Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Riverview Village during CMS and state inspections, most recent first.
Two residents had inaccurate documentation of Tramadol administration. One resident with restless leg syndrome, depression, and osteoarthritis had multiple doses recorded on the controlled substance record but not on the MAR, while another resident with diabetes and HTN had several mismatches between the controlled substance record and MAR, including doses documented on one record but not the other. An LPN stated narcotic pain meds should be signed on both records when administered.
Two residents with cognitive and behavioral disorders were found living in unsanitary conditions, including soiled linens, old food, and strong odors, due to hoarding behaviors and resistance to care. Staff and housekeeping reported difficulty cleaning the rooms because of the residents' aggression, resulting in persistent foul odors and unclean environments that affected the surrounding areas.
A resident with dementia and a history of escalating aggression was not adequately monitored or provided with increased safety interventions, resulting in another resident sustaining a head injury after being struck with a wheelchair foot pedal. Despite multiple documented behavioral incidents, the care plan lacked specific measures to protect others, and staff did not implement additional precautions when the injured resident returned from the hospital.
A resident with severe dementia and bipolar disorder had a wanderguard discontinued after an interdisciplinary team determined it was no longer needed due to the resident's inability to self-propel. However, staff continued to document the presence and function of the wanderguard in the treatment administration record for several weeks, despite the device not being in place. Leadership confirmed staff were aware of the discontinuation but did not update the order.
A resident with diabetes did not receive their scheduled insulin dose due to unavailability at the time of administration. The insulin arrived later, but the oncoming RN was unaware of the missed dose and did not administer it. The DON confirmed the insulin should have been given upon arrival, highlighting a failure to adhere to the facility's medication error policy.
An LPN failed to prime insulin pens before administering doses to two residents with type 2 diabetes, leading to a deficiency in quality of care. Both residents were cognitively intact and had been receiving regular insulin injections as prescribed. The facility's procedure required priming the pen, which was not followed during the observed administrations.
The facility failed to maintain oxygen concentrator filters for three residents, leading to deficiencies in respiratory care. One resident's filter was covered with a white powdery substance, another's filters were similarly neglected, and a third resident's concentrator lacked a filter entirely. Staff were unaware of the need for regular cleaning, despite physician's orders and facility policy requiring it.
Inaccurate Documentation of Tramadol Administration
Penalty
Summary
The facility failed to ensure that medication administration records accurately reflected the administration of narcotic pain medication for Resident C and Resident F. Resident C’s clinical record showed diagnoses including restless leg syndrome, depression, and osteoarthritis, and the physician ordered Tramadol 50 mg every 6 hours for pain at 8:00 a.m., 2:00 p.m., 8:00 p.m., and 2:00 a.m. Review of the October 2025 and November 2025 controlled substance record showed multiple doses documented as received, but the corresponding MAR lacked documentation that the medication was administered for those doses. Resident F’s clinical record showed diagnoses including diabetes and hypertension, and the physician ordered Tramadol 50 mg three times daily for pain at 8:00 a.m., 2:00 p.m., and 8:00 p.m. Review of the October 2025 and November 2025 controlled substance records and MAR showed several mismatches, including doses signed out on the controlled substance record but not on the MAR, and doses signed on the MAR but not on the controlled substance record. During interview, an LPN stated that when a narcotic pain medication is administered, the nurse should sign it on both the controlled substance record and the MAR.
Failure to Maintain Safe and Sanitary Resident Environments Due to Hoarding and Behavioral Issues
Penalty
Summary
The facility failed to maintain a safe and sanitary environment in two resident rooms, as evidenced by direct observations and record reviews. In one instance, a resident with diagnoses including dementia, obsessive-compulsive disorder, and a history of traumatic brain disorder was found in a room with significant clutter, old food, and soiled linens. The resident's room contained multiple Styrofoam cups, food containers with old food, and stained linens and clothing, all emitting a strong foul odor detectable from the hallway. The care plan noted the resident's tendency to hoard and become combative when staff attempted to clean, and staff documentation confirmed repeated episodes of combative behavior during personal care and cleaning attempts. Another resident, diagnosed with dementia, bipolar disorder, and anxiety, was observed in a similarly unsanitary environment. The resident's room contained a cup of urine, food debris, stained and wet linens, and a privacy curtain with a foul odor. The resident was also noted to hoard food and refuse personal care, including showers. Staff interviews confirmed that the resident frequently left soiled items throughout the room and would become aggressive when staff attempted to clean or remove items. The odor from the room was strong enough to be noticed in the hallway, and staff reported reluctance to enter the room due to the smell and the resident's behavior. Housekeeping staff reported difficulty maintaining cleanliness in these rooms due to the residents' behaviors, including hoarding and aggression. Despite daily cleaning assignments, the rooms were not adequately maintained, and deep cleaning was not performed as needed. Facility leadership acknowledged the ongoing issues with these rooms and the impact on other residents but expressed uncertainty about how to resolve the situation.
Failure to Protect Resident from Aggressive Roommate with Dementia
Penalty
Summary
The facility failed to ensure the safety of a resident with dementia (Resident C) upon return from the hospital, resulting in a head injury caused by another resident (Resident D) with a documented history of escalating behavioral disturbances. Resident D had multiple documented incidents of aggression, paranoia, and combative behavior, including attempts to hit staff, threatening behavior, and use of objects as weapons. Despite these behaviors, interventions were limited to offering snacks, ensuring the room door remained open, and psychiatric referrals, with no evidence of increased monitoring or safety measures such as one-on-one supervision or frequent checks. On the day Resident C returned from the hospital, Resident D, who was his roommate, continued to display agitation and paranoia. Later that evening, staff responded to Resident C's call for help and found Resident D standing over him, striking him with a wheelchair foot pedal. The room door was blocked, delaying staff entry. Resident C sustained multiple head injuries and was bleeding heavily, requiring immediate transfer to the emergency department, where he was diagnosed with a concussion. The clinical records for both residents lacked documentation of enhanced safety interventions or monitoring in response to Resident D's escalating behaviors, particularly upon Resident C's readmission. The facility's care plan for Resident D did not include specific measures to address the risk to other residents, and staff interviews confirmed that no additional precautions were implemented, as previous behaviors were perceived to be directed only at staff.
Failure to Update Medical Record After Wanderguard Discontinuation
Penalty
Summary
The facility failed to ensure that a resident's medical record accurately reflected the discontinuation of a wanderguard device. The resident, who had severe dementia with agitation and bipolar disorder, was previously ordered to have a security bracelet (wanderguard) checked each day and night shift. An elopement risk assessment and an interdisciplinary team progress note indicated that the resident no longer required the wanderguard due to being in a wheelchair and unable to self-propel. Despite this, staff continued to document in the treatment administration record that the wanderguard was in place and functioning properly for several weeks after the discontinuation decision. Observations confirmed that the resident did not have the wanderguard in place, and interviews with facility leadership revealed that staff were aware of the discontinuation but failed to update the order accordingly.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to prevent a significant medication error involving insulin administration for a resident diagnosed with diabetes and hyperglycemia. The resident was supposed to receive 50 units of insulin degludec subcutaneously every morning at 6:30 a.m. as per the physician's order. On the morning of the incident, the resident's blood sugar was recorded at 390, but the insulin was not administered because the medication was not available at the time. RN 4 noted that the insulin was unavailable and reported the situation to the oncoming nurse, RN 3. The insulin arrived at the facility at 7:19 a.m., but RN 3 did not administer it, as she was unaware that the resident had not received the insulin. The Director of Nursing later confirmed that the insulin should have been administered upon its arrival. The facility's policy on medication errors, which aims to ensure residents are free from medication errors, was not adhered to in this instance, leading to the deficiency.
Failure to Prime Insulin Pens Before Administration
Penalty
Summary
The facility failed to ensure proper administration of insulin for two residents, leading to a deficiency in quality of care. During an observation, an LPN prepared a lispro flexpen for Resident 6 without priming the needle before dialing the prescribed dosage of 10 units. The insulin was administered into the resident's abdomen without following the correct procedure. Resident 6, who has type 2 diabetes mellitus, was cognitively intact and had been receiving insulin injections regularly as per the physician's order. Similarly, the same LPN prepared an Admelog flexpen for Resident 18 and administered 25 units of insulin without priming the needle. Resident 18, also diagnosed with type 2 diabetes mellitus and diabetic neuropathy, was cognitively intact and had been receiving insulin injections as prescribed. The LPN acknowledged the failure to prime the needle during the administration process. The facility's insulin pen administration procedure, reviewed in October 2019, clearly outlined the need to prime the pen before administering the insulin dosage.
Failure to Maintain Oxygen Concentrator Filters
Penalty
Summary
The facility failed to ensure proper maintenance of oxygen concentrator filters for three residents, leading to deficiencies in respiratory care. Resident 41's oxygen concentrator filter was observed to be completely covered with a white powdery substance on multiple occasions, indicating a lack of cleaning and maintenance. Despite having a care plan and physician's orders that required regular cleaning of the concentrator and filters, these were not adhered to, compromising the resident's respiratory care. Similarly, Resident 14's oxygen concentrator filters were also found to be entirely covered with a white powdery substance, which could be easily wiped away, suggesting neglect in cleaning. The staff, including RN 4, were unaware of the presence of filters on both sides of the oxygen tank, indicating a lack of training or awareness. Despite physician's orders for weekly cleaning, the filters were not maintained, potentially affecting the resident's oxygenation. Resident 31's oxygen concentrator was missing a filter entirely, with visible dust in the louvers, further highlighting the facility's failure to maintain equipment. The absence of a filter was noted over several days, and staff, including RN 4 and the DON, acknowledged the need for a filter to ensure proper oxygen output and air quality. The facility's policy clearly stated the importance of operating the concentrator with a clean filter, yet this was not followed, resulting in inadequate respiratory care for the resident.
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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 Clarksville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hillcrest Village | 1.3 mi | ★★★★★ | 11 | 0 |
| Clark Rehabilitation And Skilled Nursing Center | 1.3 mi | ★★★★★ | 3 | 0 |
| Westminster Village Kentuckiana | 2.3 mi | ★★★★★ | 16 | 0 |
| Wedgewood Healthcare Center | 2.4 mi | ★★★★★ | 12 | 0 |
| Chestnut Ridge Health & Rehabilitation | 3.4 mi | ★★★★★ | 3 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.