Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Autumn Lake Healthcare At Riverview during CMS and state inspections, most recent first.
A facility failed to provide adequate linen for residents, with surveyors observing beds without sheets, empty linen carts and closets, and staff reporting shortages on multiple units. Residents and GNAs stated that sheets, towels, and other linens were not available in sufficient quantities, and one unit’s linen delivery was documented for fewer beds than were present.
Staff failed to follow EBP requirements during high-contact care for multiple residents. GNAs and other staff were observed providing bed baths and changing soiled linens while wearing gloves only and not gowns, even when EBP signs were posted and active EBP orders were in the chart. One staff member did not know the resident was on EBP, another thought the sign applied to the roommate, and the IP confirmed gowns and gloves were expected for bathing and incontinent care.
Verbal Abuse Toward a Resident: A GNA entered a resident’s room after a complaint about care and confronted the resident about getting the staff member in trouble. The resident reported feeling threatened and intimidated, and a roommate heard the staff member make angry comments in the hallway and then speak similarly to the resident in the room. The facility substantiated the allegation as intimidation and verbal/mental abuse.
A resident’s representative did not receive quarterly statements for the resident’s personal funds. Staff said statements were given to capable residents or mailed only when the representative was the POA, and no statement was provided because the resident lacked cognitive capacity and the representative was not the POA.
A resident’s Quarterly MDS was not completed within the required timeframe. Record review showed the assessment was finished well after the ARD-based deadline, and the MDS Coordinator confirmed it was completed late. The Corporate MDS Coordinator signed the assessment remotely, and another staff member also signed sections of the MDS at different times.
A resident’s Quarterly MDS was completed and then transmitted to CMS after the required deadline. Survey review found the assessment was sent late, and an LPN/MDS Coordinator confirmed the delay during interview.
Inaccurate MDS coding for ostomy status. A resident admitted for rehab after spinal surgery with a PEG tube was incorrectly coded in the admission MDS as having an ostomy in Section H. An LPN/MDS Coordinator stated that a PEG is not an ostomy and confirmed the ostomy entry was an error because the resident did not have an ostomy.
A resident with multiple pressure injuries had ongoing wound care documented, but the care plan did not address the wounds, their locations, associated risks, goals, or individualized interventions. An LPN and the DON both acknowledged that a targeted pressure injury care plan should have been in place, and the LPN confirmed the resident’s care plan lacked this information.
A resident with a BIMS score of 15/15 was not included in the care planning process after being notified of a scheduled care plan meeting and expecting to participate. The EHR showed the resident and family were invited but not present, and staff stated that if a resident did not respond to the invitation, it was assumed the resident was not interested in attending. The Unit Manager was unsure why the resident did not participate, and the DON acknowledged concern with the facility's process.
Late Medication Administration: The facility failed to give scheduled meds within its required time frame. Two residents on Apixaban and another resident on Metoprolol, ASA, and Famotidine reported meds were not given on time, and MAR review showed multiple doses administered more than 1 hour late. The DON confirmed that doses given more than 1 hour after the scheduled time were considered late unless a nursing note explained the delay.
A resident with stroke-related left-sided hemiplegia reported needing help with bathing and said only one shower was received after repeated complaints. Records showed shower opportunities were scheduled, but there was no documentation that any shower was provided during the stay and no shower refusal forms were in the chart. An LPN confirmed the missing refusal documentation, and a GNA stated the resident was showered outside the scheduled day because the resident had not had a shower in a while.
A resident was observed without a call bell within reach during a surveyor round. The resident stated they had not had a call bell since moving into the room, and staff were unable to locate one after checking around and under the bed. The Unit Manager stated that all residents were expected to have a call bell near reach at all times, and the DON was notified.
Failure to Report Significant Weight Loss: A resident had a documented 5.7% weight loss over 1 month, but nursing staff did not notify the RD or provider and instead waited for a reweight due to concern about scale accuracy. The resident’s care plan required reporting significant weight loss, yet the chart contained no RD or physician notes addressing the change, even after the resident was reweighed and the DON acknowledged the weight alert process.
The facility was cited for inconsistent supplemental oxygen management for two residents. One resident was observed on oxygen without an active order in the chart, and an LPN confirmed the lack of an order. Another resident was observed receiving 3 L/min via NC despite an order for 2 L/min continuous oxygen, and there was no oxygen care plan in place; the Unit Manager confirmed the mismatch and absence of care planning.
Failure to ensure annual dental visits for two residents. Two residents stated they had not seen the dentist in a while, and record review showed each had last been seen by a dentist in 2024, indicating the facility did not ensure timely dental services for the residents reviewed.
Inaccurate MOLST Documentation for Resident’s Advance Directives: A resident’s MOLST stated informed consent had been obtained from a legal guardian and other legal authority, but the paper chart and EHR contained no documentation of a current court-appointed guardian or other legal authority. Staff stated the prior guardian had died, no guardianship documents existed, and the resident’s cousin was only next of kin and not legally authorized to act as guardian; the NHA confirmed the MOLST information was inaccurate.
Missing Hospice Documentation in Resident Record: A resident admitted to hospice for metastatic colon cancer had no evidence in the EMR of the most recent hospice care plan, hospice election form, physician certification, or hospice personnel contact information. The hospice nurse stated the weekly hospice IDT care plan was brought to the building and sent to Medical Records because charts were too large, and the NHA and DON confirmed the documents were missing from the chart.
Meals and beverages did not match resident orders or preferences. During dining observations, multiple residents who had coffee listed on their meal tickets did not receive it, and staff reported coffee had not been consistently available on the units because it was not being delivered and the kitchen did not have coffee cups. One resident also received orange juice on the ticket instead of the cranberry juice they routinely drank and preferred, and another resident reported their breakfast tray did not match what they ordered.
Facility staff failed to accurately code multiple MDS assessments for several residents, leading to discrepancies between MDS entries and MARs for pain management, falls, and high-risk drug classes. In several cases, scheduled pain management was coded as provided when MARs did not show daily pain medications, often because an LPN counted low-dose Aspirin ordered for cardiovascular prophylaxis or heart failure as pain medication, contrary to RAI guidance. One resident’s falls were underreported on the MDS despite two documented falls, and daily use of a topical analgesic and an antiplatelet (Aspirin) was not correctly captured. Other residents had MDS entries indicating use of hypnotic or antianxiety medications when MARs showed none, while actual antidepressant and hypoglycemic medications administered daily were omitted from Section N0415. These errors were confirmed by the involved LPNs during surveyor interviews.
A resident with multiple fractures and chronic pain was receiving an opioid-based pain regimen, including PRN hydromorphone. The resident was later found unresponsive and "out of it" by an LPN, who located an order for Narcan and administered it, with the resident responding to the medication. A physician note documented an opioid overdose treated with Narcan. Review of the medical record showed no documentation that the resident’s representative was notified of this significant change in condition and emergency intervention, and staff interviews confirmed that notification likely did not occur, despite the DON’s expectation that the responsible party should have been informed.
Staff failed to follow updated wound care orders and to document an opioid overdose event and Narcan use for two residents. One resident with venous and arterial lower extremity wounds did not receive the prescribed change from oil emulsion to daily skin prep on one foot wound, and did not receive ordered skin prep on a new plantar wound for several days after the wound physician revised the treatment plan. Another resident with multiple fractures and chronic pain, receiving multiple opioid and adjunct analgesics, reportedly experienced an opioid overdose; an LPN found the resident unresponsive, located an existing Narcan order, administered Narcan, and observed the resident return to baseline, but did not complete or document a change-in-condition assessment, vital signs, or the Narcan administration in the medical record.
Surveyors substantiated a deficiency when disinfectant wipes, labeled for storage in areas inaccessible to children and not for personal cleansing, were observed sitting openly on a wire shelf in the dining room of a locked dementia unit while cognitively impaired residents waited for breakfast. A GNA and an LPN present on the unit stated that staff used the wipes to clean tables and that residents were never left alone in the dining room and had not been seen using the wipes. The ICP reported being unaware that the wipes’ placement in the dining room was a concern, and the NHA and DON stated they had not previously been informed about the issue, though the DON acknowledged understanding the concern.
A resident’s medical record showed multiple instances where Hydromorphone, a controlled narcotic, was documented as signed out and given on the Controlled Drug Administration Record but was not documented on the MAR on the same dates and times. An LPN reported signing only the narcotic sheet and not the MAR, while the DON acknowledged awareness that nurses were signing the narcotic sheet without completing the MAR, and a unit manager stated they were unaware this was occurring and that both records should be completed. The NHA and DON agreed with the surveyor’s findings after the issue was identified.
Surveyors found that the facility did not promptly report suspected abuse allegations and an injury of unknown origin involving three residents. In one case, a staff member delayed reporting overheard verbal abuse, while in another, staff failed to report a resident's sexual abuse allegation. Additionally, a resident's unexplained tibial fracture was not investigated or reported to the State Agency as required.
Surveyors found that staff failed to refrigerate fruit cups, resulting in applesauce and apricot slices being stored above safe temperatures during meal service, and also observed a staff member in the kitchen without a required hairnet. These deficiencies were identified through direct observation and staff interviews.
Insufficient Linen Supply on Resident Units
Penalty
Summary
The facility failed to provide adequate linen for residents, with survey observations and interviews showing that multiple units did not have enough bed sheets, towels, or other linens available. Resident #253 reported that staff did not have enough linen and that there were not enough bed sheets, stating that residents were put in wheelchairs in the morning because clean beds could not be made. Resident #128 reported that there were no sheets for the bed and that the facility had a linen shortage; the surveyor observed that resident’s bed without sheets. The surveyor also observed another resident’s bed without sheets while the resident was sitting in a wheelchair. Staff interviews confirmed the shortage on the units. A GNA reported calling laundry for bed sheets and stated that linen carts were delivered late in the morning and were not sufficient, affecting workflow. On another unit, a GNA reported there were not enough linens for residents, and the surveyor observed the linen closet and hallway linen cart with no towels or bed sheets. Another staff member stated that GNAs were hiding linens and was unsure why. The Environmental Services Director reported expected linen quantities per resident, and review of the facility’s linen par level document showed that one unit had 31 beds but sheets sent for the 7 a.m. to 3 p.m. shift were only for 30 beds. The administrator stated the document was a delivery schedule and acknowledged the linen shortage was an ongoing problem.
Failure to Use Required PPE During Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain infection prevention and control related to Enhanced Barrier Precautions (EBP) during high-contact care for four residents. On 06/08/2026, a GNA was observed giving a bed bath to Resident #12 while wearing gloves only, despite EBP signage on the door and bedside indicating that both a gown and gloves were required; the GNA stated she did not know what precautions the resident was on and was unsure whether PPE was required for bathing and direct care. RN #26 and LPN #27 confirmed the GNA was not using the required PPE, and the resident’s record showed an active physician order for EBP. A similar observation was made for Resident #24, when a GNA provided a bed bath wearing gloves only and without a gown; the GNA stated she was supposed to wear a gown and acknowledged appropriate PPE should have been used, and the resident’s record also showed an active EBP order. The deficiency also involved Resident #223 and Resident #147. Staff #21 was observed changing soiled linens on Resident #223’s bed without wearing the indicated PPE and stated she believed the EBP sign was for the roommate and had not seen the sign above the resident’s bed; the resident’s record showed an active EBP order, but the facility’s list of residents on EBP did not include this resident. The infection prevention nurse stated Resident #223 should have been on the EBP list and that staff were expected to wear gowns and gloves while changing soiled linens. For Resident #147, a GNA was observed providing a bed bath while wearing gloves but not a gown, despite an EBP sign on the door and a PPE bag with gloves and gowns hanging there; the resident’s EMR showed an EBP order for a history of ESBL infection.
Verbal Abuse Toward a Resident
Penalty
Summary
The facility failed to ensure that a resident remained free from verbal abuse when Staff #35, a GNA, entered the resident’s room and confronted the resident about a complaint regarding care. According to the resident, the staff member stood over the bed with hands on hips and stated, “You tried to get me in trouble with [NAME],” which the resident described as threatening and intimidating. The resident reported feeling as though the staff member was going to hit them. The facility investigation found that the resident consistently reported that Staff #35 entered the room the evening after the complaint and yelled at them about getting in trouble. The roommate reported hearing staff in the hallway say words to the effect of, “they are trying to get me in trouble and they are not even assigned to me,” and then heard a similar conversation occur in the room. The investigation substantiated the allegation based on the resident’s statements, corroborating witness information, and confirmation that Staff #35 entered the room and spoke with the resident. The Administrator and DON later confirmed that the facility determined the interaction constituted intimidation and verbal/mental abuse.
Failure to Provide Quarterly Personal Funds Statements
Penalty
Summary
The facility failed to provide quarterly statements for Resident #7’s personal funds to the resident’s representative. During an interview, the representative stated that quarterly statements had not been received from the facility. Record review showed Resident #7 had the representative listed as the responsible party, and the resident’s BIMS score was documented as 99, indicating the resident was unable to complete the mental status interview. During interviews with the Business Office Manager and the Nursing Home Administrator, staff stated that quarterly statements were handed to residents who were capable and mailed to representatives only if the representative was the POA. Staff stated that Resident #7’s representative did not receive a statement because the representative was not the POA, and that no statement was given to Resident #7 because the resident did not have cognitive capacity. The Administrator stated this had been the facility’s practice for years.
Late Quarterly MDS Completion
Penalty
Summary
The facility failed to complete a Quarterly MDS assessment within 14 days after the assessment reference date for Resident #185. Record review showed the resident’s quarterly MDS had an ARD of 2/4/26, making the required completion date 2/18/26, but the MDS was documented as completed on 3/25/26, 35 days after the required completion date. The record also showed RN #35, the Corporate MDS Coordinator, signed the MDS as complete on 5/14/26, while in section Z0400 RN #35 signed as the person completing the assessment or entry on 6/8/26 and dietician #36 signed one section on 6/4/26. During interview, LPN #14, the MDS Coordinator, confirmed that the February 2026 Quarterly MDS for Resident #185 was completed late and stated that RN #35 was the Corporate MDS Coordinator and worked remotely.
Late Transmission of Quarterly MDS Assessment
Penalty
Summary
The facility failed to transmit an MDS assessment to the State within the required timeframe for one resident reviewed. Resident #185’s Quarterly MDS had an ARD of 4/30/25 and was completed on 5/14/26, with a required transmission deadline to CMS of 5/28/26. Survey review of the clinical record on 6/10/26 found that the MDS was transmitted on 6/8/26, which was 11 days after the mandated transmission due date. During an interview on 6/11/26 at 9:32 AM, the LPN/MDS Coordinator confirmed that the resident’s April 2026 quarterly MDS was transmitted late.
Inaccurate MDS Coding for Ostomy Status
Penalty
Summary
The facility failed to accurately document a resident’s health status in the admission MDS. Resident #50 was admitted for rehabilitation after spinal surgery and had a PEG tube in place. In the admission MDS dated 6/1/26, the resident was incorrectly coded in Section H Bowel and Bladder as having an ostomy at H0100C. During interview, the MDS Coordinator stated that gastrostomy tubes are not considered an ostomy and should be coded in Section K, and later confirmed that the resident’s PEG was coded in Section K at K0520B and that coding the resident as having an ostomy was an error because the resident did not have an ostomy.
Failure to Care Plan Pressure Injuries
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for Resident #75’s identified pressure injuries. Medical record review showed the resident had multiple pressure injuries and ongoing wound care interventions documented in wound assessments and treatment records, but the care plan did not include the pressure injuries, their locations, associated risks, goals, or individualized interventions. During surveyor interviews, the Unit Manager stated that care plans were initiated on admission and that she was responsible for updating them, and she acknowledged that a resident with pressure injuries should have a targeted pressure injury care plan. After reviewing Resident #75’s care plan, she confirmed that no care plan specifically addressed the pressure injuries and stated that one should have been developed, including the specific wounds and corresponding interventions. The DON also stated that Unit Managers were responsible for updating care plans and acknowledged that a resident with pressure injuries should have a corresponding care plan.
Failure to Include Resident in Care Plan Meeting
Penalty
Summary
The facility failed to ensure participation of a resident in the care planning process. Resident #12 stated that he/she received notice of a care plan meeting scheduled for April 2026 and expected to participate, but the meeting did not occur and the resident was not told why it was not held. The resident's MDS assessment showed a BIMS score of 15 out of 15, indicating the resident was cognitively intact. Review of the EHR showed a care plan entry dated 04/15/2026 stating that Resident #12 and family were invited but not in attendance, that the resident preferred to remain in bed, was social one-on-one, and that all care plans and MOLST were reviewed with no changes at that time. The Social Worker Assistant stated care plan meetings were quarterly and residents were notified by invitation, but if a resident did not respond, it was assumed the resident was not interested in attending. The Unit Manager stated the resident's name did not indicate a response to the invitation and was unsure why the resident did not participate in the April 2026 care plan review. The DON was informed of the concern and acknowledged the facility's process as a concern.
Late Medication Administration
Penalty
Summary
The facility failed to ensure medications were administered within its established medication administration time frames. During interviews, Resident #18 and Resident #231 each stated that they did not receive their medications on time. Record review showed that both residents had active orders for Apixaban 5 mg by mouth every 12 hours, and multiple doses were administered later than the scheduled 8:00 AM or 8:00 PM times. For Resident #18, late administrations were documented on 6/2, 6/3, 6/4, 6/5, and 6/9/2026. For Resident #231, late administrations were documented on 6/1, 6/2, 6/3, 6/5, and 6/9/2026. Resident #252 also reported that medications were not given on time. Review of the MAR showed that Metoprolol Tartrate 25 mg ordered for 8:00 AM was given at 11:22 AM, and Aspirin 81 mg chewable and Famotidine 40 mg ordered for 9:00 AM were also given at 11:22 AM. The facility’s medication administration policy stated that scheduled medications were to be administered within 60 minutes before or after the scheduled time unless otherwise ordered by a physician. The DON confirmed that medications given more than one hour after the scheduled time were considered late unless there was a nursing note explaining the delay.
Failure to Provide Scheduled Shower Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living for one resident who was unable to shower independently. Resident #253 was admitted with diagnoses including stroke with left-sided hemiplegia and reported needing help with bathing and washing hair. The resident stated that only one shower had been received since admission and that the shower was obtained only after the resident complained. The resident also stated that no shower was refused and that assistance was needed because of the stroke-related limitations. Record review showed the resident was scheduled for showers on Wednesdays and Saturdays, and unit assignment sheets reflected shower opportunities on 5/30/26, 6/3/26, and 6/6/26. However, there was no documentation that the resident received a shower during the eleven-day stay, and there were no shower refusal forms in the medical record. An LPN confirmed the absence of refusal documentation, and a GNA stated the resident was showered on 6/4/26 outside the scheduled day because the resident had not had a shower in a while. The resident’s admission MDS also indicated that choosing between a tub bath, shower, bed bath, or sponge bath was very important to the resident.
Call Bell Not Within Reach
Penalty
Summary
The facility failed to ensure that Resident #8 had a call bell within reach. During a unit round, the surveyor observed the resident without a call bell near reach. When interviewed, the resident stated that since moving into the room, they had not had a call bell. The surveyor searched around the bed and could not locate one. Staff also checked under the bed and were unable to retrieve a call bell. The Unit Manager stated that the facility expected all residents to have a call bell near reach at all times, and the DON was notified of the concern.
Failure to Report Significant Weight Loss
Penalty
Summary
The facility failed to implement the resident’s care plan intervention to report significant weight loss to the physician and Registered Dietitian. Resident #2 had a documented decline of 9.2 lbs, or 5.7%, from 162.2 lbs on 5/6/2026 to 153.0 lbs on 6/1/2026, with the weight documented by Staff #7. A review of the progress notes showed no Dietician or Provider notes addressing the weight change, and the last Dietician note, dated 5/27/2026, had addressed a progressive weight gain and directed monitoring for weight changes, labs, and meal intake percentages. During interview, Staff #7 stated the Dietician is notified when there is a significant weight change, but in this case the staff were waiting for a reweight because of possible inaccurate scales and had not notified the Dietician. Staff #7 also stated the resident had not yet been reweighed. The care plan for Resident #2 included an intervention to monitor, record, and report to the medical doctor for signs and symptoms of malnutrition, including significant weight loss of 3 lbs in 1 week, more than 5% in 1 month, or more than 7.5% in 3 months. The DON stated the weight would be reweighed when a significant change was recognized and confirmed the EHR would alert caregivers, but the chart still showed no Dietician or physician notes addressing the resident’s weight, including after the resident was reweighed at 153.6 lbs on 6/9/2026.
Inconsistent Supplemental Oxygen Orders and Care Planning
Penalty
Summary
The facility failed to be consistent with professional standards regarding supplemental oxygen for two residents. Resident #147 was observed using supplemental oxygen at 3 L via nasal cannula on two separate occasions, but a review of the electronic medical record showed no active order for supplemental oxygen. During interview, an LPN confirmed that the resident was using oxygen and that no active order was present in the chart for that intervention. Resident #15 was observed receiving 3 liters per minute of oxygen via nasal cannula, while the resident's order was for 2 liters per minute continuously. A review of the care plan showed no care plans regarding oxygen use. During interview, the Unit Manager confirmed that residents with oxygen orders should have oxygen use care planned and acknowledged that the resident had been observed on 3 liters per minute rather than the ordered 2 liters per minute.
Failure to Ensure Annual Dental Visits
Penalty
Summary
The facility failed to ensure that residents received annual dental visits for two residents reviewed for dental services. Resident #13 stated on interview that he/she had not seen the dentist in a while, and record review showed the resident was last seen by a dentist on 2/27/2024. Resident #85 also stated on interview that he/she had not seen the dentist in a while, and record review showed the resident was last seen by a dentist on 4/2/2024. The concerns were later addressed with the Director of Nursing.
Inaccurate MOLST Documentation for Resident’s Advance Directives
Penalty
Summary
The facility failed to ensure the accuracy and completeness of the clinical record for one resident reviewed for advance directives. Review of the paper medical record showed a MOLST form stating that informed consent had been obtained from the resident’s guardian of person under court authority and other legal authority in accordance with the Health Care Decisions Act, but the paper record and EHR did not contain documentation of a current court-appointed guardian or other legal authority for the resident. Further review of the EHR showed a nurse practitioner progress note documenting communication with the resident’s surrogate, identified as the resident’s cousin. During interview, staff stated the resident’s previous legal guardian had died before hospice admission, that the guardian’s son later became involved in care, and that no legal guardianship documents existed. Staff also stated the cousin was next of kin and did not have legal authority to act as guardian. The NHA confirmed the legal guardian was deceased and acknowledged that the MOLST documentation identifying a legal guardian and legal authority was inaccurate.
Missing Hospice Documentation in Resident Record
Penalty
Summary
The facility's designated hospice interdisciplinary team member failed to ensure that hospice documentation was available in the resident's record and communicated with facility staff for Resident #147, who was admitted to hospice services on 5/12/26 for metastatic colon cancer. Review of the electronic medical record on 6/10/26 at 10:04 AM showed no evidence of the resident's most recent hospice care plan, the hospice election form, the physician certification, or the names and contact information for hospice personnel involved in the resident's care. During interview, the hospice nurse stated that weekly hospice IDT meetings generate the care plan and that the printout is brought to the building and taken to Medical Records because the charts had become too large, adding that she would bring the resident's care plan the next day. The NHA and DON later confirmed that these documents were missing from the resident's chart.
Meals and Beverages Did Not Match Resident Orders
Penalty
Summary
The facility failed to serve residents meals that matched their meal tickets, including beverages ordered or preferred by the residents. During breakfast dining observations, coffee was listed on meal tickets for multiple residents, but coffee was not served with their trays. Residents stated they had not received coffee with breakfast, and observation confirmed the beverage was absent from the trays. A GNA stated dietary staff had said coffee was unavailable because the kitchen did not have coffee cups, and also reported that residents had not received coffee for the past two days despite routinely requesting it. One resident’s breakfast tray contained cranberry juice even though the meal ticket listed orange juice. The resident stated a preference for cranberry juice and said they did not like orange juice, and the GNA confirmed the resident routinely drank cranberry juice and that family members had previously requested it. Another resident reported that meals served did not match what was ordered and stated they were not served coffee even though they had requested it. The DON was informed that coffee had not been consistently available on the units and that some menu tickets did not include sections for residents to request certain items such as hot tea.
Inaccurate MDS Coding for Pain Management, Falls, and High-Risk Drug Classes
Penalty
Summary
Facility staff failed to ensure that Minimum Data Set (MDS) assessments were accurately coded for multiple residents, based on medical record review and staff interviews. For one resident with cerebrovascular disease, an MDS with an Assessment Reference Date (ARD) of 3/2/26 coded Section J0100A (scheduled pain management) as "yes," but the March Medication Administration Record (MAR) did not show daily pain medication administration. An LPN stated she coded it that way because the resident received Aspirin 81 mg daily, although the physician’s order showed the Aspirin was prescribed as prophylaxis for cardiovascular events, and the RAI Manual specifies that medications not primarily intended for pain relief should not be coded as pain management. Another resident with cerebral infarction, congestive heart failure, and vascular dementia had two documented falls in progress notes between the prior assessment and the ARD of 2/4/26, but Section J1900 (number of falls since admission or prior assessment) captured only one fall. The same MDS coded Section J0100A (scheduled pain management) as "no" despite the February MAR documenting daily use of Diclofenac topical gel for pain. The MAR also showed daily Aspirin 81 mg for coronary artery disease, but Section N0415 (high-risk drug classes) did not capture the use of an antiplatelet medication. The responsible LPN confirmed missing the second fall and the Aspirin coding error. Additional residents had similar discrepancies: one resident’s MDS repeatedly coded use of hypnotic medications in Section N0415 when MARs showed no hypnotics administered, and failed to capture an antidepressant (Sertraline) that was given; the LPN reported coding Clonazepam as a hypnotic based on dual use, though reference guidelines did not classify it as such. Further inaccuracies were identified for other residents in pain management and high-risk drug class coding. One resident’s MDS with an ARD of 1/8/26 coded receipt of PRN pain medication in Section J0100A, but the January MAR showed no PRN pain medications given; a later MDS for the same resident coded use of an antianxiety medication in Section N0415, while the April MAR showed no such medication administered. Another resident with traumatic subarachnoid hemorrhage, type 2 diabetes with neuropathy, atrial fibrillation, and atherosclerotic heart disease had an MDS with an ARD of 2/3/26 that coded scheduled pain medication as "yes" and PRN pain medication as "no," although the MAR showed intermittent PRN Tylenol for pain and no daily pain medication, and also documented daily Aspirin 81 mg for heart failure and daily Rybelus for diabetes; the MDS failed to capture PRN pain use, incorrectly coded daily pain medication, and did not code hypoglycemic medication in Section N0415. Another resident with a history of stroke and right-sided hemiplegia/hemiparesis had two MDS assessments in February coded as receiving scheduled pain medication, but the February MAR did not show daily pain medication; the LPN reported coding based on daily prophylactic Aspirin 81 mg, which was not ordered for pain.
Failure to Notify Responsible Party After Narcan Administration for Suspected Opioid Overdose
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s responsible party when there was a significant change in the resident’s medical status requiring emergency medication. A complaint alleged that there was no communication with the responsible party when Narcan (naloxone) was administered to a resident for an alleged opioid overdose. Medical record review showed the resident was admitted in March 2026 with multiple fractures, including a nondisplaced zone 1 sacral fracture, a nondisplaced fracture of the posterior column of the right acetabulum, a fracture of the right pubis, and other chronic pain. The resident’s pain regimen included multiple opioids and other pain medications, including Hydromorphone 6 mg every 4 hours PRN, Hydromorphone 4 mg every 4 hours PRN, Tylenol, Lidocaine cream, Methocarbamol, Celebrex, and Gabapentin. A physician’s note dated 4/8/26 documented that the resident reportedly had an opioid overdose earlier that morning and responded well to Narcan administration by nursing, with the note listing chronic pain and opioid overdose status post Narcan. Further review of the resident’s medical record did not show any documentation that the resident’s representative was notified of this overdose event and Narcan administration. During interviews, an agency LPN stated that the resident was “out of it and not responding” during rounds, prompting the LPN to check for and then administer Narcan, after which the resident responded. Another LPN reported that Narcan was given because the resident appeared to be having an overdose and that the physician saw the resident afterward, but stated, “I don’t think anyone was notified, but should have been.” The DON also stated that she would have expected the responsible party to be notified. These findings confirmed that the facility failed to notify the resident’s responsible party of a significant change in condition and emergency treatment.
Failure to Follow Wound Care Orders and Document Narcan Administration
Penalty
Summary
Facility staff failed to provide treatment and care in accordance with professional standards and physician orders for two residents. For one resident admitted after hospitalization with acute systolic heart failure and peripheral edema, a wound physician initially ordered daily oil emulsion dressings for venous wounds on the right shin, left medial foot, and left second toe. At a follow-up assessment, the wound physician changed the treatment for the left medial foot from oil emulsion to daily skin prep and ordered daily skin prep for a newly identified arterial wound on the left plantar foot. Review of the March 2026 medication and treatment administration records showed staff did not discontinue the oil emulsion or initiate the ordered skin prep to the left medial foot, and did not administer skin prep to the left plantar foot wound from the date of the new orders until the resident was sent to the hospital. The DON confirmed that treatments were not administered per the updated wound care orders during this period. For another resident admitted with multiple pelvic and sacral fractures and chronic pain, the record showed extensive opioid and adjunct pain medication orders, and a physician note documented that the resident reportedly experienced an opioid overdose and responded well to Narcan administration by nursing. However, the medical record contained no nursing assessment of the resident at the time of the event, no documentation of the resident’s condition or vital signs, and no record of Narcan administration or the resident’s response afterward. An agency LPN reported finding the resident unresponsive or "out of it" during rounds, knowing the resident was on significant pain medications, and, after checking for an existing order, administering Narcan, after which the resident returned to baseline. The LPN acknowledged not completing or documenting a change-in-condition assessment, and both the DON and unit manager stated they would have expected an assessment and vital signs to be documented in this situation.
Disinfectant Wipes Left Accessible in Dementia Unit Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to keep the environment free from accident hazards on one locked dementia unit. During a complaint survey regarding unsecured cleaning supplies and the potential for residents to use cleaning wipes for personal use, a surveyor observed disinfectant wipes stored openly on a wire shelf in the dining room of the Seagull Unit, a locked dementia unit. The product labeling on the container directed that it be stored in areas inaccessible to children and specifically stated it was not to be used as a diaper wipe or for personal cleansing and that it was not a baby wipe. At the time of the observation, residents with cognitive impairment were present in the dining room awaiting breakfast. A GNA was in the dining room with the residents during the observation, and the unit manager, an LPN, accompanied the surveyor. The surveyor expressed concern about the wipes being accessible in a public area where cognitively impaired residents were present. The LPN reported she had never seen residents use or attempt to use the wipes and stated staff used them to wipe down tables before and after meals. The GNA stated she was always present when residents were in the dining room, that residents were never left alone there, and that she had never seen a resident use a wipe. The Infection Control Nurse stated she was not aware the disinfectant wipes in the dining room were a concern because no residents had gone near them and confirmed they were intended for staff use to clean tables. The NHA and DON reported they had not been made aware of the concern with the wipes, though the DON stated she understood the concern.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate medical records in accordance with accepted professional standards for one resident. Review of the resident’s April 2026 Medication Administration Record (MAR) and the Controlled Drug Administration Record showed multiple discrepancies for Hydromorphone, a narcotic medication. On several specific dates in April, the Controlled Drug Administration Record documented that Hydromorphone doses were signed out and given by licensed nursing staff at various times, but the corresponding MAR entries for those same dates and times were left blank, indicating no documentation of administration on the MAR. During interviews, an LPN stated that they sign out the medication on the narcotic sheet but do not document it on the MAR. The DON acknowledged awareness that nurses were signing off on the narcotic sheet but not on the MAR, and a unit manager reported not being aware that nurses were failing to sign the MAR when also signing the narcotic sheet, stating that documentation should occur on both records. The NHA and DON later stated they were not aware of the concern until it was identified by the surveyor and agreed with the findings. These observations and interviews demonstrate that the facility did not ensure that all medication administrations were consistently and accurately documented on the MAR for this resident.
Failure to Timely Report Abuse Allegations and Injuries of Unknown Origin
Penalty
Summary
The facility failed to timely report suspected abuse, neglect, or theft, as well as the results of related investigations, to the proper authorities for multiple residents. In one case, a staff member overheard a resident accuse another staff member of causing pain and using inappropriate language, but the report was not made until the following day. The investigation could not confirm or refute the allegation, and there was evidence suggesting possible retaliation between staff members. In another instance, two staff members overheard a resident screaming and making allegations of sexual abuse, but did not report the incident to administration as required. The allegations were later unsubstantiated, but the failure to report was confirmed through staff interviews. Additionally, the facility did not report an injury of unknown origin for a resident who sustained a left tibial fracture. The resident complained of leg pain, and imaging confirmed the fracture, but there was no documentation explaining how the injury occurred or if it was observed. The facility did not conduct or document an investigation into the cause of the injury, nor did it report the incident to the State Agency within the required timeframe. These failures were identified during a review of medical records and staff interviews, and were found to be evident for three residents reviewed for abuse allegations during the survey.
Improper Food Storage and Lack of Hair Restraints in Food Service Areas
Penalty
Summary
Surveyors observed that the facility failed to store and refrigerate food items at safe temperatures and did not ensure staff wore appropriate hair restraints in food preparation areas. During a lunch meal service, a bin of apricot and applesauce cups was found unrefrigerated and warm to the touch in the galley serving area, with measured temperatures of 70.2°F for applesauce and 50°F for apricot slices, both above the required maximum of 41°F for cold foods. The fruit cups had been prepared earlier that morning and left unrefrigerated until discovered by the surveyor, while 40 residents waited to be served in the dining room. Additionally, during an initial kitchen tour, a staff member was observed leaving the food preparation area without wearing a required hairnet, despite clear signage mandating hair restraints. These deficiencies were confirmed through direct observation and staff interviews, with the lack of proper food storage and failure to follow hair restraint protocols discussed with facility leadership. The report does not mention any specific medical history or conditions of the residents involved, but it does note that the deficiencies were evident during both the initial kitchen tour and meal service observations.
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What surveyors actually found near you
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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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Essex
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oakwood Snf Llc | 1.8 mi | ★★★★★ | 47 | 0 |
| Rossville Rehabilitation And Healthcare Center | 2.3 mi | ★★★★★ | 33 | 1 |
| Franklin Woods Center | 2.9 mi | ★★★★★ | 0 | 0 |
| Complete Care At Heritage Llc | 3.6 mi | ★★★★★ | 7 | 0 |
| Autumn Lake Healthcare Post-acute Care Center | 4.3 mi | ★★★★★ | 27 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.