Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Riverside Healthcare Center during CMS and state inspections, most recent first.
A resident with paranoid schizophrenia and anxiety, who was cognitively intact per a recent MDS/BIMS, reported that staff cleaned and organized her room without her permission while she was out of the facility, and that this bothered her. The NHA/DON acknowledged that staff cleaned the room due to its condition and stated she believed she had the guardian’s permission, but the guardian denied being consulted or giving consent and noted the resident’s delusions and paranoia. Review of the EMR showed no documentation of any rationale for cleaning the room without the resident’s permission or of any discussion with the guardian, despite facility policy requiring explanation of care before activities and respect for the resident’s living space and possessions.
A resident with intact cognition and mental health diagnoses reported that staff cleaned and organized her room without permission while she was out, after which she discovered missing personal items including blankets, a doll, a stuffed rabbit, and clothing. She stated she reported this concern to multiple staff members without resolution and felt the NHA/DON did not care. The NHA/DON acknowledged knowing about the complaint and discussing it with the ombudsman and guardian but did not complete a grievance form, did not document the concern in the EMR, and could not verify any follow-up with the resident, contrary to the facility’s written grievance policy requiring documentation and a written decision.
A resident with severe cognitive impairment and incontinence did not receive care planned interventions or physician-ordered Calmoseptine ointment for pressure ulcer prevention. Staff failed to check and change the resident every two hours as required, and there was confusion among CNAs and nurses regarding responsibility for applying the ointment. Documentation indicated the ointment was administered when it was not, and staff were unaware of the specific order to apply it after each incontinence episode.
The facility failed to maintain cleanliness in food service equipment, affecting 38 residents. Observations revealed unclean conditions, including soiled pots, pans, and kitchen appliances. The Dietary Manager acknowledged the issues and missing cleaning records.
The facility failed to maintain accurate advanced directive information for two residents, leading to potential non-compliance with their medical care preferences. One resident's directive was improperly witnessed after the guardian and doctor signed, while another resident's directive was signed by witnesses a day after the resident, indicating they did not witness the signing. These procedural errors could result in the facility not following the residents' medical care preferences.
The facility failed to provide timely and accurate Medicare coverage notices to three residents. A resident was not informed of the end date of services, and two residents did not receive proper notification 48 hours prior to the end of skilled services. Additionally, the SNFABNs lacked necessary details such as reasons for non-coverage and estimated costs. The Business Office Manager confirmed these deficiencies but could not explain the omissions.
A facility failed to include a Foley catheter in a resident's Baseline Care Plan within 48 hours of admission, despite the resident having quadriplegia and an indwelling urinary catheter. Observations confirmed the presence of the catheter, but it was not documented in the initial care plan, and interventions were only created weeks later. Staff acknowledged the omission during interviews.
A resident with severe cognitive impairment and a history of constipation experienced ongoing issues with constipation that were not adequately addressed by the facility. Despite having multiple physician's orders for constipation management, some orders lacked specific dosing and route instructions. The resident did not have a recorded bowel movement for several days, and no as-needed medications were administered, indicating a failure in the facility's protocol to manage the resident's condition effectively.
The facility failed to ensure a safe environment for two residents regarding smoking and bedrail use. A resident was allowed to smoke independently without a completed risk assessment, posing a safety risk. Another resident had a bedrail without a physician's order or care plan, and no assessments or measurements for entrapment were conducted, indicating a lack of proper safety procedures.
A facility failed to ensure recommended laboratory monitoring for a diabetic resident, who was on insulin and Metformin. Despite a pharmacy review recommending A1C and Lipid Panel tests, and the physician's agreement, the resident refused the tests in June. By October, the resident's lab results still lacked an A1C test. An RN confirmed the absence of A1C results since February, highlighting a failure in monitoring the resident's drug regimen.
A facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate. An RN did not wash her hands before preparing medications and failed to administer Lexapro and Betamethasone as ordered. The RN left medications unattended at the bedside, and the medication administration record confirmed the omissions. Interviews indicated that nurses are expected to wash hands and not leave medications at the bedside.
A facility failed to follow infection control protocols during wound care for a resident with Alzheimer's and pressure ulcers, as a nurse did not change gloves or clean scissors between handling soiled and new dressings. Additionally, the facility did not obtain proper consent for a COVID-19 immunization for a resident with Huntington's disease, as the guardian signed the declination section of the consent form, and verbal consent was not documented.
The facility did not post daily nurse staffing information for 38 residents and visitors. During facility tours, the postings were not observed, and HR reported that the information had not been completed or posted for about two months, believing it was no longer required.
The facility did not provide documentation of the required bi-annual Sensitivity Test for its fire alarm system, as required by NFPA 70 and NFPA 72. This was confirmed during a record review and interview with Facility Maintenance.
The facility did not provide a smoke barrier map showing complete compartmentalization by smoke barriers throughout the building, as required by code. The map lacked details of smoke barriers separating compartments from outside wall to outside wall, and this was confirmed by Facility Maintenance during record review.
Surveyors found that more than 100 cigarette butts were discarded on the ground in shrubbery and leaves in front of all emergency exits, rather than being placed in noncombustible containers as required by smoking regulations. This was confirmed by Facility Maintenance during the inspection.
A hasp latching mechanism with a padlock was found on the kitchen storage cooler door, allowing it to be locked from the outside and preventing egress from within. This arrangement did not meet required standards for egress doors and was confirmed by Facility Maintenance during the survey.
Staff were unable to provide access to a supply storage room in the service hall, preventing surveyors from verifying that the hazardous area was properly protected by required fire barriers or an automatic extinguishing system. This deficiency was confirmed by Facility Maintenance and could affect 20 occupants in a fire emergency.
A smoke detector was found installed within three feet of direct airflow from an air return or supply near an exit door, contrary to NFPA 70 and NFPA 72 requirements. This installation issue was confirmed by Facility Maintenance and could impact 30 occupants during a fire emergency.
A gap was found in the med supply room door handle, preventing the door from effectively resisting the passage of smoke as required by NFPA standards. This deficiency was confirmed by maintenance staff and could impact the safety of up to 20 occupants during a fire emergency.
A receptacle box with exposed live electric wires was found hanging off the wall behind the kitchen garbage disposal, creating a risk of unintentional electrical exposure. This noncompliance with NFPA 70 was confirmed by Facility Maintenance during the survey.
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of insects, including winged ants and spiders, in various areas. Staff were seen stepping on and killing the insects, but no formal pest control measures were observed. Additionally, the dining room was found to be unsanitary, with soiled tables and overflowing trashcans. Two residents, both moderately cognitively impaired, reported dissatisfaction with the cleanliness and presence of insects.
The facility failed to follow professional standards of nursing practice for medication administration, resulting in multiple medication errors and mismanagement of controlled substances for four residents. Issues included administering medication despite contraindicated vital signs, failing to document controlled substances properly, and not notifying providers of missed doses.
The facility failed to secure smoking materials per protocol. An observation revealed an open closet door in the shower room containing a plastic box with 7 packs of cigarettes and 2 lighters. Although the box had a padlock, it was not secured. The Administrator confirmed that smoking materials were supposed to be double locked but were not.
Failure to Obtain Consent Before Cleaning Cognitively Intact Resident’s Room
Penalty
Summary
The facility failed to ensure dignified care for a resident when staff cleaned and organized the resident’s room without obtaining the resident’s permission. The resident had been admitted with diagnoses including paranoid schizophrenia and anxiety, and a recent MDS with a BIMS score of 15/15 indicated the resident was cognitively intact. While the resident was out of the facility, staff entered the room and cleaned and organized it because they believed it was a mess and contained wet and dirty boxes. The resident later reported that this was done without her permission and that it bothered her. The Nursing Home Administrator/DON stated that staff cleaned the room and that she believed she had permission from the resident’s guardian to do so. However, the guardian reported that the facility had not discussed cleaning the room with her and that she had not given permission, further stating that due to the resident’s delusions and paranoia it did not make sense to clean the room when the resident was gone. The NHA/DON reviewed the electronic medical record and was unable to find any documentation of the rationale for cleaning the room without the resident’s permission or any documentation that this had been discussed with the guardian. The facility’s Promoting/Maintaining Resident Dignity policy required staff to explain care or procedures before initiating activities and to respect the resident’s living space and personal possessions, including not searching a resident’s personal possessions without consent from the resident or, if applicable, the resident’s representative.
Failure to Document and Address Resident Grievance About Missing Personal Items
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and to address a cognitively intact resident’s complaint about missing personal belongings. The resident, who had diagnoses including paranoid schizophrenia and anxiety, was admitted on a specified date and had a BIMS score of 15/15, indicating intact cognition. The resident reported that while she was out of the facility, staff cleaned and organized her room without her permission, and upon her return she discovered that personal items, including blankets, a doll, a stuffed rabbit, and several pieces of clothing, were missing. She stated that she had discussed this concern with multiple staff members, but nothing was done to resolve her complaint, and she felt that the NHA/DON did not care about her concern. The NHA/DON acknowledged awareness of the resident’s concern about missing items and confirmed that staff had cleaned and organized the room while the resident was out. The NHA/DON reported having discussions with the ombudsman and the resident’s guardian about the missing items but admitted that she did not complete a resident concern/grievance form or document the concern in the EMR. She was unable to verify that she had followed up with the resident regarding the missing items and stated that, in hindsight, she should have documented the concerns on a grievance form and in a progress note. This inaction was inconsistent with the facility’s written “Resident and Family Grievances” policy, which requires staff receiving a grievance to record the nature and specifics on the designated grievance form or assist the resident/family to complete it, and requires the Grievance Official to issue a written decision at the conclusion of the investigation.
Failure to Implement Care Plan and Physician Orders for Pressure Ulcer Prevention
Penalty
Summary
A deficiency was identified regarding the facility's failure to implement care planned interventions and physician-ordered treatments for pressure ulcer prevention for one resident. The resident in question was admitted with diagnoses including cerebral infarction and hemiplegia, was severely cognitively impaired, and was dependent on staff for toileting and personal hygiene. The care plan directed staff to keep the resident's skin clean and dry, minimize exposure to moisture, provide incontinence care after each episode, and use a moisture barrier product as needed. There was also a physician's order for Calmoseptine ointment to be applied to the buttocks after each episode of incontinence. Observations on two consecutive days revealed that the resident was left in a soaked brief and clothing for several hours after being placed in a chair by the previous shift. During incontinence care, there was no evidence of barrier cream or Calmoseptine ointment on the resident's skin, and staff did not apply these products at the time of care. Interviews with CNAs indicated that the resident had not been checked or changed for several hours, despite the expectation that incontinent residents be checked and changed every two hours. CNAs also expressed confusion about who was responsible for applying Calmoseptine ointment, with some believing it was a nursing responsibility and others stating they would apply it only if it was available in the room. Further interviews with nursing staff and the Director of Nursing confirmed that Calmoseptine ointment was considered medicated, stored in the treatment cart, and should be administered by a nurse. Documentation in the Medication Administration Record indicated that the ointment had been administered, but the nurse later admitted this was not the case and that CNAs typically performed this task. There was also a lack of awareness among staff regarding the specific order for Calmoseptine ointment to be applied after each incontinence episode. These findings demonstrate a failure to follow care plan interventions and physician orders for pressure ulcer prevention.
Deficient Cleaning and Maintenance of Food Service Equipment
Penalty
Summary
The facility failed to effectively clean and maintain food service equipment, impacting 38 residents. During an initial tour of the food services, several deficiencies were observed. A cardboard box containing dinex cup lids was found on the floor in the dry storage room, and the baseboards along the wall had a black substance on them. The door jam of the dry storage room was rusted along the floor. In the freezer, referred to as the vegetable freezer, the bottom shelf was soiled with what appeared to be a dried liquid film. Additionally, seven pots and pans were found with a dark-colored substance inside, resembling baked-on food that could not be removed. Further observations revealed that the toaster grill had baked-on substances and burnt toast crumbs on the grates. The grill, oven, and gas grills were soiled, with the upper portion of the grill covered in a dark black substance. The oven door handle was greasy, and the oven racks were discolored with food substances. The bottom of the oven was covered with burnt grease and food substances, and the side of the oven door had old yellow dark grease. During an interview, the Dietary Manager acknowledged the unclean state of the equipment and noted that cleaning records were missing for two days prior to the inspection.
Failure to Ensure Accurate Advanced Directives
Penalty
Summary
The facility failed to ensure updated and accurate advanced directive information was in place for two residents, resulting in the potential for a resident's preferences for medical care to not be followed. Resident #7, who was cognitively intact, had an advanced directive signed by a guardian on 09/24/24, but the witnessing process was not correctly followed. The social worker signed the document after the guardian and doctor, contrary to the instructions that required witnessing the guardian or resident's signature at the time of signing. This discrepancy was due to the social worker following incorrect procedures taught to her when she started working at the facility. Resident #39, who was cognitively impaired, signed his advanced directive on 01/28/25, with the provider also signing on the same day. However, the witnesses signed the document on the following day, 01/29/25, which means they did not witness the resident's signature as required. This procedural error in handling advanced directives could lead to the facility not adhering to the residents' medical care preferences.
Failure to Provide Timely and Accurate Medicare Coverage Notices
Penalty
Summary
The facility failed to provide accurate and timely notifications regarding Medicare coverage and potential liability for services not covered to three residents. Resident #5 was not given a Notice of Medicare Non-Coverage (NOMNC) indicating when services would end, and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) did not specify the last covered day of services. Resident #8 was not notified 48 hours prior to the end of skilled services, and the SNFABN did not include the estimated cost of services. Resident #35's NOMNC did not indicate when services would end, and the SNFABN lacked the reason for non-coverage and estimated costs. The Business Office Manager (BOM) confirmed these deficiencies during an interview, acknowledging the failure to provide necessary information on the NOMNC and SNFABN forms. The BOM could not explain why the required information was missing or why notifications were not completed in a timely manner. These oversights affected the residents' understanding of their Medicare coverage and potential financial responsibilities.
Failure to Include Foley Catheter in Baseline Care Plan
Penalty
Summary
The facility failed to develop a Baseline Care Plan with necessary healthcare information for a resident (R37) within 48 hours of admission. The resident was admitted with diagnoses including quadriplegia and neuromuscular dysfunction of the bladder, and had an indwelling urinary catheter. However, the Baseline Care Plan initiated on the date of admission did not reflect the presence of the Foley catheter, which is a critical component of the resident's care needs. Observations and interviews revealed that the resident was cognitively intact and had a Foley catheter, as confirmed by the resident and observed by surveyors. Despite this, the Baseline Care Plan did not include the catheter, and the approaches/interventions related to the catheter were only created weeks after admission. Staff interviews indicated that the Care Plan is used to identify resident care needs, and the omission of the catheter from the Baseline Care Plan was acknowledged by the Nursing Home Administrator/Director of Nursing.
Failure to Prevent Constipation and Ensure Proper Medication Orders
Penalty
Summary
The facility failed to prevent constipation and ensure proper medication orders for a resident with severe cognitive impairment and a history of constipation, diabetes, and hemiplegia. The resident reported ongoing issues with constipation since admission, which they felt were not adequately addressed by the staff. The medical record showed multiple physician's orders for constipation management, including Metamucil, Senna Plus, and other medications, but some orders lacked specific dosing and route instructions. Observations and interviews revealed that the resident did not have a recorded bowel movement for several consecutive days, and the Medication Administration Record did not reflect the administration of any as-needed medications for constipation. A registered nurse acknowledged the lack of bowel movements over a significant period and the absence of action to address the issue, indicating a failure in the facility's protocol to manage the resident's constipation effectively.
Failure to Ensure Safety in Smoking and Bedrail Use
Penalty
Summary
The facility failed to ensure a safe environment and provide adequate supervision for two residents regarding smoking and the use of bedrails. Resident #2 was observed to have burn marks on his hoodie and stated he could smoke independently, yet there was no completed smoking risk assessment on file since his admission. This lack of assessment and supervision poses a potential safety risk, as the resident mentioned having access to a lighter and marijuana outside, which was not addressed by the facility. Resident #5 was found to have a bedrail on the right side of his bed without a physician's order or a care plan in place. The resident explained that the bedrail was used to prevent falls, but there was no documentation of an assessment for its use, nor were any alternative interventions attempted. Additionally, the facility did not conduct measurements for possible entrapment when the bedrail was applied or on a quarterly basis, as confirmed by the Director of Nursing. This oversight indicates a failure to follow proper procedures for bedrail use and safety assessments.
Failure to Ensure Laboratory Monitoring for Diabetic Resident
Penalty
Summary
The facility failed to ensure that recommended laboratory monitoring was in place for a resident, identified as R15, who was admitted with diagnoses including diabetes, constipation, hemiplegia, and hemiparesis following a nontraumatic intracranial hemorrhage. R15's medical record included physician's orders for insulin and Metformin to manage diabetes, with instructions for fasting blood sugar checks on specific days. A pharmacy medication regimen review recommended ordering current labs, including A1C levels and a Lipid Panel, which the physician agreed to. However, R15 refused to have these tests collected in June 2024. Despite the refusal in June, the medical record showed laboratory test results from October 2024, which included fasting lipids and glucose but did not include an A1C test. During an interview, RN B confirmed that A1C tests are generally conducted every three months for diabetic residents and acknowledged that there were no A1C results for R15 dating back to February 2024. This oversight indicates a failure to ensure the resident's drug regimen was free from unnecessary drugs due to the lack of appropriate laboratory monitoring.
Medication Administration Deficiency
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a 10.34% error rate for a resident. During an observation, RN C prepared several medications for the resident but did not wash her hands or use hand sanitizer before setting up the medications. Additionally, RN C did not administer or apply Lexapro 5 mg and Betamethasone cream as ordered. RN C left the medication cup and MiraLAX mixture on the over-the-bed table and walked away to wash her hands, failing to ensure the resident took the medications. The medication administration record confirmed that Lexapro and Betamethasone were not administered or signed out. Interviews with LNA/DON A and MDS/RN B revealed that nurses are expected to wash their hands before entering and leaving the room and should not leave medications at the bedside.
Infection Control and Consent Deficiencies
Penalty
Summary
The facility failed to adhere to accepted infection control protocols during wound care for a resident with multiple health issues, including Alzheimer's Disease, legal blindness, and pressure ulcers. During an observation, a registered nurse (RN) did not change gloves or clean scissors between handling soiled and new dressings for the resident's wounds. The RN also reused a disposable gown that was hung inside the resident's room, which is against infection control expectations. The wound care orders specified the use of alginate dressing only on the wound bed, but the RN applied it over healthy tissue as well. Additionally, the facility did not obtain proper consent before administering a COVID-19 immunization to a resident with Huntington's disease and memory impairments, who had a legal guardian. The resident's medical record showed that the guardian had signed the declination section of the vaccine consent form, but the facility reported that verbal consent had been given. However, this verbal consent was not documented in the resident's medical record. These deficiencies highlight lapses in infection control practices and consent procedures, which are critical for ensuring resident safety and compliance with regulatory standards. The facility's failure to follow proper protocols and documentation requirements led to these findings during the survey.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that daily nurse staffing information was posted for 38 residents and visitors. During a tour of the facility on two separate occasions, the daily nurse staffing posting was not observed. In an interview, the Human Resources/Scheduler (HR) reported that the daily nurse staffing information had not been completed or posted for approximately two months. HR believed they had been informed that posting the daily nurse staffing information was no longer necessary.
Failure to Document Bi-Annual Fire Alarm Sensitivity Test
Penalty
Summary
The facility failed to provide documentation of the required bi-annual Sensitivity Test for the installed fire alarm system, as mandated by NFPA 70 and NFPA 72. During a record review on 03/25/2025, surveyors found that no documentation of this test was available, and this was confirmed through an interview with Facility Maintenance at the time of the review. The absence of this documentation indicates that the fire alarm system was not tested and maintained in accordance with the approved program requirements. No information about specific residents, their medical history, or their condition at the time of the deficiency was provided in the report.
Plan Of Correction
K345 - Fire alarm System The Facility failed to have the bi-annual Sensitivity Test for the installed fire system completed, putting the whole facility and all occupants at risk. The maintenance director scheduled the Smoke Detector Sensitivity Test with DeLau Fire services, this was completed on 4-14-25 with all smoker detectors passing inspection; no repair or follow-up needed. He also scheduled our next bi-annual Sensitivity Test to ensure sustained compliance. The Maintenance Director was educated on the requirements and importance of having the Sensitivity Test completed and other scheduled maintenance. The Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. The Administrator is responsible for maintaining compliance.
Failure to Provide Complete Smoke Compartmentalization
Penalty
Summary
The facility failed to ensure that smoke barriers were provided to form at least two smoke compartments on every floor as required by applicable codes. During a record review, it was found that the facility did not provide a smoke barrier map that demonstrated complete compartmentalization by smoke barriers throughout the building. The map provided did not show smoke barriers separating smoke compartments from outside wall to outside wall in each compartment, as required. This finding was confirmed during an interview with Facility Maintenance at the time of the record review. No information about specific patients, their medical history, or their condition at the time of the deficiency was included in the report.
Plan Of Correction
K 371 Facility floor plan was reviewed and revised to include smoke compartments. Floor plans in the facility will be replaced to meet requirements. Maintenance Director was educated on K371 tag that floor plan must identify smoke barrier walls. Maintenance Director will review floor plans with any changes to ensure compliance with updates. Concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Improper Disposal of Smoking Materials at Emergency Exits
Penalty
Summary
During an outside perimeter walk of the building, surveyors observed over 100 cigarette butts discarded on the ground in the tree shrubbery and leaves in front of all emergency exits. These cigarette butts were not disposed of in noncombustible containers as required by facility smoking regulations. The observation was confirmed through an interview with Facility Maintenance at the time of the finding. The report notes that the facility failed to ensure smoking regulations were adopted and implemented to meet all required provisions, specifically regarding the proper disposal of smoking materials.
Plan Of Correction
K 741 Facility moved free standing smoking ash tray pole and picnic table to required distance from building. No smoking signs were placed in areas of concern to ward off smoking near building. Staff was educated on smoking away from the building or smoking privileges would be reviewed and possibly revoked. Maintenance director was educated on K741 smoking regulation. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Improper Egress Door Locking Mechanism in Kitchen Storage
Penalty
Summary
Surveyors observed that the facility failed to ensure that doors in a required means of egress were not equipped with a latch or lock requiring the use of a tool or key from the egress side, unless compliant with special locking arrangements for clinical needs. Specifically, during an inspection, it was found that the cooler door for kitchen storage was equipped with a hasp latching mechanism and a padlock, which could allow the door to be locked from the outside. This hardware arrangement created a situation where someone inside the cooler could be locked in without a means to exit, as the locking mechanism did not meet the required standards for egress doors. The finding was confirmed through an interview with Facility Maintenance at the time of observation. The deficiency was noted to potentially affect 15 occupants in the event of an egress emergency.
Plan Of Correction
Maintenance Director adjusted the cooler door in the kitchen to ensure proper functioning. All other doors were checked and corrected as identified. The Maintenance Director was educated on K222 tag to ensure proper means of egress in the event of an emergency. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Inaccessible Hazardous Area Prevents Fire Safety Verification
Penalty
Summary
Staff were unable to provide access to a supply storage room located in the service hall between storage rooms 11 and 12 during an observation on 03/25/2025 at approximately 12:20 PM. This prevented a full inspection of the area to verify whether it was properly protected by a fire barrier with a 1-hour fire resistance rating, equipped with 3/4 hour fire rated doors, or safeguarded by an automatic fire extinguishing system as required by regulation. The inability to access the room meant that surveyors could not confirm compliance with fire safety standards for hazardous areas. This deficiency was confirmed through an interview with Facility Maintenance at the time of observation. The report specifically notes that this practice could affect 20 occupants in the event of a fire emergency, as the lack of access hindered the ability to ensure the hazardous area was adequately protected.
Plan Of Correction
Rounds being conducted during the Annual State Survey, the Maintenance director was unable to make entry into the supply closet located between rooms 11 and 12 in the service hallway, in turn not being able to ensure the automatic-closing door or the presence of an automatic fire extinguishing system, which put 20 occupants at risk. The maintenance director adjusted the door to the supply closet between rooms 11 and 12 to ensure the door would open freely with key access. The Maintenance director confirmed that the door was an automatic-closing door and was functioning properly, and there was an automatic fire extinguishing system present inside the closet. The maintenance director did a complete facility round to ensure safeguards were in place. The maintenance director was educated on K321 tag to ensure proper access to the facility, to ensure areas are protected with a fire-rated door or an automatic fire extinguishing system, and to ensure all safeguards are in place. The Maintenance director will complete bi-weekly facility rounds to ensure safeguards are in place and that all doors are functioning properly. Concerns will be addressed at the time of observation. Results of the facility rounds will be reported in QAPI monthly for 3 months. The Administrator is responsible for maintaining compliance.
Improper Smoke Detector Placement Near Airflow Source
Penalty
Summary
A deficiency was identified when a smoke detector was observed to be installed within three feet of direct airflow from an air return or supply on the ceiling near Exit Door H. This installation does not comply with the requirements of NFPA 70 and NFPA 72, which govern the proper placement and installation of fire alarm system components. The issue was confirmed during an interview with Facility Maintenance at the time of observation. The deficient practice could affect 30 occupants in the event of a fire emergency.
Plan Of Correction
Maintenance Director moved the smoke detector to an area more than 3 feet away from the air/return supply on the ceiling. All other areas were reviewed with no concerns noted. Maintenance Director was educated on K341 tag to ensure proper placement of smoke detectors from direct airflow to an air return/supply. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance of K345.
Deficiency in Corridor Door Smoke Resistance
Penalty
Summary
During an inspection, it was observed that the door handle of the medication supply room had a gap measuring approximately 2 inches long by 1/4 inch wide at the handle cover. This gap was identified during a walkthrough and was confirmed by the facility's maintenance staff at the time of observation. The deficiency pertains to the requirement that doors protecting corridor openings must be capable of resisting the passage of smoke, as outlined in NFPA 19.3.6.3. The presence of the gap in the door handle area means the door does not meet the standard for smoke resistance, which could affect the safety of up to 20 occupants in the event of a fire emergency.
Plan Of Correction
K 363: The med supply door handle was corrected related to a gap that would allow smoke to pass and addressed to remedy this concern. Like areas were reviewed for areas of concern with no concerns noted at this time. Maintenance Director was educated on K363. Tag to ensure corridors openings are capable of resisting the passage of smoke. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Noncompliance with Electrical Safety Standards in Kitchen Area
Penalty
Summary
During an observation in the facility's kitchen dish tank area, a receptacle box with electrical wiring was found hanging off the wall behind the garbage disposal. The box was electrically tapped and exposed live electric wires to water, creating a situation where unintentional exposure to electricity could occur. This condition was directly observed and confirmed through an interview with Facility Maintenance at the time of the survey. The installation did not comply with NFPA 70, National Electric Code, as required, and presented a hazard to occupants in the area. No information was provided regarding specific residents or their medical conditions at the time of the deficiency.
Plan Of Correction
K511 Live wires in kitchen were addressed. Like areas were reviewed and no concerns were noted at this time. Maintenance director was educated on K511 electrical equipment complies with NFPA 70 NEC Code for unintentional exposure to electricity. Maintenance Director will complete facility rounds to ensure concerns observed will be addressed at the time of observation. Results of audits will be reported to QAPI Monthly x3 and PRN. Administrator is responsible for maintaining compliance.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment, as evidenced by multiple observations of insects, including winged ants and spiders, in various areas of the facility. On several occasions, staff members were seen stepping on and killing the insects, but no formal pest control measures were observed. The Maintenance Director was not informed of the pest issue, indicating a breakdown in communication and protocol for addressing such problems. Additionally, the dining room was found to be in an unsanitary condition, with tables visibly soiled with dried food and drink spills, and trashcans overflowing with garbage. This was corroborated by resident interviews, who expressed dissatisfaction with the cleanliness of the dining room and the presence of insects. Two residents, one with hypertension and multiple sclerosis and another with Type 2 diabetes mellitus with diabetic neuropathy, were directly affected by these conditions. Both residents were moderately cognitively impaired, as indicated by their Brief Interview for Mental Status (BIMS) scores. One resident reported seeing bugs crawling around and pointed out insects near his feet, while the other resident complained about the filthy condition of the dining room in the mornings. These observations and resident reports highlight the facility's failure to provide a safe, clean, and comfortable environment for its residents.
Medication Administration Errors and Mismanagement of Controlled Substances
Penalty
Summary
The facility failed to follow professional standards of nursing practice for medication administration for four residents, resulting in multiple medication errors and mismanagement of controlled substances. For Resident #18, the facility administered midodrine despite blood pressure readings exceeding the physician-ordered parameters and failed to properly document the administration of gabapentin on two occasions. Resident #6 did not receive a scheduled dose of morphine, and there was no documentation indicating that the provider was notified or any follow-up actions were taken. Resident #16 had multiple instances where gabapentin and clonazepam were not signed out or administered as required, and there was a lack of proper documentation for the disposal of refused medication. Resident #88 had discrepancies in the administration and documentation of Lyrica, including missing doses and an additional dose being administered without proper documentation. The report highlights that the facility's medication administration process did not ensure that vital signs were checked and recorded before administering medications with specific parameters. Additionally, there were multiple instances where controlled substances were not properly signed out or documented, leading to potential medication errors. The facility's policy on medication administration was not consistently followed, resulting in inaccurate documentation and potential risks to resident safety. Interviews with staff, including a Registered Nurse and the Nursing Home Administrator/Director of Nursing, confirmed the medication errors and the lack of proper documentation. The facility's policy on medication administration and the fundamentals of nursing practice emphasize the importance of accurate documentation and adherence to physician orders, which were not followed in these cases. The deficiencies identified in the report indicate a need for immediate action to address the medication administration process and ensure compliance with professional standards of nursing practice.
Failure to Secure Smoking Materials
Penalty
Summary
The facility failed to secure smoking materials per protocol. During an observation, it was noted that the door to the shower room behind the nurses' desk was open. Inside the shower room, there were two separate closets. The closet on the left had an open door and contained a plastic box with 7 packs of cigarettes and 2 lighters. Although the plastic box had a small padlock attached to its lid, the lid was not secured. During an interview, the Administrator stated that resident smoking materials were supposed to be kept in a plastic box that was double locked, with the cigarettes and lighters stored in a locked closet in the shower room. However, the closet door was not locked, and the lid of the plastic box was not secured, leading to the deficiency.
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 80 citations issued within 25 miles in the last 12 months — including the 1 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 St. Louis
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Schnepp Senior Care And Rehabilitation Center | 1.5 mi | ★★★★★ | 4 | 0 |
| Michigan Masonic Home | 2.2 mi | ★★★★★ | 17 | 0 |
| The Laurels Of Mt. Pleasant | 14.8 mi | ★★★★★ | 2 | 0 |
| Isabella County Medical Care Facility | 14.9 mi | ★★★★★ | 8 | 0 |
| Medilodge Of Mt. Pleasant | 15.5 mi | ★★★★★ | 6 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverside Healthcare Center.
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.