Average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rivergate Terrace during CMS and state inspections, most recent first.
Personal Belongings Moved Out of Resident’s Reach: A resident who was cognitively intact and required assistance with most ADLs had personal items removed from the nightstand by a UM and placed in a closet box, where the resident said they could not be reached independently. The UM acknowledged the items were out of reach, and the DON stated the resident had the right to keep personal items on the nightstand.
Failure to Protect Resident PHI: An LPN left a medication cart computer screen open outside a resident's room, exposing the resident's orders, medications, and diagnoses to staff, residents, and visitors passing by. The LPN said she thought she had closed the screen before leaving for central supply, and the DON later stated the LPN knew better. The resident had multiple diagnoses and was cognitively impaired with impaired speech and ambulation.
Failure to provide ordered splinting and ROM services for two residents with contractures and severe cognitive impairment. One resident with CVA-related hemiplegia had a right resting hand splint order and restorative ROM/splint care planned, but the splint was observed off and the facility had no restorative documentation. Another resident with hand contractures had orders for bilateral palm guards and BUE/BLE ROM, but staff reported restorative care was not consistently provided, and logs showed missed splinting and ROM with no refusals documented.
PEG Tube Placement and Residual Not Verified Before Medication Administration: An LPN administered multiple medications through a resident’s PEG tube without checking tube placement or gastric residual first. The resident had diagnoses including intracranial hemorrhage, dysphagia, gastrostomy, TIA, and cerebral infarction, and was cognitively intact per MDS. The LPN acknowledged the omission, and the DON stated staff are expected to check tube placement before giving medications.
A facility used incorrect isolation signage for two residents with contagious infections, including one resident with C. diff and colonized C. auris and another resident with MRSA and a draining knee wound. Staff and the DON gave conflicting statements about whether Contact Isolation was needed, and one resident’s care plan called for Contact Isolation while the door still displayed EBP. The facility also failed to use required PPE when an LPN administered meds via a PEG tube to a resident on EBP without wearing a gown.
A resident returned from the ED with a right scalp laceration closed with a staple, but staff did not obtain or document specific MD orders for cleansing, monitoring, assessment, or staple removal. The laceration was later observed with a protruding staple, and review of care plans, MAR/TAR, and physician orders showed no interventions or scheduled removal for the staple, despite a provider note referencing the laceration and staple. Leadership interviews confirmed that nursing staff were responsible for securing appropriate orders and follow-up care, and facility policy required staple and suture removal in line with professional standards.
The facility failed to ensure timely review and submission of PASARR forms for residents with mental disorders or intellectual disabilities. Missing PASARR 3878 forms for two residents with dementia and epilepsy were due to physicians not completing them in the OBRA system. Another resident's annual PASARR 3877 and OBRA Level II Evaluation were overdue due to oversight during hospitalizations. Additionally, a resident's PASARR Level II screening was missing from records. These deficiencies could impact residents' care for mental health and dementia needs.
The facility failed to provide wheelchair footrests for two residents, leading to potential injury risks. A resident was observed without footrests during therapy transport, and their family member expressed concern. Another resident was transported to the dining room without footrests, requiring them to lift their feet. Staff acknowledged a shortage of footrests, and the facility lacked a specific policy addressing this issue.
A facility failed to secure a resident's protected health information, leading to potential unauthorized access. A computer on a medication cart was left open to a resident's EMR, visible to passersby for several minutes. The Unit Manager and ADON closed the screen upon noticing the surveyor observing it. The DON confirmed this was a HIPAA violation. The resident had multiple diagnoses, including Memory Deficit and Major Depressive Disorder, and was cognitively intact.
The facility failed to develop and implement comprehensive care plans for three residents, leading to potential unmet care needs. A resident with an indwelling catheter was not educated on its care, another receiving oxygen therapy lacked a care plan for its administration, and a third with a colostomy had no care plan for ostomy care. The Director of Nursing acknowledged these oversights, which were contrary to the facility's policy.
The facility failed to prevent and treat pressure ulcers for two residents. One resident was not repositioned as required, leading to a worsening stage 4 sacral ulcer, with missed dressing changes. Another resident, at high risk for pressure sores, had her heels resting directly on the mattress despite care plan instructions to offload them. Staff interviews revealed a lack of adherence to care plans and facility policies.
A facility failed to properly store an oxygen cylinder in a resident's room, creating a potential fire hazard. An oxygen tank was found leaning against a dresser instead of being secured in a metal carrier. A respiratory therapist confirmed the improper storage, and the Environmental Director acknowledged the deviation from the facility's safety protocols, which require tanks to be stored in a metal carrier or cage.
A resident with an indwelling urinary catheter experienced unresolved UTIs due to inadequate care at the facility. The catheter was not securely anchored, and the tubing was improperly positioned. Despite orders for catheter care and a urology consult, the facility staff failed to change the entire catheter system as needed and did not schedule the consult, leading to the resident seeking emergency care.
A resident with severe cognitive impairment was not administered oxygen as prescribed, resulting in a low pulse oximetry reading. Observations revealed the oxygen tubing on the floor and the concentrator not properly connected. The facility's policy on oxygen administration was not followed, leading to the deficiency.
A facility failed to ensure proper PPE use for a resident under enhanced-barrier precautions and did not follow aseptic techniques for IV line management. Staff were observed performing hygiene care and medication administration without required PPE, and an LPN connected an IV-line without using a sterile cap, contrary to facility policies.
A resident with Alzheimer's Disease, identified as at risk for elopement, managed to leave the facility unsupervised by following a visitor through the front door. The receptionist, responsible for monitoring the entrance, was distracted and did not notice the resident leaving. The facility's door setup allowed the resident to exit without detection, despite prior assessments and a care plan in place to prevent such incidents.
A resident with dementia and osteoporosis suffered a leg fracture due to improper transfer by CNAs who did not use the required mechanical lift, contrary to the care plan and facility policy. The resident was hospitalized following the incident, which revealed a lack of adherence to established transfer procedures.
A cognitively impaired resident at risk for elopement exited an LTC facility unsupervised, following an activities aide distracted by a cell phone. The resident, diagnosed with dementia and a history of wandering, was outside for two minutes before being returned by the Director of Rehab. The incident highlighted lapses in supervision, as the aide and receptionist failed to notice the resident's exit.
Personal Belongings Moved Out of Resident’s Reach
Penalty
Summary
The facility failed to ensure that R169’s personal belongings were kept within reach. On 3/24/26, R169 was observed sitting in a specialized wheelchair in the bedroom and was alert, oriented to person, place, and situation. R169 stated that Unit Manager F removed personal items from the nightstand because the State was in the building and said the items were moved because it looked messy. R169 reported that the belongings had been placed in a box in the closet and were not reachable there, explaining that when the items were on the nightstand they could be reached easily and independently. At 3:35 p.m., R169’s belongings, including shampoo, deodorant, shaving cream, and body lotion, were observed in a box on the closet floor. R169 said the items had been on the top of the closet and asked staff to place the box on the floor, but also stated the items would not be easily accessible without staff assistance. Unit Manager F stated the belongings were not supposed to be on the nightstand and moved them to the closet, acknowledging they would not be easily accessible and were out of R169’s reach. The DON stated R169 had the right to have personal items on the nightstand and did not know why they were moved to the closet and out of reach. R169’s record showed diagnoses including dysphagia, adjustment disorder with anxiety, bipolar disorder, schizoaffective disorder, malignant neoplasm of female breast, and above the right leg amputation, with a BIMS of 15 and assistance needed with most ADLs.
Failure to Protect Resident PHI
Penalty
Summary
The facility failed to keep one resident's personal and medical records private and confidential when an LPN left a medication cart computer screen open outside a resident's room in the Therapy Department. The screen displayed the resident's written orders, medications, and diagnoses, and it remained visible to anyone passing by while the LPN left the area to go to central supply. During this time, a respiratory therapist, a wound care nurse, a housekeeper, and three residents escorted by guests passed the cart. When the LPN returned, the screen was closing automatically, and she stated that she thought she had closed it but had not. The DON was later informed and stated that the LPN had already reported the incident herself and that she knew better. The resident whose information was visible had diagnoses including bacteremia, MSSA infection, anxiety disorder, depression, hypertensive heart disease with heart failure, myositis, COPD, cognitive communication deficit, severe morbid obesity, and hyperlipidemia, and the admission MDS indicated the resident was cognitively impaired with impaired speech and ambulation.
Failure to Provide Ordered Splinting and ROM Services
Penalty
Summary
The facility failed to apply splinting devices and perform range of motion (ROM) exercises as care planned for two residents with limited ROM and contractures. One resident had a history of hemiplegia and hemiparesis following a cerebral infarction affecting the right dominant side, severe cognitive impairment, and dependence for ADLs. That resident had an order for a right resting hand splint to be applied for 4 hours in the morning and removed in the evening, with assessment of pain, circulation, and skin integrity, and the care plan included restorative passive ROM for both upper and lower extremities and splint application for the right hand to manage contracture. The resident was observed in bed with the right-hand splint on the bedside table on one occasion and later observed again without the splint in place. The facility did not have documentation of restorative services for that resident when requested. The restorative nursing program entries for the resident were revised, but the Nursing Home Administrator stated the facility did not have documentation of restorative services for the resident. The second resident had diagnoses including contracture of the left hand and pain in both hands, severe cognitive impairment, and dependence for ADLs. That resident had an order for bilateral palm guards to be applied for 4 to 6 hours as tolerated and care plan interventions for bilateral upper extremity active ROM and bilateral lower extremity passive ROM. The resident was observed with a palm protector on the bedside table and later with one hand protected while the other hand was not wearing the palm protector. A CNA stated she did not apply splints or perform ROM exercises and that restorative staff performed that care, while the restorative aide stated the residents did not receive restorative services when she was pulled to the floor to work and when the facility was short staffed. Review of the restorative logs showed the resident’s bilateral palm guards and ROM program were not performed during multiple weeks, with no refusals documented.
PEG Tube Placement and Residual Not Verified Before Medication Administration
Penalty
Summary
The facility failed to verify PEG tube placement and assess gastric residual before administering medications through a PEG tube for one resident, R185, who was observed receiving multiple crushed medications via the tube. On 3/26/26 at 8:56 AM, an LPN administered Potassium chloride 15 ml, oxybutynin chloride 5 mg, Coreg 12.5 mg, metoclopramide 10 mg, sulfasalazine 500 mg, apixaban 5 mg, folic acid 1 mg, and losartan potassium 25 mg through the PEG tube without checking tube placement or gastric residual. When interviewed immediately afterward, the LPN acknowledged that placement and residual were not checked before medication administration. The DON later stated that staff are expected to check tube placement before giving medications. Record review showed that R185 was admitted with diagnoses including intracranial hemorrhage, dysphagia, gastrostomy, transient ischemic attack, and cerebral infarction, and the resident’s quarterly MDS indicated a BIMS score of 15 out of 15, showing the resident was cognitively intact. The facility’s Medication Administration Through External Tube policy, revised 11/15/24, stated that feeding tube placement should be confirmed per facility policy.
Incorrect Isolation Signage and PPE Use
Penalty
Summary
The facility failed to use proper signage for two residents with contagious infections. For one resident, an Enhanced Barrier Precaution sign was posted even though the resident’s record showed an order for Enhanced Barrier Precautions related to colonized Candida auris and laboratory results showing Clostridioides difficile. The resident’s progress note also documented ongoing oral vancomycin for C. diff with loose stool that continued but was less frequent. During interview, infection prevention staff stated the resident should have been on Contact Isolation for C. diff, and the DON later stated the resident should have been on Contact Isolation as well. For the same resident, the care plan was revised to Contact Isolation with instructions to wear gowns and mask when changing linens and to place soiled linens in biohazard bags, but at the time of observation there were no linens in biohazard bags and no trash marked biohazard. The resident was observed in bed while a family member sat at the bedside and adjusted the blanket. The family member stated they had not been told of any special precautions. The facility also failed to maintain correct isolation signage for another resident. That resident’s door initially displayed an Enhanced Barrier Precaution sign, then the sign was changed to Contact Isolation after staff stated the resident had MRSA. The resident’s record showed diagnoses including MRSA, bacteremia, diabetes, edema, congestive heart disease, total knee replacement, and a wound with drainage. The DON stated the resident was not on isolation precautions while in the hospital and did not need Contact Isolation, and also stated the resident did not have MRSA, despite the admitting diagnosis and physician order for rifampin for MRSA. The facility additionally failed to don appropriate PPE for a resident on Enhanced Barrier Precautions. An LPN administered medications via the resident’s PEG tube without wearing a gown, even though the Enhanced Barrier Precaution sign was posted on the door. The LPN acknowledged that a gown should have been worn for the medication administration. The resident had diagnoses including intracranial hemorrhage, dysphagia, gastrostomy, transient ischemic attack, and cerebral infarction, and the facility policy identified feeding tubes as an indwelling medical device requiring gown and gloves during high-contact care.
Failure to Obtain and Implement Orders for Scalp Laceration and Staple Care
Penalty
Summary
Surveyors identified that the facility failed to consistently assess and monitor a scalp laceration for one resident. Observation showed the resident had an intact laceration on the right side of the scalp with one staple protruding, and the resident could not recall when or why the staple was placed. Record review revealed the resident had an unwitnessed fall that resulted in a right scalp laceration and transfer to the ED, after which the resident returned to the facility. A subsequent physician/PA/NP note documented that the resident had a fall with head trauma and laceration, that a staple was intact, and that it should be removed as directed, with continued supportive care and monitoring of mentation. Further record review showed that none of the resident’s care plans contained interventions for cleansing, monitoring, or assessing the laceration, and there was no documented order specifying a date or plan for staple removal. The MAR and TAR for the relevant months contained no physician orders for laceration care or assessment, and physician orders over the same period did not include any orders for laceration care or staple removal. In interviews, the ADON acknowledged that a physician order should have been obtained and documented for care, monitoring, and timely removal of the staple, and the NHA stated that nursing staff were responsible for ensuring appropriate orders and follow-up care were obtained and implemented. The facility’s policy stated that skin staple, suture, and clip removal would be provided in accordance with professional standards of practice.
Deficiency in PASARR Documentation for Residents with Mental Disorders
Penalty
Summary
The facility failed to ensure timely review, revision, and submission of Preadmission Screening and Annual Resident Review (PASARR) forms for residents with mental disorders or intellectual disabilities. Specifically, the facility did not have the required PASARR 3878 forms for residents R22 and R52, who had diagnoses of dementia and epilepsy. The absence of these forms was due to the physicians not completing and signing them in the OBRA system, despite being aware of the process. Resident R175's records lacked an annual PASARR 3877 and the required OBRA Level II Evaluation, which was overdue. The Social Service Director acknowledged the delay, attributing it to the resident's multiple hospitalizations and the oversight during readmissions and discharges. This oversight resulted in the absence of necessary documentation for residents with mental illness diagnoses, including schizoaffective disorder and bipolar disorder. Resident R190's records showed a completed PASARR Level I screening, but the required Level II screening was missing. The Social Work Assistant was unable to locate the Level II documentation in the electronic medical record. These deficiencies indicate a failure to maintain accurate and timely PASARR documentation, potentially affecting the residents' receipt of appropriate care and services for their mental health and dementia needs.
Failure to Provide Wheelchair Footrests for Residents
Penalty
Summary
The facility failed to provide wheelchair footrests for two residents, resulting in a potential risk for injury to their lower extremities. Resident R93 was observed without footrests on their wheelchair during transportation to therapy, and their family member expressed concern about the absence of footrests, which were necessary for safe mobility at home. The clinical record indicated that R93 was readmitted with diagnoses including dementia and was totally dependent on staff for ambulation and transfer, being unable to propel themselves in the wheelchair. Similarly, Resident R86 was observed being transported to the dining room without footrests, requiring the resident to lift their feet repeatedly. R86, who had a moderate cognitive impairment and was wheelchair dependent, was unable to recall the last use of footrests. An anonymous staff member acknowledged the shortage of footrests, which had been a concern since June 2024. The Director of Nursing and the Administrator confirmed the lack of a specific policy addressing footrests, and a check of the residents' rooms revealed no available footrests.
Failure to Secure Resident's Protected Health Information
Penalty
Summary
The facility failed to properly secure protected health information for a resident, resulting in the potential for unauthorized disclosure and access. During an observation, a computer on a medication cart was found open to a resident's Electronic Medical Record (EMR) on the Blue unit. The computer screen was visible for approximately five minutes, during which several residents and staff were present in the hallway. The Unit Manager and Assistant Director of Nursing noticed the surveyor observing the open computer screen and subsequently closed it. The Unit Manager confirmed that the resident's medical record was accessible to anyone passing by. The Director of Nursing acknowledged that leaving a computer open with resident information visible is a violation of HIPAA. The resident involved was admitted to the facility with diagnoses including Memory Deficit following a stroke, Cognitive Communication Deficit, Generalized Anxiety, Major Depressive Disorder, Epilepsy, and Repeated Falls. The resident's Minimum Data Set (MDS) Admission assessment indicated they were cognitively intact.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive care plans for three residents, resulting in potential unmet care needs and lack of coordination of care. Resident R91, who was admitted with an indwelling urethral catheter, was not provided with a care plan addressing the catheter. Despite being cognitively intact and requiring supervision for personal hygiene and toileting, R91 was not educated on catheter care, and the Director of Nursing acknowledged the absence of a necessary care plan. Resident R85, who was receiving oxygen therapy for asthma and chronic obstructive pulmonary disease, also lacked a care plan for oxygen administration. Although the resident was observed receiving a nebulizer treatment and oxygen, the care plan did not reflect the physician's order for oxygen therapy. A Licensed Practical Nurse confirmed the oversight and acknowledged the need for a care plan. Resident R206, who had a colostomy, was observed with a leaking ostomy bag, yet there was no care plan for ostomy care. The resident, who was severely cognitively impaired and non-verbal, had orders for ostomy care every three days and as needed. The Director of Nursing confirmed that a care plan should have been in place for the colostomy, highlighting a failure to adhere to the facility's policy for comprehensive care plans and revisions.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to implement necessary interventions to prevent the development or worsening of pressure injuries for two residents, R206 and R155. R206 was observed lying on their back for extended periods without the use of a positioning wedge, despite having a care plan that required frequent repositioning to avoid pressure on the sacrum. The resident had a large unstageable sacral pressure ulcer that was present upon admission, which later progressed to a stage 4 ulcer. The facility's records showed that the pressure ulcer treatments were not documented as administered for two consecutive days, and the dressing was not changed as ordered, leading to a saturated dressing with drainage. R155, who was at high risk for developing pressure sores, was observed multiple times with her heels resting directly on the mattress, contrary to her care plan that required offloading of heels while in bed. Despite the resident's complaints of pain and requests for support under her feet, staff failed to consistently provide the necessary support to elevate her heels. Interviews with staff revealed a lack of awareness or adherence to the care plan requirements for heel elevation. The facility's policy on skin integrity and pressure ulcer prevention was not followed, as evidenced by the lack of consistent repositioning and failure to implement protective measures against pressure, friction, and shear. The Director of Nursing acknowledged the lapses in care, including the failure to change R206's dressing and the need for R155's heels to be offloaded to prevent skin breakdown.
Improper Storage of Oxygen Cylinder Creates Fire Hazard
Penalty
Summary
The facility failed to ensure proper storage of an oxygen cylinder in a resident's room, creating a potential fire hazard. During an observation, three oxygen tanks were found in the room of a resident, with one tank leaning against a dresser and not secured in a metal carrier. At the time, one resident was not present, and the other resident in the room stated that the oxygen tank was not for them and they did not pay attention to it. A respiratory therapist confirmed that the tanks were not stored according to safety protocols, emphasizing the flammable nature of the tanks and the necessity for them to be stored in a metal carrier. The Environmental Director was informed of the unsafe storage practice and confirmed that the facility's policy requires oxygen tanks to be stored in a metal carrier or cage to prevent safety issues. The facility's policy on oxygen administration and storage specifies that tanks should not be fastened to a resident's bed and must be installed on a stable, wheeled dolly or portable stand. Additionally, tanks in storage rooms should be chained to the wall or installed on a stable dolly or floor stand. This incident highlights a deviation from the facility's established safety protocols for oxygen tank storage.
Inadequate Catheter Care Leads to Unresolved UTIs
Penalty
Summary
The facility failed to provide adequate care for a resident with an indwelling urinary catheter, leading to multiple unresolved urinary tract infections (UTIs). The resident, who had been admitted with urinary retention and a UTI, was observed with a catheter that was not securely anchored, and the tubing was improperly positioned. Despite physician orders for catheter care every shift and to secure the catheter with an anchoring device, these instructions were not followed, contributing to the resident's ongoing health issues. The resident's medical records indicated that a urinalysis confirmed a UTI, and the resident experienced gross hematuria and urinary obstruction. However, the facility staff failed to change the entire catheter system as clinically indicated, opting instead to change only the collection bag. This decision was contrary to the facility's policy and the nurse practitioner's verbal orders, which specified changing the entire catheter system in cases of obstruction and infection. Additionally, the facility did not schedule a urology consult as ordered by the physician, further delaying appropriate treatment for the resident's condition. The lack of adherence to established guidelines and physician orders resulted in the resident's condition not being properly managed, leading to the resident and their family seeking emergency medical care outside the facility.
Failure to Administer Prescribed Oxygen
Penalty
Summary
The facility failed to administer oxygen as prescribed to a resident, resulting in a low pulse oximetry reading of 82%. The resident, who had severe cognitive impairment and was non-verbal, was observed multiple times over a 5.5-hour period without the prescribed oxygen via nasal cannula. The oxygen tubing and nasal cannula were found on the floor, and the oxygen concentrator was turned on but not properly connected to the resident. The resident's electronic health record indicated a prescription for continuous oxygen at 4 liters per minute, but this was not adhered to, as evidenced by the lack of oxygen administration during the observations. The resident's pulse oximetry reading remained low until a stat respiratory treatment was administered. The facility's oxygen administration policy requires specific liter flow orders and the use of humidifiers for flows of 4 liters or greater, which were not followed in this case. The Director of Nursing acknowledged the failure to administer oxygen per the physician's orders, and the facility's staff was educated on the issue following the incident.
Inadequate PPE Use and IV Line Management
Penalty
Summary
The facility failed to ensure appropriate use of personal protective equipment (PPE) for a resident under enhanced-barrier precautions. During an observation, a Certified Nurse Aide (CNA) and a Licensed Practical Nurse (LPN) entered the resident's room and performed hygiene care and medication administration without donning the required PPE, such as gowns and gloves. The facility's policy indicated that PPE should be worn during high-contact care for residents with wounds or indwelling medical devices, which was not adhered to in this instance. Both the CNA and LPN acknowledged the oversight after reviewing the enhanced barrier precautions sign and the facility's policy. Additionally, the facility failed to implement proper preventative measures for a resident receiving IV antibiotics. An LPN was observed connecting an IV-line without using a sterile cap, contrary to the facility's policy on maintaining aseptic techniques. The policy required that a new sterile end cap be placed on the administration set after medication administration if it would be used again within 24 hours. The Assistant Director of Nursing and the Director of Nursing both acknowledged the lapse in following the policy, which could potentially lead to infection due to poor sterile technique.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision for a resident identified as R912, who was at risk for elopement due to cognitive impairment and a history of exit-seeking behavior. On the day of the incident, R912, who was diagnosed with Alzheimer's Disease, managed to walk out of the facility unsupervised by following a visitor through the front door. The receptionist, responsible for monitoring the entrance, was distracted while replacing coffee cups and did not notice the resident leaving. The facility's layout included a series of doors, with the second set requiring activation by the receptionist to open. However, the third set of doors leading to the resident's living area was not locked and could be easily opened. This setup contributed to the resident's ability to exit the facility without being detected. The resident was later returned by another visitor without injury. Prior assessments had identified R912 as being at risk for elopement, and a care plan was in place, including frequent monitoring and inclusion in an 'elopement book' at the front desk. Despite these measures, the lapse in supervision allowed the resident to leave the facility, highlighting a failure in the implementation of the elopement prevention policy at the time of the incident.
Failure to Use Mechanical Lift Results in Resident Injury
Penalty
Summary
The facility failed to ensure adequate assistance during a mechanical lift transfer for a resident, resulting in a fracture of the right lower leg and subsequent hospitalization. The resident, who had a history of dementia, Alzheimer's disease, osteoporosis, and a previous fracture, was observed with a soft cast on the right lower leg. The care plan indicated that the resident required a mechanical lift with two-person assistance for transfers. However, on a specific day, two CNAs transferred the resident without using the mechanical lift, instead opting for a manual transfer method. This action was contrary to the care plan and the facility's policy, which mandates the use of mechanical lifts for non-ambulatory patients. Interviews with staff revealed discrepancies in the accounts of the transfer process. One CNA admitted to not being aware of the requirement for a mechanical lift and acknowledged not consulting the care guide. The facility's policy on the Limited Lift Program emphasized the necessity of using mechanical lifting devices and having two associates present during transfers. Despite this policy, the CNAs involved did not adhere to the established procedures, leading to the resident's injury. The incident highlights a failure in following the care plan and facility policy, resulting in harm to the resident.
Inadequate Supervision Leads to Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision for a cognitively impaired resident, identified as R701, who was at risk for elopement. On the day of the incident, R701 exited the facility unsupervised through the main entrance, following an activities aide who was distracted by a cell phone. The resident was outside the facility for approximately two minutes before being brought back inside by the Director of Rehab, with no reported injuries. R701 had been admitted to the facility with diagnoses including dementia, a history of falling, anxiety, and a psychotic disorder with hallucinations. The resident's care plan, initiated five days prior to the incident, identified them as at risk for elopement due to wandering behavior. Despite this, the resident managed to exit the facility, indicating a lapse in the supervision and monitoring protocols that were supposed to be in place. The incident was compounded by the failure of staff to adequately monitor the resident. The activities aide, who was not on break, was preoccupied with a cell phone and did not notice the resident following them outside. Additionally, the receptionist, responsible for monitoring the main entrance, was distracted by conversations with staff and guests, allowing the resident to pass unnoticed. This series of oversights led to the resident's unsupervised exit from the facility.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 872 citations issued within 25 miles in the last 12 months — including the 5 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 | 0.1 mi | ★★★★★ | 4 | 0 |
| Belle Fountain Nursing & Rehabilitation Center | 0.8 mi | ★★★★★ | 0 | 0 |
| The Orchards At Southgate | 0.9 mi | ★★★★★ | 8 | 0 |
| Aerius Health Center | 2 mi | ★★★★★ | 0 | 0 |
| The Lodge At Taylor | 3.7 mi | ★★★★★ | 16 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Rivergate Terrace.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.