Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverbend Post Acute Rehabilitation during CMS and state inspections, most recent first.
Unsafe and Unsanitary Common Areas: Multiple second-floor areas were observed with poor sanitation and unsafe conditions, including dirty and contaminated ice room surfaces, overfilled sharps containers, a dirty hopper and utility room, glass pebbles and torn window screens with exposed sharp metal, a missing thermostat cover, soiled wheelchairs and lifts, an uncovered suction machine, a cracked cart with sharp edges, and a handwashing sink with no hot water and visible soil. Staff interviews confirmed routine cleaning and sharps handling expectations, but the observed conditions showed the environment was not maintained in a clean, safe, and homelike manner.
Staff failed to follow infection control practices involving shared equipment, hand hygiene, and respiratory equipment storage. A vitals machine was used between residents, including in an EHB room, without being sanitized before or after use. A resident’s CPAP and nebulizer masks were left on the bedside table instead of being stored in a sanitary container, and CNAs and a CMA donned and removed PPE without hand hygiene while providing in-bed care to an incontinent resident.
Failure to Assess Safe Self-Administration of Medications: A resident with moderately impaired cognition, dementia, seizures, dysphagia, weakness, and multiple chronic conditions was found with four oral meds left in a labeled cup on her breakfast tray while she lay in bed. The EMR lacked evidence of an assessment for safe self-administration and there was no MD order to keep meds at bedside; staff stated meds should not be left unattended and that residents able to self-administer would be documented in the care plan.
A resident with stroke-related deficits and moderate cognitive impairment had a signed DNR in the EHR, but the chart also showed full code in the home tab and on a physician order. Staff interviews confirmed the mismatch, and the resident stated she was DNR. The care plan did not document her advance directive wishes, and the record contained conflicting code status information.
Failure to Protect Residents from Abuse: A resident with bipolar disorder, MDD, and dementia grabbed another resident by the neck after approaching her at the nurse’s station and later was involved in another altercation in which he pushed a female resident down. Witnesses and staff documented the assaults, and the resident’s care plan noted agitation, verbal or physical altercations, and a tendency to insert himself into other residents’ situations.
Failure to assist a resident with eating. A resident with hemiparesis s/p CVA, severely impaired cognition, and a care plan for substantial/maximal assist with eating was observed eating breakfast alone in bed on separate occasions, with food dripping onto his chin, neck, and gown and no staff present. Staff stated they used the Kardex and care plan to identify residents needing monitoring or assistance, and an admin nurse stated that a resident care planned for one assistant while eating should be assisted.
A resident with hemiplegia, hemiparesis, DM, and a cognitive communication deficit was dependent on staff for bathing and hygiene care, but the care plan did not include nail care instructions and the EHR showed no nail care documented over the review period. Observations showed brown substance on both hands and under the fingernails, and the resident said staff did not ask if he wanted his nails cleaned. Staff gave inconsistent accounts of who provided nail care, while the facility policy stated nails should be cleaned, trimmed, and kept free of debris.
A resident with severe cognitive impairment, aphasia, stroke-related hemiplegia/hemiparesis, and total ADL dependence did not receive consistent activity programming despite care plan directions for preferred music, one-to-one visits, and other individualized activities. Records showed limited activity documentation, no refusal documentation, and staff interviews confirmed uncertainty about the frequency of one-to-one activities and that refusals were not being charted, while observations found the resident in bed with the TV on and no staff present during group activities.
A resident with dementia, severe cognitive impairment, weakness, and a care plan for 1-person ADL assistance was left alone in the shower by a CNA and was later found face down after a fall. Staff observed bleeding from the face and emesis, EMS was called, and the resident was sent to the hospital where a lower lip laceration required a stitch. Staff interviews confirmed the resident should not have been left unattended in the shower.
Unsecured Medication Cart Observed in Hallway: Surveyors observed a large rolling med cart unattended in a second-floor hallway with the lock partially pushed in. The cart contained stock bottles, resident-specific med cards, and personal drink cups. An LPN stated she thought the cart was locked and confirmed it should always be locked when unattended or out of sight. The facility policy did not address resident med carts.
A resident with generalized muscle weakness, difficulty walking, unsteadiness on feet, and dementia had a call light that was within reach but did not alert at the door or staff monitor when pressed. Staff interviews showed the CNA was unaware it was not working, another CNA entered a work order, and Maintenance confirmed a work order existed for the room’s call light issue.
A stairwell had a white, wet, organic-type substance on the walls, a strong musty odor, dusty debris on the handrail and floor, and ceiling stains that appeared to be water damage. Housekeeping said it cleaned the floors and handrails but not the walls or ceilings, while maintenance and admin identified a roof leak and moisture as the source of the wall substance.
A resident with severe cognitive impairment did not have a call light within reach, three residents were pushed in wheelchairs without foot pedals while their feet dragged on the floor, and another resident with CVA, COPD, dysphagia, and severe cognitive impairment was observed in bed without his prescribed sensory hand item. Staff stated foot pedals should be used and that the sensory object should be placed in the resident’s hand, but the items were not in place during observations.
Unsecured hazardous materials were found in multiple areas accessible to cognitively impaired residents, including disinfectant wipes, a spray bottle of disinfectant, and overfilled sharps containers. The facility also did not follow fall care plan interventions for two residents: one resident with severe cognitive impairment had a call light out of reach and no Dycem in the wheelchair, and another resident with a history of falls and supervision needs had a documented fall involving a walker and oxygen tank, with staff later showing inconsistent awareness of the resident’s fall history and ordered interventions.
Failure to assess self-administration of inhaler medication: A resident with COPD and respiratory failure, who had intact cognition, was handed an inhaler by an LPN without instructions and without a documented self-medication assessment or physician order for self-administration. The resident found the inhaler empty, and the nurse later acknowledged the dose was missed and that the resident should not have been given the inhaler to self-medicate.
A resident with PTSD and a history of abuse stated she preferred no male caregivers, but that preference was not documented on the care plan. Staff interviews showed the LN was unaware of the PTSD and caregiver preference, a CNA had assisted her before learning of the request, and Social Services was unaware the preference was missing from the care plan. Administrative staff confirmed the resident’s PTSD, triggers, and preference for female caregivers should have been on the care plan and shared with staff.
Failure to provide a final discharge summary for a resident with multiple diagnoses, including cognitive communication deficit, weakness, depression, dialysis dependence, and dysphagia. The record showed the resident had a fall from bed, was sent to the ER while on Heparin, and social services documented that the spouse declined a bed hold and said the resident would not return. Staff interviews indicated uncertainty about responsibility for the unplanned discharge summary, and the facility could not locate the discharge summary or recompilation of care.
A facility failed to develop comprehensive care plans for two residents. One resident had COPD, respiratory failure, oxygen use, and smoked outside with staff supervision, but no smoking care plan was documented. Another resident had PTSD, insomnia, a trauma history, loud-noise triggers, and a preference for female caregivers, but the record lacked a PTSD care plan and staff were unaware of the diagnosis and triggers.
Pressure-reducing interventions were not carried out as ordered for two residents. One resident with CHF, heart disease, severe cognitive impairment, and a stage III pressure injury had a low-air-loss mattress set to 200 lbs despite weighing 132.1 lbs, while the care plan only directed staff to check placement and function. Another resident with CVA, COPD, dysphagia, contracture, severe cognitive impairment, and high pressure-ulcer risk had an order to offload heels in bed, but observations showed both heels resting directly on the mattress.
Failure to provide trauma-informed care for a resident with PTSD. The resident’s record documented PTSD, insomnia, a history of abuse, loud noises as a trigger, and a preference for female caregivers, but the EMR lacked a PTSD care plan and staff were unaware of the diagnosis, triggers, and caregiver preference. Social Services also stated she did not discuss the resident’s past trauma because she did not want to upset her, and the resident had refused psych services at the time.
Failure to Follow Medication Hold Parameters: The facility did not administer meds as ordered for three residents. An RN/LN gave Midodrine to two residents when SBP was above the physician’s hold parameters, and Humalog was given to a resident when FBS was below the ordered hold threshold. The TARs and staff interviews confirmed multiple doses were administered outside the prescribed parameters.
A resident receiving hospice services had diagnoses including Huntington’s disease, bladder dysfunction, anxiety, and major depressive disorder, and required staff help with ADLs, mobility, and transfers. The facility failed to ensure communication with the hospice provider included a plan of care and a description of services provided, including CNA visit frequency, chaplain services, medications, and medical equipment. Staff interviews confirmed hospice CNA showers and hospice nurse visits, while the AD noted the care plan should reflect what hospice provided.
Failure to provide scheduled shower assistance for a resident with CVA, COPD, dysphagia, contracture, and severely impaired cognition. The resident was totally dependent on staff for ADLs, and the spouse requested full showers instead of bed baths. Records and staff interviews showed showers were not consistently completed as scheduled, and staff described a process of deferring missed showers to the next day rather than ensuring they occurred on the scheduled day.
The facility did not notify the LTCO of several residents' hospital transfers or discharges, as required by policy. In multiple cases, residents with complex medical needs were transferred to the hospital, but the facility's records and staff interviews confirmed that the LTCO was not informed, particularly when residents were on bed hold or returned within the bed hold period.
Surveyors found that multiple insulin pens and vials used by several residents were not labeled with the date opened or the expiration date, and some expired insulin was not removed from storage as required by facility policy. This deficiency was identified through observation, interview, and record review, and involved various types of insulin including Aspart, Lispro, Lantus, Glargine, Humalog, Novolog, and Tresiba.
A nurse provided wound care to a resident with diabetic foot ulcers without wearing a gown as required by Enhanced Barrier Precautions (EBP), using only gloves and lacking appropriate PPE and signage in the room. The nurse stated she was instructed to use gloves only, and administrative staff confirmed that EBP protocols, including gown and glove use, were not followed or communicated as required by facility policy.
Two residents with complex medical needs did not have their care plans updated to include individualized, resident-centered instructions for ADLs such as toileting, transfers, bathing, oral hygiene, dressing, and eating. Despite documented dependence on staff and significant health conditions, care plans lacked specific guidance, and staff relied on verbal reports rather than written directions, contrary to facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive consistent bathing and grooming assistance, as required by facility policy. Extended periods without showers or bed baths were documented, and observations showed the resident had tangled, matted hair and wore the same clothes for over a week. Staff reported repeated refusals of care, but documentation of multiple attempts was lacking, and only one staff member was permitted to attempt showers.
A resident with multiple neurocognitive and psychiatric diagnoses, including dementia, exhibited ongoing wandering and rummaging behaviors, such as going through staff belongings and attempting to take items from others. Despite care plan interventions like redirection and snacks, these actions were not consistently effective, and the behaviors persisted. Staff primarily responded by redirecting the resident and removing personal items from accessible areas, rather than implementing more effective individualized interventions.
A resident with hypotension and severe cognitive impairment received midodrine for low blood pressure on multiple occasions when their systolic blood pressure was above the physician-ordered threshold. Staff did not recognize or act on out-of-parameter readings, resulting in the medication being administered contrary to orders.
A resident with hypotension and severe cognitive impairment received midodrine on multiple occasions when their systolic blood pressure was above the physician-ordered hold parameter. Staff failed to recognize and act on the out-of-range blood pressure readings, resulting in the medication being administered contrary to orders and facility policy.
The facility failed to secure hazardous materials, such as alcohol-based disinfectant wipes, in a secured unit, placing seven cognitively impaired residents at risk. The wipes were accessible on the 2nd-floor nursing station, despite warnings of potential harm. Staff interviews confirmed that such products should be locked away to prevent access by residents, but the facility lacked a formal policy on safe chemical storage.
A resident with major depressive disorder, diabetes, and heart failure was found uncovered from the waist down with her groin area visible from the hallway due to an open door and undrawn privacy curtain. Despite requiring substantial assistance for daily activities, the facility did not ensure her privacy, contrary to their dignity and respect policy.
The facility failed to use wheelchair foot pedals for three severely cognitively impaired residents, resulting in their feet sliding on the ground while being pushed. Staff confirmed that foot pedals should be used to prevent such incidents, as per the facility's policy. This oversight placed the residents at risk for preventable accidents and injuries.
A resident with multiple health conditions refused daily weight checks, and the facility failed to notify the physician of these refusals. Staff interviews revealed inconsistent communication practices, and the facility lacked a policy for notifying the physician about such refusals.
A resident with a pressure ulcer on the right buttocks did not have a pressure-reducing heel supportive device in place as required by their care plan. Observations showed the resident's heels resting directly on the mattress, despite their medical history indicating a high risk for pressure ulcers. Staff interviews confirmed the oversight in implementing necessary pressure-relieving measures.
A resident with cerebral palsy and contractures did not have their orthotic device applied, as required by their care plan, leading to a risk of discomfort and decreased range of motion. Observations showed the resident's wrist was consistently curled, and staff interviews revealed confusion over responsibility for applying the splint. The facility lacked a policy for positioning or ROM, and the restorative aide responsible for these tasks was on maternity leave without a replacement.
A resident with COPD and other health conditions had their CPAP mask improperly stored, increasing the risk of respiratory infection. Observations showed the mask was left on surfaces without sanitary protection, contrary to facility policy and staff statements that equipment should be stored in plastic bags when not in use.
A facility failed to document a risk assessment and obtain consent for a resident's use of side rails, as required by their policy. The resident, who had multiple health issues requiring assistance, was using side rails without documented safety assessments or informed consent. This oversight placed the resident at risk for uninformed decision-making and potential safety hazards.
A resident with multiple medical conditions, including foot drop and pressure ulcers, was not seen by their attending physician for six months, contrary to the facility's policy requiring quarterly visits. Staff were unaware of the physician's visit schedule, leading to a lack of documentation and oversight, placing the resident at risk of complications.
A resident with severe cognitive impairment and dementia experienced multiple non-injury falls and incidents due to inadequate supervision and care in an LTC facility. Despite documented needs for assistance with ADLs and incontinence, the facility failed to implement effective interventions, leading to the resident being found on the floor or in inappropriate locations. Staff interviews revealed a lack of consistent monitoring and supervision, compromising the resident's safety and well-being.
The facility failed to properly store respiratory equipment for three residents, including a CPAP mask, tracheal tubing, and nasal cannula, leading to potential infection risks. Staff interviews confirmed that equipment should be stored in plastic bags when not in use, as per the facility's infection prevention policy.
A resident with complex medical needs, including a colostomy and indwelling catheter, was neglected by staff, resulting in maggot infestation in her genital area. Despite requiring substantial assistance, the resident was left unsupervised outside without proper clothing, and staff failed to provide necessary catheter and perineal care. The facility's care plan lacked specific interventions for the resident's care refusals, and staff inconsistently documented and provided care, leading to significant harm.
Unsafe and Unsanitary Common Areas
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for residents. During observation on the second floor, the ice room contained a dirty towel under the door, a tray of clean cups placed beside a tray holding cups, plates, and food from a previous meal, dirty towels next to the clean cups, a handwashing sink with food debris, a cabinet under the sink that was sunken with wet and soiled towels and a black substance on the floor, water-damaged cabinet doors, and a dusty fan blowing directly onto the clean cups. The ice chest also had a dirty, stained lid, an ice scoop lying on it, and ice water with debris floating in it. Additional observations showed multiple environmental and sanitation concerns throughout the area. The soiled utility room had nine overfilled sharps containers, including one without a lid and another with the lid open, along with a dirty and rusty file cabinet, a mop bucket blocking the sink, a dirty hopper bowl with brown and black substance, and a stained floor corner. The activity room floor had small glass pebbles, the window screen was torn with exposed sharp metal, the thermostat cover was missing, and food debris and a white liquid were on the floor and in cabinets. Other areas included a drinking fountain with bandage tape and a glass in it, black substance in the fountain well, soiled wheelchairs, lifts with debris and dirt on the bases, a visibly soiled crash cart with an uncovered suction machine, a cracked cart with sharp edges, and a handwashing sink with no hot water and visible soil. Staff interviews confirmed sharps containers should be filled only to the marked line and secured, housekeeping cleaned dining areas after meals and resident rooms daily, maintenance was responsible for damaged equipment and torn screens, and the facility policy required a safe, clean, comfortable, and homelike environment.
Infection Control Failures With Shared Equipment, Hand Hygiene, and Respiratory Storage
Penalty
Summary
The facility failed to implement adequate infection control practices related to hand hygiene, cleaning of shared equipment, and sanitary storage of respiratory equipment. On 05/06/26 at 07:40 AM, CMA R obtained R6’s blood pressure and pulse using a vital machine taken from a neighboring room without sanitizing it first. LN G then took the same machine from R6’s room, did not sanitize it before or after use, and used it to obtain vitals from another resident seated next to her medication cart. LN G returned the machine to CMA R, who also did not sanitize it before taking it to the next resident’s room. LN H stated the vitals machine was cleaned before each shift and that staff should not take it into rooms with EHB precautions, but also stated she did not think the equipment needed to be cleaned between each resident. Respiratory equipment for R100 was observed on 05/05/26 at 08:12 AM and again on 05/06/26 at 09:11 AM lying on the bedside table rather than being stored in a sanitary container. R100 stated she did not have bags or containers for her CPAP mask and nebulizer mask. On 05/06/26 at 09:45 AM, CNA SS and CMA S donned gowns and gloves outside R3’s room without handwashing or sanitizer use before putting on PPE. R3 was incontinent of bladder and was changed in bed. CNA SS removed PPE to leave the room to get the Hoyer lift and did not wash hands or use sanitizer after removing gown and gloves. CMA S removed gloves and reapplied gloves after providing personal care without using sanitizer or washing hands, and CNA SS returned with the lift and donned new gloves in the room without hand hygiene. Staff interviews showed differing understanding of when respiratory equipment should be bagged and who was responsible for doing so, while the Administrative Nurse stated nurses were responsible for placing cleaned respiratory equipment in bags and that all equipment should be sanitized between residents, especially after use in an EHB precautions room.
Failure to Assess Resident for Safe Self-Administration of Medications
Penalty
Summary
The facility failed to ensure a resident was assessed for the ability to safely self-administer oral medications before staff left medications in a medication cup in the resident’s room. The resident had diagnoses including GERD, osteoarthritis, chronic pain syndrome, seizures, muscle weakness, dysphagia, vascular dementia, CKD, anxiety, and HTN. Her annual MDS documented a BIMS score of 11, indicating moderately impaired cognition, and she used a walker or wheelchair for mobility. Her care plan documented altered self-care related to bowel and bladder incontinence and risk for complications due to decreased functional mobility, pain, seizures, weakness, and dementia; she required one staff member to assist with ADLs including bed mobility, dressing, bathing, and personal hygiene. The resident’s EMR lacked evidence that the facility assessed her ability to safely administer her medications, and the clinical record lacked a physician’s order to keep medications at bedside. During observation, a small plastic cup containing four different medications labeled with the resident’s first name and last initial was found on her breakfast tray while she lay in bed with her eyes closed, facing away from the tray. Staff interviews indicated medications should not be left unattended and that residents who could self-administer medications would be identified in the care plan. The administrative nurse stated a resident must be assessed to determine whether self-administration was permitted and that this would be documented in the care plan, but she was not sure which residents were able to self-administer their medications.
Failure to Match Code Status With Signed DNR Directive
Penalty
Summary
The facility failed to verify that Resident 16’s advance directive information in the clinical record accurately reflected her DNR status. Resident 16 had diagnoses including cerebral infarction, hemiplegia, hypertension, anxiety disorder, and cognitive communication deficit, and her quarterly MDS documented a BIMS of 12, indicating moderate cognitive impairment. She used a wheelchair, required set-up/clean-up assistance for eating and oral hygiene, and was dependent on staff for all other ADLs. Her care plan did not document her advance directive wishes, although the scanned documents section of the EHR contained a signed DNR directive dated 01/21/25. Despite the signed DNR in the record, the EHR Home tab documented her code status as full code, and a physician order dated 02/02/26 also listed her as full code until it was discontinued on 05/06/26. On 05/05/26, the resident stated that she was a DNR. Staff interviews confirmed the inconsistency: a CMA, an LN, and administrative nurses all verified that the EHR showed full code while a signed DNR was also present in the chart. Administrative Nurse E stated that the code status had been wrong and that the EHR was reviewed and changed to DNR to reflect the resident’s wishes and DNR documentation.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to ensure a resident was free from abuse when a resident with diagnoses of bipolar disorder, major depressive disorder, and dementia grabbed another resident by the neck. The resident involved in the incident had an EMR documenting those diagnoses, an MDS showing a BIMS score of 14 and walker use, and a care plan noting verbal behaviors toward staff, agitation, verbal or physical altercations, attempts to assist other residents, and a tendency to insert himself into other residents’ situations and become easily excitable with loud noise or voices. According to the facility report, the incident occurred while one resident was standing at the nurse’s station talking with a CNA and turned to walk away. As she walked away, the other resident approached from the dining area, cursed aloud that the walker was his, and grabbed her by the neck, causing a small scratch near her left eye. Staff separated the residents, and the resident who initiated the incident was placed on 1-on-1 supervision. Witness statements described the resident as having hands on the other resident’s neck, and one witness reported hearing staff yell to stop and then seeing the residents face to face before they were separated. The record also documented a later altercation in which the same resident was heard yelling in the hallway and was seen pushing a female resident down. Staff redirected him, noted a scratch to his face, and placed him on 1-on-1 supervision. Progress notes further documented psychiatric involvement, severe impairment in judgment and decision making due to cognitive impairment, and that the resident was later accepted to a psychiatric hospital. Staff interviews reflected that residents involved in altercations were to be separated, assessed, and placed on 1-on-1, but the report documents that the abuse incidents occurred before those measures were in place.
Failure to Assist Resident With Eating
Penalty
Summary
The facility failed to ensure a resident received the assistance needed with eating. The resident had diagnoses including hemiparesis following a CVA, hypertension, obesity, need for assistance with personal care, and cognitive communication deficit. The admission MDS documented a BIMS score of zero, indicating severely impaired cognition, and also documented impairment of the extremities on both sides of the body and a need for substantial/maximal assistance with eating. The resident’s care plan documented that he was to receive a regular diet with pureed texture, later a mechanically altered diet with thickened liquids, and substantial/maximal assistance of one person with eating. However, on two separate morning observations, the resident was seen in bed eating breakfast by himself while his tray sat on the bedside table, with food dripping down his chin, mouth, neck, and gown, and no staff present to assist him. Staff interviews indicated they relied on the Kardex and care plan to identify residents needing assistance or monitoring while eating, and an administrative nurse stated that if a resident’s care plan called for one assistant while eating, staff should assist that resident.
Failure to Provide Nail Care and Hygiene Assistance
Penalty
Summary
The facility failed to provide a resident the necessary ADL care, including hygiene assistance with cleaning his fingernails. The resident had diagnoses including hemiplegia, hemiparesis, anxiety disorder, major depressive disorder, seizures, DM, and a cognitive communication deficit. His MDS documented that he used a wheelchair, was dependent on staff for bathing and hygiene care, and required assistance with all ADLs. His care plan directed staff that he was dependent on one staff member for bathing, but it did not include instructions for nail care. The EHR task record showed no evidence that nail care was provided from 04/07/26 through 05/07/26, and there were no documented refusals or progress notes indicating he refused nail care. Observations on 05/06/26 and 05/07/26 showed a brown substance on both hands, on the fingertips, and underneath the fingernails. The resident stated he would not mind if staff cleaned his fingertips and fingernails and reported that staff did not ask him if he wanted his nails cleaned. Staff interviews showed mixed understanding of who provided nail care: one nurse said support staff could provide it, a CMA said activities did nail care and verified the resident's nails should never look like they did, a CNA said staff should clean the nails if the resident wanted them cleaned, and activity staff said nail care was done during spa days every other Wednesday. The activity director stated spa days included cleaning underneath the nails and soaking nails to remove dirt and debris, and the administrative nurse stated nail care could be provided with showers and charted under resident tasks. The facility policy stated it was the policy to clean the nail bed, keep nails trimmed, and prevent infections.
Inconsistent Activity Programming for a Resident with Severe Cognitive and Physical Impairment
Penalty
Summary
The facility failed to provide consistent activities for a resident with hemiplegia and hemiparesis following a cerebral infarction, major depressive disorder, aphasia, severe cognitive impairment, wheelchair dependence, total dependence for ADLs, an indwelling urinary catheter, and a PEG tube for feeding. The resident’s MDS and care plan documented that listening to music was very important, and preferred activities included country music, old rock and roll, being outdoors, parties, getting nails done, watching television, and pets. The care plan also directed staff to provide one-to-one bedside or in-room activities when the resident could not attend out-of-room events and to offer activities that supported choice, self-expression, and responsibility. The one-to-one activity lists showed the resident was to receive activities three times weekly, but documentation reflected activity only on three dates during the review period, with no refusal documented. An activity progress note stated the resident would not wake up for visits and did not want to be bothered, while also noting that the resident enjoyed people-watching and observing group activities when awake and out of bed. Survey observations found the resident in bed with the television on and no staff present during times when group activities were occurring in the facility. Staff interviews showed uncertainty about how often one-to-one activities were provided, and the activity staff acknowledged that refusals were not being documented and that the resident had been offered activities only once weekly during the reviewed period.
Unsupervised Shower Fall With Injury
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and adequate supervision when a cognitively impaired resident was left alone in the shower and fell with injury. Resident 127 had diagnoses including dementia, muscle weakness, cognitive communication deficit, and iron deficiency anemia. Her MDS documented a BIMS score of 3, indicating severe cognitive impairment, and her care plan stated she required one staff member to assist with ADLs because of unsteadiness, decreased functional mobility, and dementia. Her falls CAA also identified her as a fall risk due to bowel and bladder incontinence, need for ADL assistance, decreased functional mobility, unsteadiness, and dementia. The facility’s fall investigation documented that a CNA left Resident 127 unattended in the shower and returned to find her lying face down in the shower. Staff notified the nurse, who observed that the resident had a pulse, blood from the left side of her face, and emesis from her mouth. EMS was called, and the resident was responsive when EMS arrived. She was transferred to a local hospital for evaluation and treatment and required one stitch to close a lower lip laceration from the fall. Staff interviews supported that Resident 127 should not have been left alone in the shower. One CNA stated no resident on the second floor should be left alone in the shower, especially Resident 127. Another CNA stated Resident 127 should not be left alone in the shower and that she allowed staff to assist with washing without difficulty. A nurse also stated Resident 127 was a resident who should not be left alone, even if she or another resident requested privacy. The facility’s Providence Policy stated residents unable to carry out ADLs would receive assistance with personal and oral hygiene.
Unsecured Medication Cart Observed in Hallway
Penalty
Summary
The facility failed to ensure medications were labeled and stored appropriately when staff did not properly secure a medication cart. On 05/06/26 at 08:17 AM, surveyors observed a large rolling medication cart on the second-floor hall, unattended, with the lock partially pushed in. The cart contained stock bottles of medications, cards of resident-specific medication, and personal drink cups. During an interview at 08:19 AM, Licensed Nurse L stated she thought the cart was locked and confirmed that the medication cart should always be locked when unattended or out of sight. The facility policy titled Medication Labels and Storage, dated 03/2024, did not address resident medication carts.
Nonfunctional Call Light for Resident in Bed
Penalty
Summary
A functional call light system was not available for a resident with generalized muscle weakness, difficulty walking, unsteadiness on feet, occasional bladder incontinence, decreased functional mobility, and dementia. The resident’s care plan directed staff to ensure the call light was within reach and to encourage use of it for assistance as needed. On observation, the resident was in bed or at the edge of the bed with the call light within reach, but when the button was activated it did not alert at the door or at the staff monitor. The same problem was observed again when the resident was in his wheelchair at breakfast and later when he was awake in bed and pressed the call light, which still did not alert at the monitor or above the room door. During interviews, a CNA stated she was not aware the call light was not working and would inform the nurse, and another CNA stated anyone could place a work order in the computer. Maintenance stated a work order had been entered for the call light not working in the resident’s room. The facility did not provide a policy for a functional call light system.
Unsafe and Unsanitary Stairwell Conditions
Penalty
Summary
The facility failed to ensure a safe, sanitary, and functional environment in one stairwell. On observation, the stairwell had a white, wet, organic-type substance on the walls with a strong musty odor, dusty debris that appeared to be flaked plaster on the handrail and floor at the back wall, and stains on the ceiling that appeared to be water damage. Housekeeping staff stated they were responsible for cleaning the floors and handrails in the stairwell, but not the walls and ceilings. Maintenance staff stated the maintenance department would be responsible for cleaning the stairwell walls and said he would get a plan in place to spray the white substance on the walls with bleach. Administrative staff stated the white substance developed due to increased moisture from a roof leak that had not yet been fixed and that maintenance was responsible for cleaning the walls.
Failure to Provide Reasonable Accommodations for Call Light, Wheelchair Foot Pedals, and Sensory Item
Penalty
Summary
The facility failed to reasonably accommodate resident needs and preferences by not ensuring a resident with severe cognitive impairment had a call light he could functionally activate for staff assistance. On 11/18/25, the resident was observed sitting in bed with his bedside table over him after stating he was finished with breakfast and needed staff help, but his call light was placed inside the dresser next to his bed and out of reach. The resident’s low air-loss mattress was set to 200 lbs. The facility also failed to ensure three severely cognitively impaired residents had foot pedals on their wheelchairs while being pushed. On 11/18/25 and again on 11/19/25, residents were observed being pushed from their rooms to the dining room in wheelchairs without foot pedals attached, and their feet slid on the floor as staff pushed them. CNA M stated staff should use the foot pedals while pushing residents in wheelchairs, LN G stated all residents had foot pedals and staff were expected to use them, and Administrative Nurse D stated staff were never to allow residents’ feet to drag while being pushed. The facility additionally failed to provide a resident’s sensory hand item while he was in bed. The resident’s EMR documented diagnoses including CVA, HTN, COPD, dysphagia, and contracture, and the MDS recorded severely impaired cognition, impairment in one side of the body, and total dependence on staff for ADLs. His care plan directed staff to ensure he had one of his sensory objects in his right hand while in bed, and his wife preferred the flashlight be placed in his right hand. On 11/17/25 and 11/18/25, he was observed in bed without the sensory object in his right hand, and staff stated any staff member could place the object in his hand and that it was the nurse’s responsibility to ensure the task was completed.
Unsecured Hazardous Materials and Missed Fall Interventions
Penalty
Summary
The facility failed to secure rooms containing hazardous materials so they were not accessible to 12 cognitively impaired, independently mobile residents. During a walkthrough of the secured 2nd floor, an unsecured linen closet next to the nurse’s station by the elevator contained a container of purple disinfectant wipes on top of the counter, a cabinet in the dining area contained a container of purple wipes in the upper cabinet, an unsecured soiled utility closet next to the rear nurse’s station contained two overfilled sharps containers with syringes, and an unsecured shower room next to the rear nurse’s station contained a spray bottle of disinfectant. A licensed nurse later secured the doors and stated the rooms with potentially hazardous chemicals were supposed to be secured and residents were not to have access to secured areas. The facility also failed to follow fall interventions for R61. R61’s EMR documented diagnoses of major depressive disorder, anxiety, dementia, and anemia. Her MDS documented a BIMS score of 4, indicating severely impaired cognition, and that she needed staff assistance with eating, toileting, bathing, dressing, chair-to-bed transfer, and toilet transfers. Her care plan included keeping the call light within reach and changing Dycem to a one-way slide. During observation, R61 was lying in bed with the call light placed at the top of the bed under her pillow and out of reach, and her wheelchair did not have Dycem in it. The facility further failed to follow fall interventions for R67. R67’s EMR documented unsteadiness, COPD, history of falls, and muscle weakness. Her MDS documented intact cognition and need for supervision with showers, dressing, mobility, transfers, and ambulation. Her care plan included supervision with transfers, ensuring her call light was within reach, not allowing her in the shower room alone, supervising her with her walker, and assisting with placement of her oxygen tank in the proper bag on her wheelchair or walker. R67 had a documented fall when her walker and oxygen tank tipped as she returned from a smoke break, causing neck and right knee pain and an abrasion to her right knee. Later observations showed her ambulating with a walker and oxygen tank in a pouch, while staff interviews reflected uncertainty about her fall history and the responsibility for ensuring her oxygen tank and supervision needs were followed.
Failure to Assess Self-Administration of Inhaler Medication
Penalty
Summary
The facility failed to ensure a resident with COPD and acute and chronic respiratory failure with hypercapnia had a physician's order and an assessment for the ability to safely self-administer an inhaler medication. The resident's EMR documented intact cognition on the quarterly MDS, and the care plan included interventions for COPD, including administering inhalers as ordered. A physician's order directed staff to administer fluticasone-umeclidinium-vilanterol 100-62.5-25 mcg, one inhalation daily for COPD, and the EMR showed the inhaler was scheduled for 7:00 AM daily. On 11/18/25, a nurse handed the resident the inhaler without providing instructions on how to use it, then left the room to get applesauce to mix into the resident's medication. The resident attempted to use the inhaler and found it was empty, then returned it to the nurse and stated it was empty. The nurse stated the resident had not received the inhaler as scheduled, that staff should have seen it was almost empty and reordered it, and that she was not sure whether the resident had been assessed for self-administration. An administrative nurse later verified that the resident did not have an assessment for self-administration of medications and should not have been given the inhaler to self-medicate.
Failure to Honor Resident Preference for Female Caregivers
Penalty
Summary
The facility failed to honor a resident’s stated preference for only female caregivers. The resident had diagnoses of PTSD and insomnia, and the Quarterly MDS documented intact cognition, independence with dressing, personal hygiene, mobility, transfers, and ambulation, with no behaviors and no psychotropic medications. The Social Services Assessment documented that the resident had been abused by her ex-husband, with the abuse described as primarily emotional, mental, and financial, and that she preferred no male caregivers; her trigger was loud noises. The care plan, however, did not document the resident’s request for no male caregivers. The Social Services Assessment later noted the resident’s trauma had been identified previously and had not changed, but the assessment lacked documentation that psychiatric services were offered. During interviews, an LN stated she was unaware the resident had PTSD or preferred not to have male caregivers, a CNA stated he had assisted the resident many times before being made aware of her preference, and Social Services stated she had been unaware the request was not on the care plan. Administrative staff confirmed the request should have been on the care plan and that staff should have been made aware the resident had PTSD and preferred female caregivers.
Failure to Provide Final Discharge Summary
Penalty
Summary
The facility failed to provide a final summary of R128’s status at discharge. R128’s EMR documented diagnoses including unsteadiness on feet, cognitive communication deficit, weakness, major depressive disorder, dependence on renal dialysis, acquired absence of the left great toe, blindness in the right eye muscle, and dysphagia. The record also showed an Entry MDS completed on 09/18/25, a care plan stating the resident wanted to be discharged home after the skilled stay, and a plan dated 10/03/25 noting that a pre-discharge plan would be held with the resident and family caregivers to evaluate progress and revise the discharge plan as needed. Additional record review showed a BIMS score of 15, indicating intact cognition, and a fall committee IDT note dated 09/22/25 documenting that the resident fell out of bed on 09/21/25, was sent to the ER because he was on Heparin, and that staff would place a falling star outside the room. Social services documentation noted the spouse declined a bed hold and stated the resident would not be returning because bed rails were not allowed. During interviews, an LN stated she was unsure whose responsibility it was to complete a discharge summary for an unplanned discharge, an administrative nurse stated social services completed part of the discharge summary and the remainder was her responsibility, and administrative staff stated the facility could not locate a discharge summary or recompilation of R128’s care.
Failure to Develop Comprehensive Care Plans for Smoking and PTSD
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident with COPD, acute and chronic respiratory failure with hypercapnia, intact cognition, and a need for oxygen therapy who also smoked. The resident’s quarterly MDS documented supervision needs for showers, dressing, mobility, transfers, and ambulation, and the smoking assessment documented no visual deficits, no cognitive loss, no falls, that the resident could light her own cigarette, used oxygen, and had been educated on safe smoking practices and the risks of smoking. However, the resident’s care plan lacked documentation of a smoking care plan. Staff observations and interviews confirmed the resident was smoking outside with supervision, and an administrative nurse verified there was not a smoking care plan and stated there should have been one. The facility also failed to develop a comprehensive care plan for a resident with PTSD and insomnia. The resident’s quarterly MDS documented intact cognition and independence with dressing, personal hygiene, mobility, transfers, and ambulation, and the care plan only addressed psychosocial support as needed. Social services assessments documented a PTSD diagnosis, abuse by the resident’s ex-husband, emotional, mental, and financial abuse, a preference for no male caregivers, and loud noises as a trigger; the resident refused psychiatric services at the time. The record lacked documentation that a PTSD care plan was developed, and staff interviews showed CNA and nursing staff were unaware of the diagnosis, triggers, or preference for female caregivers. Social services stated there was no care plan for staff to provide PTSD triggers during care, and an administrative nurse stated the PTSD care plan should have been in place after the assessment was completed.
Pressure-Reducing Interventions Not Implemented as Ordered
Penalty
Summary
The facility failed to ensure Resident 84’s pressure-reducing interventions were implemented correctly when his low-air-loss mattress was not set within his current weight range. Resident 84 had diagnoses including CHF and heart disease, severe cognitive impairment, dependence on staff for multiple ADLs, substantial to maximal assistance needs for bed mobility and transfers, and a stage-three pressure injury. His care plan identified that he was at risk for pressure ulcers and that staff were to check the placement and function of the mattress, but it did not include instructions for the low-air-loss mattress settings. Resident 84’s records showed he weighed 132.1 pounds, while the low-air-loss mattress was observed set to 200 pounds on multiple occasions. The manufacturer’s manual stated the mattress pump’s pressure levels and firmness were preset based on the selected weight range and that using the mattress while deflated puts the resident at risk for injuries. Staff interviews indicated the mattress was being set based on the care plan and the resident’s current weight, and that staff were expected to check bed settings each shift. The facility also failed to float Resident 10’s heels as directed by physician order. Resident 10 had diagnoses including CVA, HTN, COPD, dysphagia, and contracture, severe cognitive impairment, and was at high risk for pressure ulcers. His care plan and physician order directed heel offloading while in bed, but observations showed his heels directly on the mattress during two separate checks. Staff interviews indicated responsibility for ensuring heels were floated was shared among nursing and therapy staff, and that the nurse signed off when heel floating was completed during care.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to ensure Resident 82 received trauma-informed care to eliminate or mitigate triggers related to a diagnosis of PTSD. The resident’s EMR documented PTSD and insomnia, and the Quarterly MDS documented intact cognition, independence with dressing, personal hygiene, mobility, transfers, and ambulation, and no behaviors or psychotropic medications. The Social Services Assessment dated 07/06/25 documented that the resident had been abused by her ex-husband, with the abuse described as primarily emotional, mental, and financial. It also documented that she preferred no male caregivers and identified loud noises as a trigger, and that she refused psychiatric services at that time. The EMR lacked documentation of a care plan for the resident’s PTSD that had been developed, and the Social Services Assessment dated 10/06/25 stated the trauma had been identified in the previous assessment and had not changed, with a reference to the care plan, but lacked documentation that psychiatric services were offered. Staff interviews showed the resident’s PTSD and preferences were not known to multiple caregivers: a CNA stated she was not aware of the PTSD diagnosis or triggers, another CNA stated he had just been made aware the resident did not want male caregivers, and an LN stated she was unaware of the PTSD diagnosis and the preference for female caregivers. Social Services stated she had been unaware there was no care plan for staff to provide PTSD triggers and that she did not talk to the resident about past trauma because she did not want to upset her. Administrative staff stated the PTSD care plan should have been in place after the assessment and that staff should have been made aware of the diagnosis, triggers, and preference for female caregivers.
Failure to Follow Medication Hold Parameters
Penalty
Summary
The facility failed to administer medications according to physician orders for three residents reviewed for unnecessary medications. For Resident 26, the record showed diagnoses of hyperlipidemia and hypotension, and the care plan directed staff to administer medications as ordered for hypotension and monitor for adverse effects. A physician order directed Midodrine 5 mg by mouth twice daily and to hold the medication if systolic blood pressure was over 150 mmHg, yet the TAR documented doses given when the resident’s systolic blood pressure was above that parameter on multiple occasions in September and October 2025. During observation and interview, nursing staff confirmed the resident had received Midodrine when blood pressures were out of the ordered range. Resident 97 also had diagnoses of hyperlipidemia and hypotension, with a care plan directing medications to be administered as ordered and monitored for side effects and effectiveness. The physician ordered Midodrine 10 mg by mouth twice daily and to hold it if systolic blood pressure was over 130 mmHg. The TAR documented multiple administrations in October and November 2025 when the resident’s systolic blood pressure exceeded the ordered hold parameter, including readings of 131/61, 138/67, 142/78, and 142/62. On observation, the resident was in bed with eyes closed, and nursing staff acknowledged that the medication had been given when it should have been held. Resident 67 had diabetes mellitus and a care plan directing insulin administration as ordered and blood sugar monitoring. The physician ordered Humalog 5 units subcutaneously before meals and at bedtime, with instructions to hold the insulin if fasting blood sugar was below 100 mg/dl and to call the physician if below 70 mg/dl or over 400 mg/dl. The TAR documented several instances in September, October, and November 2025 when Humalog was administered even though blood sugars were below 100 mg/dl, including values of 87, 98, 95, 93, 91, 96, and 88 mg/dl. Nursing staff confirmed the insulin had been given when it was outside the ordered parameters.
Hospice Communication and Care Plan Not Fully Documented
Penalty
Summary
The facility failed to ensure a communication process between the hospice provider and the facility for R34 that included a plan of care and a description of the services provided, including visit frequency for CNA services, chaplain services, medications, and medical equipment. R34’s EMR documented diagnoses of Huntington’s disease, neuromuscular dysfunction of the bladder, anxiety, and major depressive disorder. The Significant Change MDS documented that R34 had intact cognition, required staff supervision for toileting hygiene, dressing, personal hygiene, mobility, and transfers, did not ambulate, and received hospice services. R34’s care plan included hospice-related interventions such as adjusting ADL support, chaplain visits, consultation with the physician and Social Services for hospice care in the facility, weekly hospice nurse visits, hospice showers, and supplies as needed. A physician’s order directed staff to admit R34 to hospice care. During interviews, a CNA stated that a hospice CNA provided showers, and an LN stated that the hospice nurse visited a couple of times a week. The Administrative Nurse stated that R34’s care plan should reflect the services and what was provided by hospice. The facility’s hospice policy stated that collaboration with hospice would include processes for orienting staff to facility policies and procedures, including residents’ rights, documentation, and record-keeping requirements.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to ensure staff assisted a resident with showers as scheduled. The resident had diagnoses including CVA, HTN, COPD, dysphagia, and contracture. The annual MDS documented a BIMS score of 99, indicating severely impaired cognition, and noted impairment in the upper and lower extremities on one side of the body with staff assistance required for all ADLs. The CAA documented altered cognition related to dementia and risk for complications due to restricted mobility and inability to communicate. The care plan stated the resident was totally dependent on staff for ADLs, including bathing, and a progress note documented that the resident's spouse requested full showers rather than bed baths and asked that showers be moved to the evening shift. The resident's task record showed showers on some dates and a sponge bath on one date, but on observation the resident was lying in bed with eyes closed and had greasy hair. During interviews, the Administrative Nurse stated she oversaw that residents received showers or baths as requested and that if a resident did not get a shower as scheduled, staff were told the resident would get one the next day. A CNA stated CNAs were responsible for ensuring the resident received his shower and that if a bath was missed, the information was expected to be passed to the next shift. Another Administrative Nurse stated showers were expected to be completed on the day scheduled and that follow-up for missed showers was the responsibility of the Administrative Nurse.
Failure to Notify Ombudsman of Resident Hospital Transfers and Discharges
Penalty
Summary
The facility failed to notify the Office of the Long-Term Care Ombudsman (LTCO) regarding the discharge or hospital transfer of several residents, as required by both federal regulations and the facility's own Admission, Transfer, and Discharge policy. The policy specified that a list of residents who had an emergency transfer and/or discharge would be sent to the LTCO monthly. However, documentation and staff interviews revealed that this notification was not consistently completed for residents who were transferred to the hospital but remained on bed hold or returned within the bed hold period. One resident with diagnoses including diabetes mellitus, major depressive disorder, and muscle weakness was transferred to the hospital for evaluation of increased pain, swelling, and an open area on the foot. The clinical record showed that while emergency services and the responsible party were notified, there was no documentation that the LTCO was informed of the discharge. Similar deficiencies were found for other residents with complex medical conditions, such as rhabdomyolysis, lactic acidosis, acute respiratory failure, and chronic respiratory failure, who were also transferred to the hospital. In each case, the facility's records lacked evidence of LTCO notification at the time of transfer or discharge. Interviews with administrative and social services staff confirmed that the facility's reporting system did not capture residents who were transferred to the hospital and remained on bed hold, unless they did not return within the 10-day period. As a result, the LTCO was not notified of these residents' transfers or discharges, contrary to the facility's policy. This failure was observed in multiple cases reviewed during the survey, indicating a pattern of non-compliance with required notification procedures.
Failure to Label and Remove Expired Insulin Products
Penalty
Summary
Surveyors observed that multiple insulin flex pens and vials belonging to several residents were not labeled with the date opened or the date expired. Specific types of insulin, including Aspart, Lispro, Lantus, Glargine, Humalog, Novolog, and Tresiba, were found on the South Hall medication cart without proper labeling. In one instance, an insulin flex pen was labeled with the date opened but lacked an expiration date, and the insulin had already expired according to the 28-day in-use guideline. The facility's policy requires that medications which are expired, contaminated, or in containers without secure closures be immediately removed and disposed of, but this was not followed for the insulin products observed. The failure to label insulin products with the date opened and the expiration date was identified through observation, interview, and record review. The report specifically notes that the affected insulin products were not removed from storage after their expiration, as required by facility policy and professional standards. The sample included 24 residents out of a census of 113, and the deficiency was documented for insulin belonging to at least eleven residents.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
A deficiency occurred when a licensed nurse provided wound care to a resident with diabetic neuropathy ulcers on the right great toe and right second toe without adhering to Enhanced Barrier Precautions (EBP). The nurse washed her hands and wore gloves but did not don a gown while removing and reapplying dressings to the resident's open wounds. There was no personal protective equipment (PPE) available in the resident's room, nor were there instructions or signage regarding the required use of PPE for EBP during care activities involving the resident's wounds. The nurse confirmed during an interview that she was instructed to use gloves only and did not believe a gown or additional PPE was necessary. Administrative staff later verified that staff should have been using PPE for EBP when providing care to the resident and acknowledged the absence of PPE and signage. Facility policy required the use of gown and gloves for high-contact care activities involving residents with wounds, in accordance with EBP, but these procedures were not followed during the observed wound care.
Failure to Revise Care Plans for Resident-Centered Functional Abilities
Penalty
Summary
The facility failed to revise and update the care plans for two residents to include individualized, resident-centered functional abilities and specific directions for staff regarding activities of daily living (ADLs). For one resident with chronic respiratory failure, congestive heart failure, obstructive sleep apnea, anxiety, major depressive disorder, and diabetes mellitus, the care plan did not provide instructions for staff on essential ADL support such as toileting hygiene, transfers, bed mobility, bathing, oral hygiene, dressing, and eating. This resident required substantial to maximal assistance with these activities, as documented in the Minimum Data Set (MDS), and had multiple hospitalizations for decreased oxygen levels during the review period. Observations showed the resident needed repositioning for safe meal intake, and staff interviews confirmed that care plan directions were missing due to a mishap in the care planning process. Another resident with neuromuscular bladder dysfunction, hypertension, paraplegia, major depressive disorder, traumatic brain injury, anxiety, morbid obesity, a stage four pressure ulcer, and dependence on a wheelchair also had a care plan lacking specific interventions for ADLs. The MDS and Care Area Assessment (CAA) documented the resident's dependence on staff for toileting, transfers, dressing, and personal hygiene, as well as the need for a mechanical lift and limited time in a chair due to a wound vac. Despite these needs, the care plan did not include detailed instructions for staff on how to provide necessary assistance with toileting hygiene, transfers, bathing, oral hygiene, dressing, and eating. Staff interviews revealed that CNAs relied on verbal reports from previous shifts or nurses to determine the care needs of residents, rather than written care plan instructions. Administrative nursing staff acknowledged that the care plans should have included detailed directions for staff and that the omission was an error. The facility's own policy required comprehensive, individualized care plans to guide staff in providing person-centered care, but this was not followed for the two residents identified in the sample.
Failure to Provide Consistent Bathing and Grooming for a Resident with Impaired Cognition
Penalty
Summary
The facility failed to provide consistent bathing and grooming care for one resident with multiple diagnoses, including dementia, anxiety, hypertension, atrial fibrillation, cognitive communication deficit, and depression. The resident was assessed as having severely impaired thinking and required partial staff assistance for activities of daily living (ADLs) such as dressing, mobility, transfers, ambulation, personal hygiene, and showers. Documentation showed that the resident frequently refused showers or bed baths, with extended periods where no bathing occurred, including gaps of up to 26 days. The care plan directed staff to explain care activities, negotiate ADL times, and provide consistency in caregivers and routines, but records indicated that only one staff member was allowed to attempt showers, and documentation of repeated attempts was lacking. Observations over several days revealed the resident had uncombed, tangled, and matted hair and wore the same clothes for over a week. Staff interviews confirmed that the resident often refused showers and changes of clothes, and that only one staff member was permitted to attempt showers, which limited opportunities for care. Nursing staff and administration acknowledged the resident's resistance to care and stated that the family was aware of the situation and did not wish to be contacted for each refusal. Despite these challenges, the facility's policy required that residents unable to perform ADLs receive services to maintain good hygiene and grooming, which was not consistently provided in this case.
Failure to Address Dementia Care Needs for Resident with Persistent Wandering and Rummaging Behaviors
Penalty
Summary
The facility failed to adequately address the dementia care needs of a resident who exhibited persistent wandering and rummaging behaviors, including going through staff members' belongings at the nurse's station and attempting to take items from other residents and staff. The resident had a documented history of multiple neurocognitive and psychiatric diagnoses, including Wernicke's encephalopathy, alcohol-induced persisting amnestic disorder, alcohol dementia, schizoaffective disorder, mood disorder, and anxiety. Over time, the resident's cognitive status declined from intact to moderately impaired, as reflected in the Minimum Data Set (MDS) assessments, and the care plan was updated to include interventions such as distraction with snacks, structured activities, and redirection. Despite these interventions, nursing notes repeatedly documented incidents where the resident attempted to take food, beverages, and other items from staff and other residents, rummaged through drawers, and entered unauthorized areas such as the nurse's station and other residents' rooms. Staff responses primarily involved redirection, providing snacks, and educating the resident that the behavior was inappropriate. However, these interventions were not consistently effective, as the resident continued to display the same behaviors over an extended period, and staff adapted by removing their personal belongings from accessible areas rather than addressing the underlying behavioral issues. Interviews with staff confirmed that the resident's behaviors were ongoing and that the primary approach was redirection and provision of snacks. The facility's policy on dementia care required individualized care plans and specialized staff training, but the documentation and staff interviews indicated that the interventions in place did not sufficiently address the resident's persistent behaviors. The lack of effective, individualized interventions placed the resident at risk for decreased quality of life and potential accidents.
Failure to Hold Blood Pressure Medication per Physician Parameters
Penalty
Summary
Staff failed to follow physician-ordered parameters for administering blood pressure medication to a resident with a history of hypotension, cognitive impairment, depression, and anxiety. The physician's order specified that midodrine should be held if the resident's systolic blood pressure (SBP) exceeded 130 mmHg. Despite this, the Medication Administration Record showed multiple instances over several months where the medication was administered when the resident's SBP was above the ordered threshold. The resident's care plan directed staff to administer medications as ordered and observe for adverse effects, but these instructions were not followed. Certified Medication Aides and Licensed Nurses involved in the resident's care did not recognize or act upon the out-of-parameter blood pressure readings, resulting in the medication being given inappropriately. Staff interviews confirmed a lack of awareness regarding the need to hold the medication when the SBP was above the specified limit. The facility's policy required medications to be administered as prescribed and in accordance with written orders, but this was not adhered to in the resident's case.
Failure to Hold Blood Pressure Medication per Physician Order
Penalty
Summary
A medication administration error occurred when a resident with a history of hypotension, cognitive impairment, depression, and anxiety received midodrine, an antihypotensive medication, despite their systolic blood pressure (SBP) being above the physician-ordered parameters. The physician's order specified that midodrine should be held if the SBP exceeded 130 mmHg. However, the Medication Administration Record documented multiple instances across several months where the resident received the medication when their SBP was above this threshold. The resident's care plan directed staff to administer medications as ordered and observe for adverse effects, but these instructions were not followed. Staff interviews confirmed that the medication was not held as required, and the certified medication aide administering the medication was unaware that the resident's blood pressure was out of the prescribed range. The facility's policy required immediate reporting and documentation of medication errors, as well as close monitoring of the resident's condition, but the error was only recognized after the fact. The failure to adhere to physician orders and facility policy resulted in the resident receiving medication outside of safe parameters.
Failure to Secure Hazardous Materials in Secured Unit
Penalty
Summary
The facility failed to secure areas containing hazardous materials, placing seven cognitively impaired and independently mobile residents at risk for preventable injuries and accidents. During an inspection of the 2nd-floor nursing station, alcohol-based disinfectant wipes were found on the outside counter and on a shelf next to the sensory room. These containers had warnings indicating they were hazardous to humans, could cause eye irritation, and were harmful if swallowed. Despite the presence of these warnings, the wipes were accessible to residents, including one severely cognitively impaired resident who was observed wandering around the area where the wipes were accessible. Interviews with staff revealed that cleaning products should be secured in locked closets or rooms to prevent access by cognitively impaired residents. A CNA confirmed that these residents should not have access to such products due to the risk of accidental poisoning. An administrative nurse stated that staff were expected to lock up cleaning products and areas with potential hazards to prevent accidents. However, the facility was unable to provide a policy related to accidents or safe chemical storage when requested, indicating a lack of formal procedures to ensure the safety of residents in this regard.
Failure to Maintain Resident Privacy and Dignity
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as R32, who was observed uncovered from the waist down with her incontinence brief pulled to the side, exposing her groin area. This occurred while the door to her room was open, and the privacy curtain was not drawn, allowing visibility from the hallway. The incident was noted during an observation on January 21, 2025, at 08:06 AM. The facility's policy on dignity and respect, revised in October 2023, mandates that residents should be examined and treated in a manner that maintains the privacy of their bodies, which includes closing doors or drawing curtains during personal hygiene activities. R32's medical records indicate she has major depressive disorder, type 2 diabetes mellitus, and congestive heart failure. Her cognitive status, as assessed by the Brief Interview for Mental Status (BIMS), showed a decline from intact cognition to moderately impaired cognition over time. She requires substantial assistance from staff for various activities of daily living, including toileting and personal hygiene. Despite these needs, the facility did not provide the necessary privacy, as confirmed by interviews with staff who acknowledged the expectation to maintain privacy by closing the door or drawing the curtain when the resident is exposed.
Failure to Use Wheelchair Foot Pedals for Cognitively Impaired Residents
Penalty
Summary
The facility failed to utilize wheelchair foot pedals for three residents, all of whom were severely cognitively impaired. Observations revealed that these residents were pushed in wheelchairs without foot pedals, causing their feet to slide on the ground. This occurred multiple times for each resident, including during transport to and from dining areas and their rooms. Staff were observed pushing the residents without ensuring their feet were properly supported, which is contrary to the facility's policy on accommodating residents' needs. Interviews with staff, including a CNA and an administrative nurse, confirmed that foot pedals should be used to prevent residents' feet from sliding or touching the ground while being pushed. The facility's Accommodation of Needs Policy, revised in August 2024, mandates the use of assistive devices to prevent accidents or injuries. Despite this policy, the facility did not provide the necessary accommodations for these residents, placing them at risk for preventable accidents and injuries.
Failure to Notify Physician of Resident's Refusal of Daily Weights
Penalty
Summary
The facility failed to notify a resident's physician about the resident's refusal to comply with daily weight monitoring, as ordered by the physician. The resident, identified as R13, had a complex medical history including hypertension, rheumatoid arthritis, diabetes mellitus, obesity, and congestive heart failure, among other conditions. The resident's care plan indicated a potential risk for nutrition and hydration issues, and the physician had ordered daily weight checks to monitor the resident's condition. However, the resident's electronic medical record noted that the resident refused these weight checks, and there was no documentation that the physician was informed of these refusals. Interviews with facility staff revealed a lack of consistent communication with the physician regarding missed weights. A licensed nurse indicated that it was the responsibility of the evening nurse to notify the physician if a weight was not recorded by a certain time, but this was not done regularly. An administrative nurse confirmed that the facility did not routinely call the physician for habitual refusals of weight checks. Additionally, the facility did not provide a policy for notifying the physician about such refusals, contributing to the deficiency in care.
Failure to Implement Pressure-Relieving Measures for Resident
Penalty
Summary
The facility failed to ensure that a pressure-reducing heel supportive device was in place for Resident 51, who had a pressure-related injury on his right buttocks. Observations revealed that Resident 51 was lying in bed with his heels resting directly on the mattress, contrary to the care plan that required his heels to be elevated on a supportive device. This oversight was noted on multiple occasions, indicating a lack of adherence to the prescribed care plan. Resident 51's medical records documented a history of conditions that increased his risk for pressure ulcers, including foot drop, muscle weakness, reduced mobility, and contractures. Despite these risk factors and the facility's policy to prevent pressure ulcers, the necessary pressure-relieving measures were not consistently implemented. Interviews with facility staff, including a licensed nurse and an administrative nurse, confirmed that the responsibility to ensure pressure-relieving devices were in place was not adequately fulfilled, placing Resident 51 at risk for further skin breakdown.
Failure to Apply Orthotic Device for Resident
Penalty
Summary
The facility failed to ensure that a resident's orthotic device was in place, which placed the resident at risk for discomfort and decreased range of motion. The resident, identified as R26, had a history of cerebral palsy, hypertension, and other medical conditions, including contractures of the left hand, right ankle, and left ankle. The resident's care plan required the use of a left elbow extension splint and a left hand medical device to immobilize the hand as tolerated. However, observations over several days revealed that the resident's left wrist was consistently curled upwards toward the chest, indicating that the orthotic device was not being applied. Interviews with facility staff, including a CNA, a licensed nurse, and a consult therapist, revealed a lack of clarity and responsibility regarding the application of the splint. The CNA stated that therapy was responsible for applying the splints, while the licensed nurse acknowledged the care plan requirement but was unsure why the splint was not being applied. The consult therapist confirmed that the splint was not being monitored or applied at the time. Additionally, the facility's administrative nurse mentioned that the restorative aide responsible for applying splints and performing range of motion exercises was on maternity leave, and no replacement had been arranged. The facility did not provide a policy for positioning or range of motion, contributing to the deficiency in care for the resident.
Improper Storage of CPAP Mask Increases Infection Risk
Penalty
Summary
The facility failed to ensure the sanitary storage of a CPAP mask for a resident, identified as R27, which increased the risk of respiratory infection and complications. R27's medical history included conditions such as hypertension, dependence on dialysis, hyperlipidemia, COPD, and hemiparesis affecting the left side. The resident required assistance with activities of daily living and used a CPAP device nightly due to COPD and shortness of breath when lying flat. Observations revealed that R27's CPAP mask was not stored in a sanitary manner, as it was found laid directly on the bedside table and outside of the CPAP bag on separate occasions. Interviews with facility staff, including a CNA, a licensed nurse, and an administrative nurse, confirmed that respiratory equipment should be stored in a plastic bag when not in use to maintain sanitation. The facility's policy on non-invasive ventilation required adherence to physician's orders and current standards of practice, including following the manufacturer's recommendations for equipment storage. Despite these guidelines, the facility did not ensure the CPAP mask was stored properly, leading to the identified deficiency.
Failure to Document Risk Assessment and Obtain Consent for Side Rail Use
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, had a documented risk assessment for the use of side rails, consent for their use, and failed to inform the resident and/or responsible party of the risks and benefits associated with side rails. R51's medical records indicated several diagnoses, including foot drop, pressure ulcers, and muscle weakness, requiring assistance with personal care and mobility. Despite these conditions, the facility did not provide documentation of a safety assessment addressing the risk of entrapment between the side rails and the mattress, nor was there evidence of informed consent or communication of risks and benefits to the resident or their representative. Observations and interviews revealed that R51 was using side rails without the necessary assessments and consents in place. The facility's policy on side rails, which emphasizes limiting their use and ensuring thorough assessments and informed consent, was not followed. This oversight placed R51 at risk for uninformed decision-making and potential safety hazards related to side rail use. The facility's failure to adhere to its own policy and regulatory requirements resulted in a deficiency concerning the safety and informed consent processes for side rail use.
Failure to Ensure Timely Physician Visits for Resident
Penalty
Summary
The facility failed to ensure that a resident, identified as R51, was seen by their attending physician as required by state and federal regulations. R51's electronic medical record documented several diagnoses, including foot drop, pressure ulcer, muscle weakness, and contractures, indicating a need for regular medical oversight. Despite these conditions, there were no physician progress notes for R51 in the past six months, and the facility was unable to provide documentation of any attending physician visits during this period. Observations and interviews revealed that the facility's administrative and nursing staff were unaware of the attending physician's visit schedule, with some staff assuming visits occurred every three months. The facility's policy required residents to be seen by their attending physician at least once every quarter, but this was not adhered to for R51. This oversight placed R51 at risk of unrealized changes in condition, potentially leading to unnecessary complications in their well-being.
Inadequate Dementia Care and Supervision for Resident
Penalty
Summary
The facility failed to provide adequate dementia-related behavioral services for Resident 14, who was diagnosed with severe cognitive impairment, dementia, and other medical conditions. The resident's care plan indicated she required assistance with activities of daily living, was at risk for falls, and had occasional bladder incontinence. Despite these documented needs, the facility did not implement effective interventions to manage her dementia-related behaviors and incontinence, leading to multiple incidents where the resident was found on the floor or in inappropriate locations. Resident 14 experienced several non-injury falls and incidents due to inadequate supervision and care. She was found on the floor in her restroom's doorway, on a fall mat between her bed and bathroom entryway, and in the sensory room, which she mistook for a bathroom. These incidents highlight the facility's failure to provide consistent and effective toileting assistance and supervision, as the resident was often confused and unable to call for help. Additionally, the facility did not ensure that potentially hazardous items, such as disinfectant containers, were stored out of the resident's reach, further compromising her safety. Interviews with staff revealed that Resident 14 required close monitoring due to her wandering and confusion, yet she was left unsupervised in areas like the sensory room. The facility's dementia care policy emphasized the importance of providing person-centered care to ensure residents' well-being, but the lack of proper supervision and intervention for Resident 14 demonstrated a deficiency in meeting these standards. This failure placed the resident at risk for decreased quality of life, isolation, and impaired dignity.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to ensure proper storage of respiratory equipment for three residents, leading to potential infection risks. Resident 27's CPAP mask was observed on multiple occasions to be improperly stored, either directly on the bedside table or outside of its designated bag. Similarly, Resident 315's tracheal tubing was found disconnected and placed unsanitarily in a drawer. Resident 48's nasal cannula was observed lying on the floor, which is against the facility's infection prevention protocols. Interviews with facility staff, including a Licensed Nurse and an Administrative Nurse, confirmed that respiratory equipment should be stored in provided plastic bags when not in use to prevent contamination. The facility's Infection Prevention and Control Program policy, last revised in October 2022, mandates adherence to these guidelines to prevent infections. Despite these policies, the improper storage of respiratory equipment for Residents 27, 315, and 48 was noted, placing them at risk for infection and respiratory complications.
Neglect Leads to Harm in Resident with Complex Needs
Penalty
Summary
The facility failed to protect a resident, identified as R1, from neglect, resulting in significant harm. R1, who was legally blind and dependent on staff for hygiene, had a colostomy and an indwelling urinary catheter. Despite requiring substantial assistance with activities of daily living, R1 was left outside without staff supervision for extended periods, without a brief or underwear, and with exposed urinary catheter tubing. On one occasion, R1 complained of a burning sensation in her genital area, and upon assessment, maggots were discovered in her genital area and vagina, leading to her being sent to the hospital for evaluation. R1's medical records indicated she had multiple health issues, including neuromuscular dysfunction of the bladder, bilateral leg amputations, and type two diabetes mellitus. Despite these conditions, the facility's care plan lacked specific interventions for R1's refusal to allow care related to changing her clothing or refusal of catheter and perineal care. The facility's documentation also lacked records of R1 refusing catheter and perineal care, and staff were found to have signed off on care that was not provided. Interviews with staff revealed inconsistencies in the provision of care and training. Some staff members reported that R1 rarely refused care, while others stated she often refused to change clothes or allow catheter care. Additionally, some staff had not received recent training on catheter and perineal care. The facility's policy required daily catheter care to promote hygiene and reduce infection risk, but this was not consistently followed, leading to the neglect and subsequent harm experienced by R1.
Removal Plan
- The staff cleaned the resident and the resident room completely.
- The facility in-serviced the nursing staff for notification of resident refusals, changes in resident preferences, refusal of resident cares, refusal of peri-care, residents who go outside without wearing a brief. Staff were inserviced on what to do in the event a resident refused care and to notify the nurse and then reattempt to go and render the care as necessary.
- The facility would provide on-going nursing in-services to staff regarding documenting only the cares that are completed and charting refusals as refusals. The facility will in-service on thorough and complete catheter and peri-care for all nursing staff. Inservice staff on how neglecting this practice is both harmful to the resident psychologically and physically and that it is neglectful treatment. All nursing staff will be inserviced now and any staff who come to work will be inserviced prior to starting their shift.
- The Director of Nursing (DON) provided education to the resident on the importance of always wearing a brief. Educated on necessity of sanitary care of peri area and catheter care given to resident.
- The DON and ADON would complete frequent checks on the resident to ensure care was provided and there was no reoccurrence of the issue.
- The facility conducted an audit of all residents who were potentially affected to ensure appropriate peri-care and catheter care.
- The facility will conduct ongoing audits on appropriate pericare, catheter care and monitoring for correct documentation by nursing staff, and complete nursing in-services recompleted quarterly to ensure correct peri care and catheter care per doctor's orders.
- The facility would monitor to ensure on-going compliance by following up monthly in QAPI, with review of all audits completed and changes made as needed. ED to ensure that ANE is discussed in the next three all staff meetings.
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 838 citations issued within 25 miles in the last 12 months — including the 20 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 Kansas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Providence Place | 1.3 mi | ★★★★★ | 16 | 0 |
| The Healthcare Resort Of Kansas City | 1.4 mi | ★★★★★ | 32 | 0 |
| Willow Point Rehabilitation And Nursing Center | 1.8 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Kansas City | 2.7 mi | ★★★★★ | 20 | 0 |
| Kaw River Care And Rehab | 5.4 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverbend Post Acute 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.