assisted by staff, but personal restrictions prevented the CNA from bringing residents to activities. The facility's policy required effective communication and documentation of resident participation in activities, which was not adhered to in this case.
Failure to Arrange Vision Services for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident 29, received proper treatment to maintain vision abilities. Resident 29, who has diagnoses including multiple sclerosis, diplopia, and involuntary eye movements, was observed wearing cloudy glasses and reported not having been assessed by vision services in over a year. The resident's clinical record indicated a lack of documentation showing that she had been evaluated by vision services or offered transportation for such services since April 2023, despite care plan interventions requiring consultation with an eye care practitioner and ensuring glasses are in good repair. Interviews with facility staff revealed a gap in the process for arranging vision services. The Social Services Director indicated that residents must request health services like vision screenings, or it should be agreed upon admission and discussed during care plan conferences. However, the facility's policy on the care of visually impaired residents states that it is the facility's responsibility to assist residents in locating resources, scheduling appointments, and arranging transportation for needed services. This discrepancy contributed to the failure in providing necessary vision care for Resident 29.
Inadequate Suprapubic Catheter Care Leads to Infections
Penalty
Summary
The facility failed to provide appropriate care for a resident with a suprapubic catheter, leading to an infection at the catheter insertion site and multiple urinary tract infections. The resident, who had a history of prostate cancer and other medical conditions, was found to have a suprapubic catheter that was not being maintained according to physician orders. The clinical record lacked specific orders for routine catheter care beyond monthly changes, and there were inconsistencies in the documentation of catheter changes in the Medication/Treatment Administration Record. Observations revealed that the resident's catheter bag was improperly placed on the floor, and staff did not adhere to enhanced barrier precautions during care. Certified Nursing Aides (CNAs) were observed using a mechanical lift sling on the resident without washing it between uses, and they did not wear gowns as required for enhanced barrier precautions. Additionally, the facility's policies did not specify the frequency of suprapubic catheter care, and there was a lack of in-service training for CNAs on catheter care. Interviews with staff indicated confusion and lack of clarity regarding the responsibilities for catheter care. The Registered Nurse (RN) and Director of Nursing (DON) acknowledged that the catheter site should be cleansed daily, but this was not consistently documented or performed. The facility's failure to ensure proper catheter care and adherence to infection control protocols contributed to the resident's infections.
Failure to Provide Adequate Hydration to Resident
Penalty
Summary
The facility failed to ensure that a resident was offered sufficient fluid intake to maintain proper hydration and health. During an observation, the resident was found in bed with the call light out of reach and an empty cup labeled from the previous night on the bedside table. The resident expressed that she did not feel she received enough fluids and was unable to call for staff assistance due to her physical condition and the call light being out of reach. The resident's clinical record indicated she was dependent on staff for eating, toileting, bathing, and transfers, and was on diuretic medication, which increases the risk of dehydration. The resident had a history of multiple sclerosis, hydronephrosis, and kidney stones, and had been admitted to the hospital for kidney stones and a urinary tract infection related to sepsis. A nutritional risk assessment indicated the resident was at risk for dehydration due to recurrent infection and diuretic use, requiring an estimated 1600-1900 mL of fluid daily. However, the facility's Director of Nursing indicated that residents were not closely monitored for exact fluid intake unless on a fluid restriction, and nurses were expected to assess for signs of dehydration each shift. The facility's policy on hydration required staff to identify and report individuals with signs of fluid imbalance, but this was not effectively implemented for the resident in question.
Medication Availability and Dispensing Deficiency
Penalty
Summary
The facility failed to ensure that routine medications were available and dispensed according to physician's orders for two residents. For Resident 15, it was observed that the medication cart did not contain ProStat, a protein supplement prescribed to be administered twice daily. The Qualified Medicine Aide (QMA) indicated that the medication was not available and mistakenly believed it could be obtained from medications of discharged residents. Resident 15's medical history included dysphagia and gastro-esophageal reflux disease, necessitating the prescribed supplements. For Resident 47, the facility did not maintain an adequate supply of ProStat AWC SF, a wound healing supplement. The Medication Administration Record indicated multiple instances where the supplement was not administered as ordered, with some doses being missed or incorrectly administered. The Registered Nurse (RN) and Director of Nursing (DON) confirmed the absence of the supplement in the supply room, and it was noted that the resident had been receiving the supplement from a general supply that had run out. Resident 47's medical conditions included pressure ulcers, hemiplegia, cancer, diabetes, and coronary artery disease, highlighting the importance of the prescribed wound healing supplement.
Medication Error Rate Exceeds 5% Due to Improper Insulin Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5 percent, resulting in an observed error rate of 8 percent during a medication pass. This deficiency was identified through the observation of two medication errors out of 25 opportunities for error. Specifically, the errors involved the administration of insulin to two residents. In both cases, the Licensed Practical Nurse (LPN) did not prime the insulin pens before administering the medication, which is a necessary step to ensure accurate dosing as per the manufacturer's instructions. The first incident involved a resident with a blood glucose level of 198 mg/dL, who was administered 3 units of insulin lispro without priming the pen. The second incident involved another resident with a blood glucose level of 145 mg/dL, who was administered 2 units of insulin aspart, again without priming the pen. The facility's insulin administration policy, which requires nursing staff to follow manufacturer instructions for insulin delivery systems, was not adhered to. This oversight was further compounded by a registered nurse's incorrect assertion that priming was unnecessary, despite clear instructions in the insulin pen manuals.
Inconsistent Documentation of Wound Care Treatments
Penalty
Summary
The facility failed to ensure consistent documentation for wound care treatments for a resident with multiple pressure injuries. The resident, who was diagnosed with pressure ulcers on the right buttock and right heel, along with other medical conditions such as hemiplegia, hemiparesis, prostate cancer, diabetes mellitus type 2, coronary artery disease, and peripheral vascular disease, required specific wound care treatments. The clinical records indicated that the resident was mild to moderately cognitively impaired and required extensive assistance from two staff members for bed mobility, transferring, and toileting. Despite having orders for specific wound care treatments, the Medication Administration Record/Treatment Administration Record showed incomplete documentation of these treatments on several dates in October and November 2024. The Director of Nursing was unable to provide an explanation for the inconsistent documentation of the treatments. The job description for the staff nurse indicated responsibilities for receiving and transcribing orders and ensuring the competent administration of care and treatments according to physician orders and facility policy. However, the records revealed that the treatments for the resident's pressure injuries were not consistently documented, leading to a deficiency in the facility's care practices.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to adhere to proper infection prevention and control practices for three residents, leading to deficiencies in care. For Resident 47, who had multiple open wounds and an indwelling suprapubic catheter, CNAs used a mechanical lift sling that had been previously used on another resident without washing it between uses. Additionally, the CNAs did not wear gowns for enhanced barrier precautions during the care of Resident 47. In another instance, CNAs providing incontinence care for Resident 8 did not change gloves or sanitize their hands before placing a new brief on the resident. Furthermore, an LPN changing a dressing on Resident 8's right shoulder did not change gloves or sanitize hands before applying a clean bandage. During catheter care for Resident 29, the resident expressed discomfort with staff wearing gowns and face masks, which was not a usual practice. The facility's policies on infection control and enhanced barrier precautions were not followed, contributing to these deficiencies.
Pest Control Deficiency in Resident Areas
Penalty
Summary
The facility failed to maintain a safe environment free of pests, as evidenced by multiple observations of flies and gnats in resident areas. On three separate occasions, surveyors observed flies and gnats in Resident 15's room and the Second Floor Nurse's Station. Resident 15 reported previous incidents of flies and gnats in their room. During an interview, the Administrator was unaware of the pest issue in the resident's room. The facility's pest control policy, dated August 2011, mandates a clean and sanitary environment free from pests and requires an appropriate pest control contract to be in operation.
Transport Safety Failures Lead to Resident Injuries
Penalty
Summary
The facility failed to ensure adequate safety measures during the transport of a resident, resulting in two separate incidents that led to injuries. In the first incident, the resident was being transported to an appointment when her foot got caught beneath the wheelchair due to the absence of footrests. This resulted in a fracture to her left ankle. The driver, who was aware that footrests should be used, did not attach them because the resident typically self-propelled her wheelchair. However, during this transport, the resident was being pushed, and the lack of footrests led to the injury. In the second incident, the same resident was being transported in the facility van when she slid out of her wheelchair. The driver had not properly secured the seatbelt, which allowed the resident to slide out of the chair, resulting in a fracture to her right ankle. The driver had previously been educated on the proper use of seatbelts but failed to apply this knowledge during the transport. The resident reported that the driver did not buckle her in properly and only secured the legs of the wheelchair, which contributed to her sliding out of the chair. The resident involved in these incidents had a medical history that included fractures to both lower legs, osteoarthritis, diabetes mellitus, and pain. She was dependent on a wheelchair for mobility and required assistance for transfers and other activities of daily living. The facility's failure to adhere to safety protocols during transport directly led to the resident sustaining injuries that required medical intervention.
Medication Disposal and Storage Deficiencies
Penalty
Summary
The facility failed to ensure proper disposal and storage of medications for discharged and deceased residents, as well as maintaining appropriate security and temperature controls for medications. Observations revealed that controlled medications were not double locked, and the refrigerator containing these medications was not secured with a locked padlock. Additionally, the refrigerator freezer had a thick layer of ice with unidentifiable medication packages stuck in it, and there was no temperature log sheet for the refrigerator. Medications for residents who had been discharged or had expired were not disposed of in a timely manner, and there was a lack of documentation for the disposition of non-narcotic medications. Specific instances included a bottle of lorazepam intensol for Resident H, whose medication had been discontinued, and a bottle for Resident G, both found in the refrigerator. A bottle of lorazepam intensol with no resident identifier was found in a cup labeled with Resident E's name, who had expired at the facility. Medications for Resident D and Resident J, who had also expired or been discharged, were found improperly stored. The facility's procedure for drug disposition was inadequate, as non-narcotic medications were placed in a tote for pharmacy pickup without proper documentation, contrary to the facility's policy requiring documentation of medication disposal.
Failure to Implement Timely Care Plan for Enteral Feeding
Penalty
Summary
The facility failed to develop and implement a timely care plan for a resident with an enteral feeding tube. The resident, admitted on 3/29/24, had diagnoses including dysphagia, speech and language deficits, and muscle weakness. Despite physician orders for enteral feeding and treatments initiated on 4/30/24, the care plan did not include a focus on the resident's feeding tube until 5/13/24. Observations on 5/13/24 and 5/14/24 revealed that the resident's enteral feeding pump was not running as ordered, and there was a lack of documentation in the medication administration record (MAR) and treatment administration record (TAR) indicating that the physician's orders were followed on multiple occasions. Interviews with staff indicated that the resident's enteral feeding should have been turned on daily at 1:00 P.M., but it was not running during observations. Additionally, the staff failed to document any refusals of the enteral feeding by the resident. The facility's policies on care plans and gastrostomy site care were not adhered to, as evidenced by the lack of a comprehensive, person-centered care plan within 21 days of admission and the failure to follow physician orders for enteral feeding and tube flushing. This deficiency was related to complaint IN00434111.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect a resident from abuse, as evidenced by an incident where Resident D inappropriately touched Resident E. This incident was observed by a staff member, who reported that Resident D had placed his hand down Resident E's pants. The incident occurred in a common area of the facility, and Resident E was visibly upset by the encounter. Despite the immediate separation of the residents and notification of relevant authorities, the incident highlights a lapse in the facility's ability to prevent resident-to-resident abuse. Resident E, who was the victim of the inappropriate touching, has a medical history that includes bipolar disorder, major depressive disorder, Parkinson's disease, generalized anxiety disorder, and unspecified dementia with mood disturbance. At the time of the incident, Resident E's cognition was moderately impaired, which may have affected his ability to fully comprehend or recall the event. Despite this, Resident E reported feelings of trauma related to past abuse, indicating that the incident had a psychological impact. Resident D, the perpetrator, also has a history of mental health issues, including altered mental status, dementia, and anxiety. His care plan noted a tendency for inappropriate sexual behavior, which suggests that the facility was aware of potential risks. However, the incident still occurred, indicating a failure in monitoring or intervention strategies to prevent such behavior. The facility's policy on abuse prevention was not effectively implemented in this case, leading to the deficiency noted in the report.
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 299 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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 Evansville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Parkview Care Center | 1.3 mi | ★★★★★ | 25 | 0 |
| Park Terrace Village | 1.9 mi | ★★★★★ | 1 | 0 |
| Envive Of River City | 2.3 mi | ★★★★★ | 25 | 0 |
| Brickyard Healthcare - Woodbridge Care Center | 2.3 mi | ★★★★★ | 0 | 0 |
| Columbia Healthcare Center | 2.4 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for River Bend Nursing 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.