Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riveroaks Health Campus during CMS and state inspections, most recent first.
A resident with encephalopathy and intact cognition repeatedly refused ordered lactulose, but the clinical record did not show physician notification for each refusal. The eMAR documented multiple missed doses, and an RN stated staff had contacted the MD before but not every time. Facility policy required documentation of the resident’s refusal and the date/time the physician was notified.
Inaccurate MDS coding affected three residents with anxiety diagnoses. One resident was coded as receiving antianxiety medication, while two residents taking clonazepam were coded only as receiving an anticonvulsant and not as receiving antianxiety medication, even though the eMAR showed the meds were given as ordered and the MDS Coordinator stated clonazepam was coded only as an anticonvulsant.
Lack of Care Plan for Long-Term Antibiotic Use: A resident with hypertensive CKD and urinary retention was receiving ciprofloxacin as a long-term prophylactic antibiotic, but the clinical record did not include a comprehensive care plan addressing the antibiotic. The MDS showed the resident was cognitively intact and had received an antibiotic during the lookback period, and a care conference was completed with care plans reviewed, yet the DON confirmed no antibiotic-related care plan was in place.
A resident with Parkinson's disease and dementia had a history of multiple falls and required substantial to maximal staff assistance with toileting and transferring. After an unwitnessed fall while attempting to walk unassisted, a therapy referral was added to the care plan, but therapy later determined it was not recommended and no other intervention was added or IDT follow-up was documented. The resident's fall risk care plan was not revised to reflect a new intervention after the fall.
Failure to Monitor Side Effects of High-Risk Medications: A resident with CHF, CKD, urinary retention, and anxiety had orders for aspirin, ciprofloxacin, furosemide, and clonazepam, but the record lacked monitoring orders for side effects of the antiplatelet, antibiotic, diuretic, and antianxiety meds. The DON stated high-risk meds should have side-effect monitoring orders, while staff used an anticonvulsant monitoring order for clonazepam and a care plan intervention for the diuretic; the antianxiety monitoring order included side effects not found in the anticonvulsant order.
A resident with encephalopathy and a cognitively intact MDS had an order for lactulose 45 mL PO TID, but the eMAR documented multiple instances of the medication being unavailable. The DON said staff could not remember the medication being unavailable and believed the missed administrations were charted in error, while the facility policy stated the prescriber is to be contacted when a medication is delayed or unavailable.
The facility did not designate a certified Infection Preventionist (IP) for its infection prevention and control program. The ADON, who was responsible for the program, began her role as IP without specialized training and was only able to dedicate limited hours to the program. This resulted in the failure to implement Enhanced Barrier Precautions, potentially affecting all residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for six residents, as EBP signs were not posted, and staff did not consistently wear gowns during high-contact activities. Residents with conditions such as anemia, COPD, pressure ulcers, and urinary catheters were affected. Observations revealed a lack of EBP signs and protective equipment, despite physician orders and care plans indicating the need for such precautions.
A facility failed to properly document and notify a resident's transfer to the hospital. The resident, who was moderately cognitively intact and diagnosed with encephalopathy, was transferred for an appointment after oral surgery. The transfer paperwork was incomplete, missing resident information and the reason for transfer, contrary to the facility's guidelines requiring such documentation.
A facility failed to obtain immediate doctor's orders for an indwelling urinary catheter for a newly admitted resident with significant medical conditions, including facial/skull fracture and brain hemorrhages. The resident was observed with a catheter, but their clinical record lacked corresponding orders. The facility's policy requires assessment for catheter removal unless clinically necessary, but orders and care plans were delayed to allow physician assessment.
A facility failed to revise a care plan quarterly for a resident with major depressive disorder and mild cognitive impairment. The care plan indicated a risk for adverse consequences from a hypnotic medication, but the resident's record showed no order for such medication, and the MDS assessment confirmed no hypnotic use. The MDS Coordinator acknowledged the need for care plan updates when medications are discontinued, which was not done, violating the facility's policy.
A facility failed to follow professional standards for a resident's PICC line care. The resident had a PICC line for osteomyelitis, but physician orders for care were not followed, and no care plan was developed. The resident's clinical record did not reflect IV access, and there was no documentation of refusal to remove the line or education provided. Observations showed the insertion site was red with purulent drainage, and the facility lacked a policy for IV care.
A medication error rate of 5.71% was identified when a nurse administered discontinued famotidine to a resident via gastric tube and incorrectly applied eye drops. The resident, with a history of colon cancer and duodenal ulcer, was not assessed for cognitive ability. Facility policies on medication administration and disposal were not followed.
A facility failed to document neurological checks for a resident with a history of falls and cognitive impairment after three unwitnessed falls. Despite the facility's policy requiring neuro-checks for 24 hours post-fall, no documentation or order sets were initiated for these checks. The Regional Support Nurse confirmed the lack of documentation and adherence to the policy.
The facility failed to provide adequate assistance with bathing and oral hygiene for four residents, as documented in the report. Residents with various medical conditions, including cognitive impairments and mobility issues, did not receive scheduled showers or daily mouth care. The facility's grievance log showed multiple complaints about inadequate assistance, and staff interviews revealed that short-staffing often prevented scheduled care. Facility policies requiring regular bathing and documentation were not consistently followed.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and incomplete ADLs for residents. Observations and interviews revealed that residents experienced long wait times for assistance, with some waiting up to an hour and a half. The grievance log showed multiple complaints about call light delays, and staffing patterns indicated inconsistencies in meeting the facility's scheduling standards.
Physician Not Notified of Repeated Medication Refusals
Penalty
Summary
The facility failed to ensure the physician was notified during a change in condition for Resident 57, who was admitted with diagnoses including encephalopathy and was assessed as cognitively intact on the most recent MDS. The resident had an order for lactulose solution 45 mL by mouth three times daily, starting 9/12/25, and the eMAR showed multiple refusals of the medication on 10/3/25, 10/4/25, 10/8/25, 10/10/25, and 10/11/25. The clinical record did not contain physician notification for the refused medication administrations. A physician note dated 10/10/25 stated the resident does take medicines and has been using lactulose. During interview, Clinical RN 3 stated staff had previously contacted the physician when the resident refused medications but did not contact the physician each time. The facility policy titled Self Determination of Care required documentation of the resident’s response and reasons for denial, including the date and time the physician was notified and the physician’s response.
Inaccurate MDS Coding for Psychotropic Medications
Penalty
Summary
The facility failed to ensure MDS assessments were completed accurately for three residents reviewed for medication coding. Resident 4 had diagnoses including generalized anxiety disorder and, on the most recent Annual MDS, was coded as cognitively impaired and as receiving antianxiety medication during the 7-day lookback period. However, the physician order for lorazepam 0.5 mg at bedtime was active, and the eMAR showed the resident received lorazepam 7 out of 7 days during the lookback period. Resident 3 had a diagnosis of anxiety disorder and, on the most current Significant Change MDS, was coded as cognitively intact, as receiving an anticonvulsant medication, and as not receiving an antianxiety medication during the 7-day lookback period. The physician order for clonazepam 0.5 mg four times a day for anxiety was active, the medication was classified as antianxiety, hypnotic, and anticonvulsant, and the eMAR showed the resident received clonazepam 7 out of 7 days. Resident 42 had a diagnosis of anxiety disorder and, on the most current Quarterly MDS, was coded as having severe cognitive impairment, as receiving an anticonvulsant medication, and as not receiving an antianxiety medication during the 7-day lookback period. The physician order for clonazepam 0.25 mg twice a day for anxiety was active, the medication was classified as antianxiety, hypnotic, and anticonvulsant, and the eMAR showed the resident received clonazepam 7 out of 7 days. The MDS Coordinator stated clonazepam was coded as an anticonvulsant and was not aware it was also classified as an antianxiety and hypnotic medication; the RAI Manual stated medications with more than one therapeutic category and/or pharmacological classification must be coded in all assigned categories.
Lack of Care Plan for Long-Term Antibiotic Use
Penalty
Summary
The facility failed to develop a comprehensive care plan for Resident 3 related to long-term prophylactic antibiotic use. Resident 3 had diagnoses including hypertensive chronic kidney disease and urinary retention, and the most current Significant Change MDS assessment dated 10/4/25 indicated the resident was cognitively intact and received an antibiotic during the 7-day lookback period. Physician orders included ciprofloxacin 250 mg by mouth once daily on the 24th of the month, along with prior ciprofloxacin 500 mg twice daily orders that were later discontinued. A care conference was completed on 10/24/25 with a family member present, and care plans were reviewed, but the clinical record lacked a care plan addressing the resident’s long-term antibiotic use. During interviews, the DON stated that residents who received an antibiotic should have a care plan addressing the antibiotic and confirmed that no such care plan was in the record prior to 12/19/25. The facility policy provided on 12/22/25 stated that new identified areas of concern should be addressed on the care plan and that ongoing or chronic problems should have a new comprehensive care plan.
Care Plan Not Updated After Fall
Penalty
Summary
The facility failed to ensure care plan interventions were revised after a fall for one resident reviewed for falls. Resident 12 had diagnoses including Parkinson's disease and dementia, and the most current Quarterly MDS assessment indicated mild cognitive impairment, substantial to maximal staff assistance with toileting and transferring, and two or more falls without injury since the prior assessment. The resident's fall risk care plan contained multiple interventions added after prior falls, including use of Dycem in the wheelchair, staff assistance to bed after meals, and a therapy referral. After an unwitnessed fall in the resident's room while attempting to walk unassisted, a therapy referral was added to the care plan. The therapy referral report later indicated therapy was not recommended at that time, but the clinical record did not show that the IDT met to review the therapy report or that another relevant intervention was added after the fall. Interviews with the DON and an RN indicated that after a fall, the IDT would review the fall and add a new intervention appropriate to the situation, but that did not occur following this event.
Failure to Monitor Side Effects of High-Risk Medications
Penalty
Summary
Resident 3, who had diagnoses including hypertensive chronic kidney disease, urinary retention, congestive heart failure, and anxiety disorder, was reviewed after a significant change MDS assessment showed the resident was cognitively intact and had received an antibiotic, diuretic, antiplatelet, and anticonvulsant medication during the look-back period. The clinical record also included care plans for diuretic use related to congestive heart failure, risk for excessive bleeding and bruising related to medications, and anxiety symptoms including fidgeting, talking quickly, and indecisiveness. Physician orders included aspirin, ciprofloxacin, furosemide, and clonazepam, but the record lacked monitoring orders for side effects of the antiplatelet, antibiotic, diuretic, and antianxiety medication. During interviews, the DON stated that residents prescribed high-risk medications should also have orders to monitor for side effects, while MDS Coordinator 5 stated clonazepam had been coded as an anticonvulsant and was unaware it was also an antianxiety medication. Staff further stated there was no monitoring order for the antibiotic or antiplatelet, the diuretic was monitored through a care plan intervention, and the anticonvulsant monitoring order was being used for clonazepam even though it did not include some side effects listed in the antianxiety monitoring order.
Incomplete Medication Documentation for Resident 57
Penalty
Summary
The facility failed to ensure documentation was complete or accurate for one resident’s closed record. Resident 57 was admitted with diagnoses including encephalopathy, and the most recent MDS dated 9/10/25 indicated the resident was cognitively intact. Physician orders included lactulose solution 45 mL by mouth three times daily starting 9/12/25. Review of the eMAR showed lactulose was documented as unavailable on multiple occasions, including 10/1/25 twice and 10/6/25 and 10/7/25 three times. During interview, the DON stated staff could not remember the lactulose being unavailable and believed the missed medication administrations were documented in error. The Administrator later provided a medication orders policy stating the prescriber is to be contacted when delivery of a medication will be delayed or the medication is not or will not be available.
Failure to Designate Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Assistant Director of Nursing (ADON) was assigned the role of IP without having received specialized training in infection prevention and control at the time of her appointment. She began her role as IP on June 4, 2024, and obtained her IP certification on June 17, 2024. Subsequently, on July 17, 2024, she was promoted to ADON. The ADON indicated that she could only dedicate approximately 5-10 hours per week to the infection control program. This lack of a dedicated IP led to the failure in implementing Enhanced Barrier Precautions, potentially affecting all 56 residents in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices for six residents who required Enhanced Barrier Precautions (EBP). Observations revealed that EBP signs were not posted on the doors of residents who required them, and staff did not consistently wear gowns during high-contact activities. For instance, Resident L, who had diagnoses including anemia and COPD, did not have an EBP sign on their door despite physician orders and care plans indicating the need for EBP. Similarly, Resident W, who had a neuromuscular dysfunction of the bladder and a malignant neoplasm of the colon, also lacked an EBP sign, and staff were not observed wearing gowns during care. Resident V, who had a stage four pressure ulcer, did not have an EBP sign until after the survey began, and there were no prior physician orders for EBP. Resident D, who had a urinary catheter, was observed being transferred without staff wearing protective gowns, and there was no EBP sign on their door. The clinical record for Resident D lacked an order for EBP, and there was confusion among staff regarding the reason for the precautions. Residents S and T also did not have EBP signs or carts with gowns and gloves near their rooms, despite having conditions that required such precautions. Resident S had severe cognitive impairment and an unhealed wound, while Resident T had obstructive and reflux uropathy with a urinary catheter. The facility's inconsistency in implementing EBP was acknowledged by Regional Clinical Support, and the facility's standard operating procedure indicated that EBP should be in place for residents with chronic wounds and indwelling medical devices.
Failure to Document and Notify Resident Transfer
Penalty
Summary
The facility failed to ensure proper notification and documentation for a resident's transfer to the hospital. Resident 21, who was moderately cognitively intact and diagnosed with encephalopathy, was transferred for an appointment following oral surgery. However, the transfer discharge paperwork provided by the facility was incomplete, lacking resident information and the reason for the transfer. Additionally, the facility's guidelines required documentation of the reason, effective date, and location of the transfer or discharge, which was not adhered to in this instance.
Failure to Obtain Immediate Orders for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident D, had immediate doctor's orders for an indwelling urinary catheter. On September 30, 2024, staff observed Resident D being transferred with a urinary catheter. However, a review of Resident D's clinical record on October 1, 2024, revealed that there were no orders for the indwelling urinary catheter or catheter care, despite the resident's diagnoses of facial/skull fracture, subdural hemorrhage, and subarachnoid hemorrhage. Further review on October 3, 2024, indicated that a nursing assessment dated October 2, 2024, noted the absence of an indwelling urinary catheter. The Regional Support RN explained that catheters are assessed during the initial admission nursing assessment, but orders and care plans are not always immediately implemented as the facility allows time for physicians to assess the medical necessity of the catheter. The facility's policy on indwelling catheter use states that residents with a catheter should be assessed for removal unless clinically necessary.
Failure to Revise Care Plan for Discontinued Medication
Penalty
Summary
The facility failed to ensure that care plans were revised quarterly for a resident reviewed for unnecessary medications. Resident 36, who had diagnoses including major depressive disorder, restlessness and agitation, and mild cognitive impairment, was found to have a care plan indicating a risk for adverse consequences related to receiving a hypnotic medication for insomnia. However, the resident's current clinical record, reviewed on 10/2/24, showed no order for a hypnotic medication, and the Annual MDS assessment indicated that the resident did not receive hypnotic medications during the assessment period. Despite this, the care plan had not been updated to reflect the discontinuation of the medication, as confirmed by the MDS Coordinator during an interview. The facility's policy requires comprehensive care plans to be reviewed at least quarterly and revised to reflect changes in the resident's condition, which was not adhered to in this case.
Failure to Implement Professional Standards for PICC Line Care
Penalty
Summary
The facility failed to ensure professional standards of practice were implemented for a resident with a PICC line. The resident, identified as Resident T, had a PICC line inserted for osteomyelitis treatment but was unsure of its purpose. The clinical record review revealed that physician orders for the PICC line care, such as changing end caps, monitoring for infiltration, flushing with normal saline, and changing the dressing, were not followed. Additionally, there was no care plan developed for the PICC line, and the resident was not marked as having IV access on the MDS assessment. The deficiency was further highlighted by the lack of documentation regarding the resident's refusal to remove the PICC line, the education provided after the refusal, and the failure to follow the physician's order for removal. Observations noted the PICC line insertion site was red and had purulent drainage, indicating potential complications. Despite requests, the facility did not provide a policy related to IV care or a PICC line care skills check-off, indicating a lack of proper procedural documentation and oversight.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below 5 percent, resulting in a rate of 5.71 percent. This deficiency was identified during an observation of a registered nurse administering medication to a resident. The nurse administered 2.5 milliliters of liquid famotidine via the resident's gastric tube, despite the medication having been discontinued on 9/24/24. Additionally, the nurse administered carboxymethylcellulose eye drops incorrectly by lifting the upper eyelids instead of pulling down the lower eyelids to form a pouch, as per the facility's policy. The resident involved had a history of malignant neoplasm of the colon and chronic duodenal ulcer with hemorrhage, and was not assessed for cognitive ability due to rarely or never being understood. The facility's policies on medication administration and disposal were not followed, as the discontinued famotidine was not removed from the medication cart. The Director of Nursing and Regional Support staff confirmed the discontinuation of the medication and the correct procedure for administering eye drops, highlighting the failure to adhere to established protocols.
Failure to Document Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that clinical records were accurate and complete for a resident who was reviewed for falls. The resident, who had a history of unsteadiness on feet, abnormalities of gait and mobility, and previous falls, was identified as mildly cognitively impaired and required substantial assistance with transfers and hygiene. Despite these conditions, neurological checks were not documented following three separate unwitnessed falls on 7/31/24, 8/11/24, and 8/25/24. During an interview, the Regional Support Nurse confirmed the absence of documented neurological checks after the fall on 7/31/24 and noted that no order sets for neurological checks were initiated for any of the falls. The facility's policy, revised on 12/31/23, required neuro-checks to be completed within the Fall Event Form for 24 hours, which was not adhered to in these instances.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with bathing and oral hygiene for four residents, as observed and documented in the report. Resident F, with diagnoses including heart failure and reduced mobility, did not receive any documented showers or complete bed baths, nor daily mouth care, despite being dependent on staff for these activities. Similarly, Resident G, who had severe cognitive impairment and was dependent for oral hygiene and bathing, also did not receive any documented showers or complete bed baths, nor daily mouth care during their stay. Resident H, with severe cognitive impairment and a history of falls, received only three showers over a period of several weeks, with no documentation of daily mouth care. Resident J, who required assistance for bathing, reported not receiving the scheduled showers or complete bed baths, with only one shower documented over several weeks. The facility's grievance log revealed multiple complaints from residents about not receiving timely assistance with showers and toileting, and not being offered necessary items like razors for personal grooming. Interviews with staff indicated that the inability to provide scheduled care was often due to being short-staffed. The facility's policies required bathing at least twice a week and documentation of ADL services by CNAs, but these were not consistently followed, leading to the deficiencies noted in the report.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by observations, interviews, and record reviews conducted during the survey. On two consecutive days, it was noted that the facility was short-staffed, leading to delays in responding to call lights and completing residents' activities of daily living (ADLs). Residents reported waiting for extended periods, sometimes up to an hour and a half, for assistance with basic needs such as standing up or using the restroom. One resident recounted an incident where she turned on her call light at 2:45 A.M. and did not receive assistance until 5:00 A.M., resulting in missed showers and meal trays left in rooms overnight. The facility's grievance log revealed multiple complaints from residents about long wait times for call lights to be answered, with some residents experiencing accidents due to the delays. The grievances spanned several weeks, indicating a persistent issue with staffing levels. Observations during the survey confirmed that call lights were frequently left unanswered, and meal trays were not cleared in a timely manner, further highlighting the staffing inadequacies. A review of the facility's staffing patterns showed inconsistencies in the number of licensed nursing staff and nurse aides scheduled for each shift. The facility's policy on scheduling standards emphasized the need for adequate staffing to meet resident needs, yet the actual staffing levels fell short of these standards. This deficiency in staffing resulted in a lack of ADL services, including bathing and oral care, for the residents.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Princeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Princeton, The | 1.3 mi | ★★★★★ | 24 | 0 |
| Transcendent Healthcare Of Owensville | 8 mi | ★★★★★ | 2 | 0 |
| Oakview Nursing & Rehab | 10.8 mi | ★★★★★ | 7 | 0 |
| Good Samaritan Home & Rehabilitative Center | 13.8 mi | ★★★★★ | 1 | 0 |
| North River Health Campus | 15.6 mi | ★★★★★ | 5 | 0 |
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