Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rivers Edge Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
Food storage was not kept sanitary in the nutrition refrigerator. Surveyors observed heavy black and gray build-up inside the walk-in refrigerator, missing temperature entries for the refrigerator and no freezer temperature log, sticky residue and ice packs stuck inside the freezer compartment, and unlabeled, undated frozen food items. The DM, LPN, DON, Maintenance Director, and Administrator all stated the refrigerator and freezer compartments were expected to be cleaned and temperatures logged, and that stored food should be labeled and dated.
Failure to develop a care plan for a resident’s tracheostomy care. The resident had a tracheostomy, COPD, chronic respiratory failure with hypoxia, and received oxygen therapy, suctioning, and tracheostomy care. The care plan addressed communication difficulty related to the tracheostomy, but it did not include a tracheostomy or respiratory services focus area. Staff and the DON confirmed there was no tracheostomy-specific care plan, despite an order for tracheostomy care every shift.
Failure to Maintain Sterile Technique During Tracheostomy Care: An LPN failed to maintain a sterile field and proper hand hygiene while performing tracheostomy care for a resident with tracheostomy status, COPD, and chronic respiratory failure. The LPN handled sterile supplies with bare hands, left and returned to the room without hand hygiene, and allowed an untied gown to touch the sterile field while opening trach care supplies. The IP nurse, DON, and Administrator stated tracheostomy care required sterile technique.
A facility failed to store medications according to professional principles, with expired drugs found on a medication cart affecting ten residents. Despite policies and monthly audits by a pharmacy representative, expired medications were not removed, indicating a lapse in protocol adherence. Staff interviews revealed that nurses were responsible for checking expiration dates, but the oversight persisted.
The facility failed to label and date food items in the refrigerator and dry storage, as required by policy. Observations revealed several opened and undated food items, including onions, chicken salad, cheese, lunch meat, and expired tortilla chips. Interviews with the Dietary Manager and staff indicated that it was the responsibility of kitchen staff to label and date food items, but sometimes this was overlooked. The Administrator noted no recent performance improvement plans related to food storage, although the Dietary Manager conducted monthly quality reviews.
The facility failed to maintain an effective infection prevention and control program during wound care for two residents. An LPN did not perform hand hygiene or change non-sterile gloves during dressing changes, contrary to facility policies. The Quality Assurance/Quality Improvement Nurse, DON, and Administrator acknowledged the importance of handwashing and clean gloves to prevent contamination.
A facility failed to document a resident's advance directive, other than their code status, despite the resident being cognitively intact and having a legally appointed guardian. The facility's policy required documentation of advance directives, but this was not done, leading to a deficiency identified by surveyors. Interviews revealed that the process for handling advance directives was manual and not integrated into the electronic admissions process.
Food Storage Not Kept Sanitary
Penalty
Summary
The facility failed to store food in a sanitary manner in the nutrition refrigerator located at the nurse's station. During observation and interview, the kitchen's walk-in refrigerator was found to have a thick black and gray build-up around the ceiling inside the refrigerator radiating out from the dual fans, and the Dietary Manager identified the material as dust and stated the refrigerator should have been cleaned weekly. Facility policy required refrigerated food to be labeled, dated, and monitored, and required food service areas to be kept clean and sanitary. During a later observation of the nutrition refrigerator, the temperature log was missing temperatures for one day and there were no temperature measurements for the freezer compartment. The freezer compartment contained a frozen, sticky, tan residue and ice packs in plastic bags stuck to the surface. Also observed inside were two 48-fluid-ounce tubs of rainbow sherbet, a popsicle box, and a bag of popsicles that were unlabeled and undated. Interviews with the DM, LPN, DON, Maintenance Director, and Administrator confirmed that temperatures were expected to be logged daily, the refrigerator was expected to be cleaned weekly, and food items stored inside should have been labeled and dated or discarded if unlabeled.
Failure to Care Plan Tracheostomy Care
Penalty
Summary
The facility failed to develop a care plan to address the tracheostomy care for Resident #5, who was admitted with diagnoses including cerebral infarction due to thrombosis of an unspecified cerebral artery, COPD, chronic respiratory failure with hypoxia, and tracheostomy status. The admission MDS showed the resident had a BIMS score of 14, indicating intact cognition, and that the resident received respiratory treatments including oxygen therapy, suctioning, and tracheostomy care during the assessment period. The facility’s care plan report included a focus area for communication difficulty related to the resident’s tracheostomy, with interventions for staff communication techniques, but there was no focus area addressing tracheostomy care or respiratory services. The resident’s active orders included an order to cleanse the tracheostomy site and perform tracheostomy care every shift. During interviews, an LPN stated she did not see a care plan specifically addressing the resident’s tracheostomy and said such a plan was essential to keep nursing staff informed on proper tracheostomy care and current interventions. The DON stated the resident did not have a tracheostomy-specific care plan and expected one to be in place, adding that it should have included the tracheostomy size, oxygen flow rates, and specific care required. The Administrator also stated care plans should have been done appropriately for the resident.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to maintain infection control practices during tracheostomy care for one resident. The resident had a history of cerebral infarction due to thrombosis of an unspecified cerebral artery, COPD, chronic respiratory failure with hypoxia, and tracheostomy status. The resident’s admission MDS indicated respiratory treatments including oxygen therapy, suctioning, and tracheostomy care, and the active order required tracheostomy site cleansing and tracheostomy care every shift. During an observation of tracheostomy care, an LPN set up a sterile field and prepared suctioning supplies, then picked up a sterile glove with bare hands and placed it back onto the sterile field before leaving the room without performing hand hygiene. When the LPN returned, she applied sterile gloves, donned a gown, and suctioned the resident’s tracheostomy. After discarding used supplies and removing the gown and gloves, she performed hand hygiene, then donned a new gown that was not tied at the neck and waist, donned gloves, and set up a new sterile field for tracheostomy supplies. As the LPN opened sterile supplies and dropped them onto the sterile field, the loose gown touched the sterile field. The LPN then tied the gown strings and continued opening the sterile supplies without performing hand hygiene. The LPN stated that the sterile field was contaminated when she did not wash her hands, picked up and replaced the sterile glove, and when her untied gown contacted the sterile field. The IP nurse stated tracheostomy care was a sterile procedure and the LPN did not follow sterile technique. The DON and Administrator also stated that tracheostomy care required sterile technique.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to store drugs in accordance with currently accepted professional principles, as observed during an audit of the East Wing Medication cart. Seventeen cards of medications were found to be stored beyond their expiration dates, affecting ten residents. The medications included Compazine, Zofran, Tylenol, and Bisacodyl, with expiration dates ranging from January to October 2024. The facility's policies on medication storage and administration did not specify guidelines regarding expiration dates, contributing to the oversight. Interviews with staff, including an LPN, the Unit Manager, the DON, and the Administrator, revealed that nurses were responsible for checking medication carts for expired medications. The Unit Manager and DON stated that these checks were part of the facility's Quality Assurance Performance Improvement program, with a pharmacy representative visiting monthly to audit medication carts. Despite these procedures, expired medications were found, indicating a lapse in adherence to the expected protocols. The Administrator expressed the expectation that expired medications would be removed and replaced promptly.
Deficiency in Food Labeling and Storage Practices
Penalty
Summary
The facility failed to ensure that food items stored in the refrigerator and dry storage were properly labeled and dated, as observed during a survey. The facility's policy required all incoming foods to have a delivery date and an open date or use-by date, and when stored in a container other than the original, the container should be labeled with the product name and date. However, during an inspection of the walk-in refrigerator, several opened and undated food items were found, including sliced onions, chicken salad, cheese, lunch meat, bologna, cheese spread, jelly, barbecue sauce, picante sauce, and a bag of ready-to-eat salad with brown lettuce. In the dry storage area, expired tortilla chips, opened and undated spaghetti noodles, and Ritz crackers were observed, along with bulk storage bins of flour and breadcrumbs that were not completely covered due to broken lids. Interviews with the Dietary Manager and staff revealed that it was the responsibility of each kitchen staff member to ensure food items were labeled and dated when opened. The Dietary Manager acknowledged that sometimes staff forgot to date opened items, which should be discarded to prevent foodborne illnesses. The Dietary Aide and Cook confirmed that all dietary staff were responsible for labeling and dating incoming food items, and if they found undated food, it was discarded to avoid potential sickness or infection in residents. The Administrator stated that there were no recent performance improvement plans related to food storage, and the Dietary Manager was responsible for ensuring compliance with food labeling and dating. The Administrator also mentioned that the Dietary Manager conducted monthly kitchen quality reviews discussed in Quality Assurance Performance Improvement (QAPI) meetings. Despite being in the kitchen quarterly, the Administrator had not observed outdated, uncovered, or unlabeled food items, emphasizing the importance of labeling and dating food to ensure residents receive quality food.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during wound care for two residents. The Treatment Nurse/LPN1 did not perform hand hygiene after entering the residents' rooms and before initiating wound care. Additionally, the nurse did not change non-sterile gloves or perform hand hygiene after the gloves were potentially contaminated during the dressing change procedure. This was observed during wound care for a resident with a right buttock wound and another resident with sacral pressure injuries. The facility's policies required personnel to wash their hands after each direct or indirect resident contact and to change gloves and wash hands during dressing changes. However, the Treatment Nurse/LPN1 failed to adhere to these policies. The Quality Assurance/Quality Improvement Nurse and the Director of Nursing both acknowledged the importance of handwashing to prevent contamination. The Administrator also stated that handwashing and clean gloves were expected to prevent infection control issues during wound care.
Failure to Document Advance Directive for Resident
Penalty
Summary
The facility failed to uphold a resident's right to formulate an advance directive, as evidenced by the lack of documentation for one resident's advance directive, other than their code status. The resident, who was admitted with diagnoses including bipolar disorder, dysphagia, and chronic obstructive pulmonary disease, was assessed to be cognitively intact. Despite this, there was no evidence in the medical record of the resident's legally appointed guardian's choice for the advance directive, except for a Do Not Resuscitate (DNR) order. The facility's policy required that any advance directive be documented in the resident's medical record, but this was not done for the resident in question. Interviews with facility staff revealed that the process for handling advance directives was not integrated into the electronic admissions process and was instead managed manually by Social Services. The Social Services Director confirmed that the resident's advance directive was initially a DNR upon admission, but the resident later requested a change to Full Code status, which was documented in a note. However, the facility failed to provide documentation that advance directive materials were reviewed with the resident or their representative upon admission or quarterly thereafter, as required by their policy. This lack of documentation and adherence to policy led to the deficiency identified by the State Survey Agency.
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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 Prospect
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Willows At Springhurst | 5.1 mi | ★★★★★ | 4 | 0 |
| Signature Healthcare At Jefferson Manor Rehab & We | 5.2 mi | ★★★★★ | 0 | 0 |
| Signature Healthcare At Jefferson Place Rehab & We | 5.2 mi | ★★★★★ | 0 | 0 |
| The Episcopal Church Home | 5.5 mi | ★★★★★ | 0 | 0 |
| Lyndon Crossing, Llc | 5.9 mi | — | 6 | 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 August 2026) and official state health department websites.