Average — CMS composite of the measures below.
The next survey window likely opens around March 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 Belle Fountain Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A resident with stroke-related hemiplegia and muscle weakness fell from bed during incontinence care when only one CNA was present, despite two staff being required. The CNA said the resident was rolled away from the staff member and fell out of bed, and later acknowledged not knowing the correct rolling technique. The resident reported pain afterward, and hospital imaging confirmed a dislocated L shoulder.
Food service equipment and related areas were found dirty or in poor repair, including residue on cooler shelving, brown buildup on a stand mixer, and red residue inside a juice gun nozzle. The dish machine wash gauge was unreliable, plumbing observations showed improper or hidden drain line connections without a visible air gap, and a two-door cooler had peeling paint exposing metal. A container of thickening agent was also observed in a medication refrigerator despite a posted sign stating no food is to be kept there.
Incomplete Legionella Water Management Program: The facility failed to maintain an active plan to reduce the risk of Legionella and other OPPP. Surveyors observed inoperable water fountains, a therapy tub with unclear use, and converted shower rooms where the faucet and shower head were left on. Staff stated the fountains had been off since COVID, free chlorine was not tested in the domestic water supply, aerators were changed on a need-be basis, and some infrequently used areas were not flushed on a regular cycle. Record review showed the Water Management Program plan did not identify areas where Legionella could grow and spread or describe control measures.
Incomplete Advance Directive Documentation: Multiple residents had Full Code status documented without complete written evidence supporting informed decisions about CPR and other advance directive choices such as peg tube, IV hydration, and diagnostic testing. Several residents had moderate cognitive impairment, and the chart often contained only a social work note stating advance directives were reviewed and full code status was placed per wishes, while other records lacked documentation that the resident or legal guardian was educated, agreed, or signed consent for the code status.
A resident was observed lying in bed with a brief and lower body exposed in full view of hallway traffic, with no covering and no privacy curtain pulled. The resident had multiple diagnoses including morbid obesity, schizophrenia, developmental disorder, and developmental delay, and was dependent on staff for several ADLs. The UM acknowledged the exposure, said the resident had been educated to cover lower extremities, and had no response when asked how the resident’s understanding was ensured despite cognitive impairment.
Inadequate Age-Appropriate Activities: A cognitively intact resident reported boredom and lack of interest in facility life because activities were not meaningful or age appropriate, describing current crafts as childish and noting the absence of live entertainment and outings. Staff were observed offering an unlisted sand art activity and a movie selected by the AD, while the AD stated activities were chosen from a website for lower functioning residents and no alternative was offered for higher functioning residents. The resident's care plan called for activities compatible with the resident's capabilities, interests, needs, and age.
Failure to Monitor Antibiotic Use and Document Stop Dates: A resident with dementia, AKI, COPD, and a history of UTI received multiple antibiotic orders and changes, including prophylactic antibiotics with no stop date, while nursing and physician notes did not document UTI monitoring or antibiotic review. The resident denied urinary symptoms, had diarrhea during treatment, and no UA or urine culture was ordered after admission despite the facility’s antibiotic stewardship policy calling for diagnostic testing and antibiotic orders with an indication and stop date.
The facility failed to maintain an adequate emergency food supply, as observed during a survey. The Dietary Manager noted missing items such as chicken noodle soup, cheese sauce, and green beans from the designated emergency food area. The facility's policy requires maintaining sufficient food and supplies for emergencies, which was not adhered to.
The facility's kitchen had several food safety and sanitation deficiencies, including improper cleaning and drying of pans, failure to date-label food items, and storing milk cartons directly on the floor. Additionally, the air gap basin used for cleaning produce was inadequately cleaned, increasing the risk of foodborne illness.
A resident with hearing loss was not provided with a care plan to address their communication needs, despite being observed using writing materials to communicate. The Unit Manager was unaware of the need for communication aids, and the resident's medical record lacked interventions. The DON confirmed a care plan was created but resolved without reason, leaving staff without guidance. The MDS Nurse admitted to resolving the care plan without completion, impacting the resident's communication.
A resident with moderately impaired cognition and requiring assistance with ADLs was observed with unkempt personal hygiene, expressing a desire for grooming care that was not provided on scheduled shower days. The care plan indicated the need for assistance, which was confirmed by the Unit Manager and DON.
A resident with a Foley catheter was found with the catheter bag resting on the floor, contrary to the facility's care plan and policy. The resident, who required assistance with daily activities and had a neuromuscular dysfunction of the bladder, was observed in bed with the catheter bag improperly positioned. Staff interviews confirmed that a barrier should have been used to prevent the bag from touching the floor, highlighting a deficiency in catheter management.
The facility did not have a Registered Nurse (RN) on duty for eight consecutive hours a day, seven days a week, potentially affecting all residents. The Master Schedule for Nurses showed no 8-hour RN coverage on specific days, confirmed by the Director of Nursing (DON), who acknowledged staffing issues. The facility's staffing policy did not address the required RN coverage.
A resident was prescribed Seroquel without a specific diagnosis or valid informed consent. Despite declining psychiatric treatment, the resident was given the medication, and consent was improperly obtained from a family member who was not the DPOA. The facility's policy for psychotropic medication use was not followed.
The facility failed to develop or implement care plans for two residents receiving warfarin, despite physician orders to monitor anticoagulation therapy. Both residents lacked documented care plans for monitoring side effects or bleeding risks. The DON acknowledged the absence of care plans and the lack of a specific policy for anticoagulant use.
A facility failed to maintain accurate medical records for a resident on warfarin, resulting in incomplete documentation of INR results in the EHR. Despite physician orders to review the Warfarin Flowsheet nightly, only one entry was documented, and additional INR results were not included in the EHR. The DON acknowledged the oversight, and the physician confirmed that INR tests were conducted but not properly documented.
The facility failed to prevent expired food from being stored with active stock, risking foodborne illness for residents. Moldy hamburger and hot dog buns, along with undated or expired refrigerated items, were found during a kitchen inspection. Staff confirmed a resident was served moldy bread, violating the facility's food storage policy.
The facility failed to promptly respond to call lights for four residents, resulting in unmet healthcare needs. One resident waited over 15 minutes for bathroom assistance, another was left in a wheelchair for hours, and a third needed a bedpan urgently. A fourth resident reported waiting over two hours for assistance, leading to severe discomfort. The facility's policy required prompt response to call lights, but staff were busy, and a nurse turned off call lights before meeting residents' needs.
A resident with dementia and a history of falls was transferred to a hospital without proper documentation or communication of their medical needs. The facility's policy required a transfer form with specific information, which was not completed, leading to a deficiency.
The facility failed to conduct timely fall risk assessments for three residents, leading to falls without injury. Despite having policies requiring assessments within 24 hours of admission, these were not completed for residents with cognitive impairments and histories of falls. The DON confirmed the oversight, highlighting a deficiency in adhering to the facility's Fall Risk/Injury Prevention policy.
A resident with multiple diagnoses was repeatedly prescribed Ativan 0.5 mg every 12 hours PRN without proper documentation, behavioral monitoring, or physician evaluation. The resident reported difficulty receiving the medication and concerns about withdrawal symptoms. The facility failed to follow its policy on psychotropic medication use, including gradual dose reductions and non-pharmacological approaches.
Unsafe Repositioning During Incontinence Care Led to Resident Fall
Penalty
Summary
The facility failed to ensure staff used safe repositioning techniques during incontinence care for a resident with hemiplegia and hemiparesis following a cerebral infarction, transient cerebral ischemic attack, dysphagia, chronic kidney disease, respiratory failure, and muscle weakness. The resident was cognitively intact per the MDS. During bed care, the resident reported that only one staff member was present even though two staff were required, and that while the pad underneath them was being changed, they were rolled onto their left, weakened side and fell out of bed. The resident stated they were unsure whether the CNA pushed too hard or whether the fall occurred from being turned with too much force. The CNA involved reported that the resident said their pad was wet and that, while attempting to change it, the resident was rolled away from the CNA and fell out of bed. The CNA acknowledged they had not been trained on the correct method of rolling a resident prior to the incident and later learned the resident should have been rolled toward the staff member for safety. After the fall, the resident reported pain in the left arm and left knee and later stated hospital imaging confirmed a dislocated left shoulder. The DON confirmed that two staff should have been used for the resident’s care and that staff are expected to follow care plan interventions, including rolling residents toward staff and using two-person assistance when indicated by the Kardex.
Food Service Equipment, Sanitation, and Drain Line Deficiencies
Penalty
Summary
Food service equipment and surfaces were not maintained in clean condition. On 4/26/2026 at 8:51 AM, residue was observed on the shelving surface of the food storage racks in the walk-in cooler, and the Dietary Manager stated the shelves are cleaned weekly or monthly. At 8:53 AM, a stand mixer covered with a plastic cover was observed in use, and when the cover was removed, brown buildup was seen accumulated on the upper portion of the mixer above the mixing bowl. The Dietary Manager stated someone would clean it. At 9:15 AM, red residue buildup was observed on the inside nozzle of the juice gun, and the Dietary Manager stated the nozzle is run through the dishwasher daily. The report also cited the 2022 FDA Food Code requirement that food-contact surfaces and nonfood-contact surfaces be kept clean and free of soil accumulation. The kitchen high temperature dishwasher was also found to have an unreliable wash gauge. At 8:56 AM, the Dietary Manager stated the rinse gauge moves throughout the cycle but the wash gauge stays the same, and the dish machine was run through two full cycles with the wash gauge remaining at 140 F while the rinse gauge fluctuated to 180 F. In addition, plumbing and equipment issues were observed in the kitchen and dining room: the prep sink drain line extended into the janitor sink below the flood level rim, the three-compartment sink drain line was directly connected to the wastewater line, and the drain line behind the ice machine in the dining room had no visible air gap. The two-door cooler also had chipped and worn paint on multiple storage rack surfaces with peeling paint exposing metal. A container of thickening agent was observed in the medication refrigerator, which had a sign stating no food is to be kept in medication refrigerators.
Incomplete Legionella Water Management Program
Penalty
Summary
The facility failed to have an active plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing. During observation, an inoperable water fountain was seen in the front entrance lobby with the electric plug unplugged and hanging, and another inoperable water fountain was observed in the hearth room, indicating a possible stagnant line. A therapy tub was observed in spa room A hall, and the Housekeeping/Laundry Supervisor was not sure whether it was used. Two shower rooms that had been converted to clean linen rooms were also observed, and in both rooms the hand sink faucet and shower head were left on. During interview, the Housekeeping/Laundry Supervisor stated the water fountains had been turned off during COVID and had not been turned back on. The Nursing Home Administrator and Maintenance Director stated they do weekly water temperature checks and yearly Legionella testing, but they do not test free chlorine in the domestic cold or hot water supply and only review municipal water reports. The Maintenance Director stated decorative fountains are treated when opened and on a need-be basis, aerators are changed on a need-be basis, unoccupied rooms are flushed weekly, and the converted shower rooms are flushed only when water temperatures are taken and not on a regular cycle. Record review showed the facility's Legionella Water Management Program dated 2/2019 identified fountains, aerators, showerheads, hoses, hot tubs, and other water system components, but the February 12, 2026 Water Management Program Plan did not include identified areas where Legionella could grow and spread or a description of control measures taken.
Incomplete Advance Directive Documentation
Penalty
Summary
The facility failed to develop and implement written comprehensive advance directives for multiple residents, including decisions related to CPR, artificial nutrition/peg tube, artificial hydration/IV, and diagnostic testing. The report identified six residents reviewed for advance directives who did not have complete written documentation supporting how their code status or other life-sustaining or life-withholding choices were determined, despite facility records showing full code status or social work notes indicating discussions had occurred. For one resident, the record showed diagnoses including fracture of the right femur, acute kidney failure, pain, dementia, delirium, and UTI, and the resident had moderate cognitive impairment on the BIMS. The resident stated they would not want chest compressions if their heart or breathing stopped, yet the physician order listed Full CPR and the chart contained only a social work note stating advance directives were reviewed and full code status was placed per the resident’s wishes, with no other documentation supporting that decision. Another resident with diagnoses including pressure ulcer of the sacral region, CKD, heart failure, anxiety, depression, chronic respiratory failure, COPD, sleep apnea, and type II diabetes also had moderate cognitive impairment, no active advance directive order, and a face sheet listing Full CPR; the chart again contained only a social work note referencing discussion and placement of full code status, without supporting documentation. A third resident with diagnoses including metabolic encephalopathy, adjustment disorder, dementia, delirium, respiratory failure, acute kidney failure, heart failure, type II diabetes, and obesity had moderate cognitive impairment and a physician order for Full CPR, but the only supporting note was a social work entry stating advance directives were reviewed and full code status was placed per the resident’s wishes. Another resident’s record identified Full Code status, but there was no documented evidence that the resident or responsible party had been educated regarding advance directives, no signed consent, and no documentation showing how the status was determined; this resident was cognitively intact on MDS and had diagnoses including fractures of the right tibia and fibula, paranoid schizophrenia, chronic diastolic heart failure, and dysphagia. A resident with a court-appointed legal guardian had a Full Code form signed by the resident, but there was no revised written evidence that the guardian was informed or agreed with the code status. Another cognitively intact resident who made decisions independently was documented as Full Code, but there was no written evidence that the resident was informed or agreed with the code status; the resident later stated they did not know what an advance directive was and said someone had spoken about it but did not discuss wanting a peg tube.
Resident’s exposed body parts were visible from the hallway
Penalty
Summary
The facility failed to ensure dignity was maintained for one resident, who was observed lying supine in the first bed with a brief and entire upper thighs exposed in full view of the survey team and hallway traffic. The resident’s arms were extended to the sides of the bariatric bed, each exposed leg was positioned at the end of the bed, and the body was not covered. Because of the resident’s size and the position of the bed, the brief and body parts were visible from the hallway. The resident remained in the first bed without a privacy curtain being pulled or a change of rooms. The resident was readmitted with diagnoses including defect of end plate of vertebrate, acute and chronic respiratory failure with hypoxia, adult sexual abuse, morbid obesity, schizophrenia, developmental disorder, seizure, obstructive sleep apnea, and developmental delay. The MDS indicated a BIMs score of 12 of 15 with moderately cognitive impairment and dependence on staff for toileting, dressing, showering/bathing, rolling, and transfers. During interview, the Unit Manager acknowledged the resident’s exposed body parts were visible from the hallway, stated the resident had been educated on covering lower extremities and staff tried to check on the resident frequently, and had no response when asked how the facility ensured the resident understood the education given the developmental delay and limited ability to express herself. The facility policy stated that demeaning practices and standards of care that compromise dignity are prohibited and that staff are expected to promote dignity and assist residents, including cognitively impaired residents.
Inadequate Age-Appropriate Activities
Penalty
Summary
The facility failed to provide age-appropriate, meaningful activities for one cognitively intact resident who was reviewed for activities. The resident was observed resting in bed watching television and was alert, oriented to person, place, and time, and able to make all needs known. The resident stated they no longer attended activities because there were not enough activities of interest, said the facility no longer offered live entertainment or trips outside the facility, and expressed that springtime activities such as planting a small garden or building a bird feeder would be more appropriate than the current crafts, which the resident described as "kiddie shit." The resident also pointed to bedroom decorations that included cartoon stickers and glitter on a closet door and a paper plate with cotton balls, stickers, and glitter. Activities staff were observed offering residents sand art and a movie, but the sand art activity was not listed on the April activities calendar. The Activities Aide stated the movie was decided by the Activities Director and that the sand art was added that day. The Activities Director stated the movie was selected by one resident and another resident was okay with it, and no other residents were asked. The Activities Director also stated activities were chosen from a website for lower functioning residents, that no alternative activity was offered for higher functioning residents, and that they waited until something was suggested and then tried to do it. The resident was initially admitted with diagnoses including COPD, muscular sclerosis, and CHF, and the quarter MDS identified the resident as cognitively intact with a BIMS of 15 and requiring total two-person assistance with most ADLs. The Activities/Recreation care plan documented that activities should be compatible with the resident's physical and mental capabilities, known interests and preferences, individual needs and abilities, and age appropriate.
Failure to Monitor Antibiotic Use and Document Stop Dates
Penalty
Summary
The facility failed to ensure adequate monitoring of antibiotic use for one resident, R64, who had diagnoses including fracture of the right femur, acute kidney failure, metabolic encephalopathy, chronic obstructive pulmonary disease, dementia, and urinary tract infection. R64’s MDS showed a Brief Interview for Mental Status score of 12/15, indicating moderate cognitive impairment. During observation on 4/27/2026, R64 was in bed and stated they would always have to take antibiotics because they would always have a UTI, and denied current urinary symptoms such as burning with urination. Record review showed multiple antibiotic orders and changes over a short period of time. The MAR documented levofloxacin for UTI starting 3/15/2026, followed by nitrofurantoin ordered as chronic UTI prophylaxis with no stop date, then additional nitrofurantoin orders for UTI treatment, sulfamethoxazole-trimethoprim for UTI, Macrodantin for prophylactic use, and then Bactrim DS ordered again for UTI prophylaxis with no stop date. Nursing notes documented that the resident continued on oral antibiotics for UTI, had no urinary complaints, and experienced diarrhea during treatment. Physician progress notes dated 3/16/2026, 3/18/2026, 3/27/2026, 3/31/2026, and 4/24/2026 did not mention the UTI, antibiotic usage, or monitoring of the medication. The record also showed that no urinalysis with urine culture had been ordered since admission. During interview, the attending physician stated that the nurse practitioner was adjusting the doses and that testing was not wanted unless there were signs and symptoms, citing chronic urinary retention and a history of UTIs. The DON stated medications were reviewed in the EHR for alerts and corrections were made, and the corporate nurse consultant stated continued antibiotic use would keep the resident from going to the hospital and that no stop date was necessary for the prophylactic antibiotic. The facility policy stated that antibiotic stewardship includes diagnostic testing per McGeer’s criteria before starting antibiotics and that antibiotic orders should include the name, dose, route, frequency, indication, and stop date.
Inadequate Emergency Food Supply
Penalty
Summary
The facility failed to ensure an adequate supply of emergency food was available, as observed during a survey. On March 10, 2025, an observation and interview with the Dietary Manager (DM) revealed that the emergency food supply was insufficient. A designated section in the dry food storage room was marked for emergency food, but upon comparison with the facility's emergency food supply list, it was found that chicken noodle soup, cheese sauce, and green beans were missing. The facility's policy, titled 'Disaster and Emergency Planning for Food Service,' dated February 3, 2023, mandates that adequate food, water, and disposable supplies be maintained to ensure meals can be prepared and served during emergencies. The Nursing Home Administrator acknowledged that the kitchen should audit the emergency food supply to ensure compliance.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain proper food safety and sanitation standards in the kitchen, as observed during a survey. Several deficiencies were noted, including the improper cleaning and drying of pans before stacking them with clean ones, and the failure to properly date-label food items. Specifically, opened containers of chicken and vegetable base were not labeled with expiration dates, and expired apple juice containers were found in the cooler. Additionally, a bag of hot dogs was labeled with an opened date but lacked an expiration date. In the dry food storage room, opened packages of spaghetti and polenta were not labeled with expiration dates. Further observations revealed that milk cartons were stored directly on the cooler floor, contrary to the requirement that they be stored at least 12 inches off the floor to prevent contamination. The air gap basin used for cleaning produce and thawing meat was found to be inadequately cleaned, with a build-up of residue and food debris. The Maintenance Director admitted to using bleach but not cleaning the basin, and the Dietary Manager acknowledged its dirty appearance. These practices increased the potential for foodborne illness among residents consuming food from the kitchen.
Failure to Implement Communication Care Plan for Hearing-Impaired Resident
Penalty
Summary
The facility failed to develop and implement a care plan for a communication deficit for a resident with hearing loss. The resident, who was observed to be alert and using writing materials to communicate, expressed difficulty in hearing and interacting with others due to ineffective hearing aids. Despite the resident's clear communication needs, the Unit Manager was unaware of the necessity for communication aids, and the resident's medical record lacked any documented communication interventions. The Director of Nursing confirmed that a care plan for the resident's hearing deficit was created but was resolved without a reason, leaving no guidance for staff to provide appropriate care. The MDS Nurse admitted to resolving the care plan without completing it, acknowledging that this oversight negatively impacted the resident's ability to communicate. The absence of a care plan and corresponding Kardex for the CNAs hindered the resident's care and interaction with others.
Failure to Provide Timely ADL Care
Penalty
Summary
The facility failed to provide timely Activities of Daily Living (ADLs) care for a resident, identified as R23, who was observed on two occasions sitting in a wheelchair with facial hair, greasy unkempt hair, and long dirty untrimmed fingernails. During an interview, R23 expressed a desire to be shaved, have their hair washed and combed, and receive nail care, confirming that no assistance was offered for these tasks on scheduled shower days. R23, who has moderately impaired cognition and requires one-person assistance with all ADLs, was unable to recall the last time they received a shower or their scheduled shower days. The care plan, revised in February 2025, indicated that R23 required assistance with bathing, dressing, and personal hygiene due to muscle weakness. The Unit Manager confirmed that R23's scheduled shower days were Mondays and Thursdays, during which they should have received grooming care. The Director of Nursing stated that all residents should receive nail care and shaves if it is their preference.
Improper Catheter Bag Management
Penalty
Summary
The facility failed to ensure proper care for a resident with a Foley catheter, leading to a deficiency in catheter management. The resident, who was admitted with a neuromuscular dysfunction of the bladder and a history of repeated falls, was observed with a catheter bag resting on the floor. This observation was made while the resident was asleep in bed, which was positioned low to the ground. The facility's care plan for the resident included securing the catheter with a securement device and providing a barrier when the bed was in a low position. However, these interventions were not implemented, as evidenced by the catheter bag being wedged between the floor mat and the wheel of the bed. Interviews with the Unit Manager and the Director of Nursing revealed that the nurse aides were responsible for ensuring the catheter bags were properly hung and not on the floor. Both staff members acknowledged that a white basin should have been placed under the catheter bag to prevent it from touching the floor. The facility's policy on catheter care, dated August 2023, mandates appropriate care for residents with indwelling catheters, which was not adhered to in this instance. The failure to follow the care plan and facility policy potentially resulted in the risk of infection and dislodgement of the catheter.
Failure to Ensure RN Coverage for 8 Consecutive Hours Daily
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for eight consecutive hours a day, seven days a week, which could potentially lead to inadequate coordination of emergency or routine care and unmet care needs for all residents. During the review of the Master Schedule for Nurses from January 1, 2025, to January 26, 2025, it was found that there was no consecutive 8-hour scheduled RN coverage on January 12, 19, and 25, 2025, with resident census numbers of 72, 77, and 71, respectively. The Director of Nursing (DON) confirmed the absence of RNs on these days and acknowledged the staffing issue, stating that RNs were recently hired to assist with coverage. Additionally, the facility's staffing policy, dated November 3, 2023, did not address the requirement for RN coverage for at least 8 consecutive hours a day, 7 days a week.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident, identified as R506, had a specific diagnosis, clinical indications for use, or valid informed consent for the use of psychotropic medications. R506 was admitted with diagnoses including multiple falls, traumatic ischemia of muscle, and diabetes, and had a BIMS score indicating no cognitive impairment. Despite declining psychiatric treatment and services, R506 was prescribed Seroquel by Physician K without a corresponding diagnosis or clinical indication. The resident expressed a desire not to be on Seroquel, and the social worker informed the nurse and physician, but the medication was not discontinued. The facility's policy requires informed consent for psychotropic medications, which was not obtained from the appropriate authorized representative. A consent form was signed by a family member who was not the resident's DPOA, and the family member later clarified they had directed the social worker to contact another family member for consent. The resident was taken off Seroquel at the hospital, and the facility's policy for psychotropic medication use was acknowledged as not being followed by the Nursing Home Administrator.
Failure to Implement Care Plans for Anticoagulant Therapy
Penalty
Summary
The facility failed to develop or implement care plans for anticoagulant administration for two residents, R801 and R802, who were receiving warfarin. R801 was admitted with a history of pulmonary embolism and was prescribed warfarin 7.5 mg daily. Despite the physician's order to review the warfarin flowsheet every nightshift, there was no care plan or interventions documented for monitoring the side effects or risk of bleeding due to warfarin administration. The Director of Nursing (DON) acknowledged the absence of a care plan for R801 and confirmed that the facility lacked a specific policy for anticoagulant use. Similarly, R802, admitted with a history of Atrial Fibrillation, was prescribed warfarin 12.0 mg daily. The resident's care plan also lacked documentation for monitoring side effects or the risk of bleeding associated with anticoagulation therapy. The DON confirmed the absence of a care plan for R802 as well. The facility's Care Plan policy, last revised on 8/25/23, mandates a comprehensive, person-centered care plan with measurable objectives and timetables for each resident, which was not adhered to in these cases.
Incomplete Documentation of INR Results for Resident on Warfarin
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, identified as R801, who was receiving warfarin for anticoagulation therapy. The deficiency was identified when the State Agency received a complaint regarding the monitoring of the resident's side effects from warfarin. The resident's Electronic Health Record (EHR) was found to be incomplete, with only one Warfarin Flowsheet documented, despite the physician's order to review the Warfarin Flowsheet every night shift. The missing documentation resulted in an unclear picture of the resident's blood clotting times and healthcare needs. The Director of Nursing (DON) acknowledged the incomplete documentation and produced two additional INR lab results that were not part of the resident's EHR. These results were obtained from the lab and were not documented in the facility's records. The facility's policy required that laboratory results be uploaded into the resident's EHR, but this was not done for R801. The physician confirmed that the INR blood tests were being conducted and reviewed through the lab, but the Warfarin Flowsheets were not up-to-date in the EHR.
Expired Food Storage and Labeling Deficiency
Penalty
Summary
The facility failed to ensure that expired food was not stored with active food stock, which could potentially lead to foodborne illness for all residents consuming food from the kitchen. During a kitchen tour, it was observed that several packs of hamburger and hot dog buns were opened, undated, and showed signs of mold. Additionally, other food items in the refrigerator, such as pre-made breakfast biscuits and sausages, were either undated or past their use-by dates. This oversight in food storage and labeling was confirmed by kitchen staff, who acknowledged the presence of mold on a sandwich served to a resident. The facility's Food Storage policy mandates that all food items be labeled and used within recommended time guidelines to prevent foodborne illness. However, the policy was not adhered to, as evidenced by the undated and expired food items found during the inspection. The Nursing Home Administrator was aware of the incident involving a resident being served moldy bread, indicating a lapse in monitoring and enforcing food safety protocols. This deficiency highlights a failure in the facility's food storage and labeling practices, posing a risk to resident health.
Delayed Response to Call Lights
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for four residents, leading to unmet healthcare needs. Observations on a specific date revealed that call lights for three residents remained on for an extended period, with one resident waiting over 15 minutes for assistance to go to the bathroom. Another resident had been waiting for hours to be assisted back to bed, and a third resident needed a bedpan urgently but was left waiting. The call lights were turned off by a nurse before the residents' needs were met, indicating a delay in response. Resident 810, who had chronic obstructive pulmonary disease and a history of falls, was observed waiting for assistance to use the bathroom. Resident 811, with Down's syndrome and a fracture, was left in a wheelchair for hours without being assisted back to bed. Resident 812, who had a fracture and required extensive assistance, was left waiting for a bedpan, risking incontinence. These residents had intact cognition, as indicated by their BIMS scores, and required varying levels of assistance for mobility. Resident 805 reported waiting over two hours for assistance on two occasions, leading to severe discomfort and the need to call emergency services. The facility's policy stated that staff should respond to call lights promptly and leave them on until the resident's needs were met. However, the nurse unit manager confirmed that the CNAs were busy, and she had to answer most call lights herself, turning them off before addressing the residents' needs.
Failure to Communicate Transfer Information to Hospital
Penalty
Summary
The facility failed to ensure proper communication of transfer information for a resident, identified as R802, to the receiving hospital. The resident, who had multiple diagnoses including dementia and a history of a fall with a fractured tibia, was admitted to the facility with severe cognitive impairment and required substantial assistance for mobility. On a specific date, the resident was found on the floor with a skin tear, prompting a physician to order a transfer to the hospital. However, there were no progress notes or transfer forms documenting the transfer, leaving the receiving hospital potentially unaware of the resident's medical needs and history. The Director of Nursing (DON) confirmed the absence of documentation regarding the transfer, acknowledging that the nurse should have completed a transfer form. The facility's policy on transfers and discharges, last revised in November 2023, outlines the necessary information to be included in a transfer form, such as contact information, advance directives, resident status, diagnoses, allergies, and special care instructions. The lack of adherence to this policy resulted in a deficiency, as the required information was not communicated to the hospital, potentially impacting the resident's care.
Failure to Implement Fall Interventions and Assessments
Penalty
Summary
The facility failed to implement fall interventions for three residents, resulting in a deficiency related to fall risk assessments. Resident 802, who had severe cognitive impairment and a history of falls, was admitted without a fall risk assessment. This resident experienced two falls, one resulting in a skin tear and another in a laceration, before being sent to the hospital. Similarly, Resident 807, with intact cognition and a history of joint replacement surgery, and Resident 809, with moderately impaired cognition and a history of a lumbar fracture, were also admitted without fall risk assessments. Both residents experienced falls without injury. The Director of Nursing confirmed that no fall risk assessments were conducted within 24 hours of admission or prior to the falls for these residents. The facility's Fall Risk/Injury Prevention policy mandates that a fall risk assessment be completed within 24 hours of admission, quarterly, or when a significant change in condition occurs. The policy also states that a score of greater than 10 on the assessment indicates an increased risk of falls, and the interdisciplinary team may add interventions for residents deemed at risk. The lack of timely fall risk assessments for these residents represents a failure to adhere to the facility's policy, contributing to the deficiency.
Failure to Provide Rationale and Monitoring for Extended Use of PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide rationale, behavioral monitoring, or a physician evaluation for the extended use of a PRN psychotropic medication for a resident. The resident, who had multiple diagnoses including Sepsis, Depression, Anxiety, and Adjustment Disorder, was prescribed Ativan 0.5 mg every 12 hours PRN for 14 days, which was repeatedly re-ordered without proper documentation or evaluation. The resident reported difficulty in receiving the medication and expressed concerns about withdrawal symptoms due to her long-term use of Ativan at home. There was no evidence of psychiatric services being offered or accepted, and no documentation of discussions regarding the risks and benefits of the medication use was found in the resident's EHR. The care plan for the use of psychotropic medications was initiated 15 days after the initial prescription of Ativan, but it lacked proper follow-up and documentation. The interventions included consulting with pharmacy, considering dosage reduction, and reviewing behaviors and alternate therapies, but there were no records of these actions being taken. The resident's physician continued prescribing the medication based on the resident's requests without documented discussions about alternative treatments or non-pharmaceutical interventions. Additionally, there was no AIMS assessment or behavior monitoring documented in the resident's EHR. The Director of Nursing confirmed the lack of psychiatric services and the responsibility of social work and the resident's physician in managing the psychotropic medication. The social worker admitted to not following up with the resident due to the absence of reported concerns from nursing staff. The physician acknowledged the continued prescription of Ativan without considering alternative treatments or a gradual dose reduction. The facility's policy on psychotropic medication use emphasized the need for gradual dose reductions, non-pharmacological approaches, and proper documentation, which were not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 780 citations issued within 25 miles in the last 12 months — including the 4 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 Riverview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Rivergate Health Care Center | 0.8 mi | ★★★★★ | 4 | 0 |
| Rivergate Terrace | 0.8 mi | ★★★★★ | 13 | 0 |
| The Orchards At Southgate | 1.3 mi | ★★★★★ | 2 | 0 |
| Aerius Health Center | 1.9 mi | ★★★★★ | 0 | 0 |
| Applewood Nursing Center, Inc | 4.3 mi | ★★★★★ | 1 | 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 August 2026) and official state health department websites.