Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverbend Heights Health & Rehabilitation during CMS and state inspections, most recent first.
The facility failed to maintain a complete infection prevention and control program for Legionella and other water-borne pathogens, with an incomplete water management program, missing risk assessment elements, and unanswered CDC assessment items. It also failed to keep accurate infection surveillance logs for 12 months, with multiple months inaccurate or incomplete and the IP unsure whether prior tracking was correct. In addition, staff did not follow EBP for a resident with chronic wounds and Alzheimer’s disease, as the resident’s door lacked EBP signage and PPE availability until staff placed them later, and staff reported they had not been using EBP before then.
Incomplete Antibiotic Stewardship Surveillance: The facility failed to maintain an effective antibiotic stewardship program to monitor antibiotic use and outcomes. The infection control log showed missing or incomplete surveillance data for multiple months, and interviews revealed the prior IP had lost the tracking log, the current IP was rebuilding it, and staff including a CMT, an LPN, and the DON could not clearly explain the program or its requirements.
Psychotropic medication side effect monitoring was not in place for five residents receiving antipsychotic, antianxiety, and/or antidepressant medications. Records showed multiple psychotropic orders for residents with diagnoses such as depression, bipolar disorder, schizophrenia, delusional disorder, anxiety, schizoaffective disorder, and vascular dementia, but no corresponding monitoring orders or documentation on the MAR/TAR. Interviews with the resident, CMT, LPN, and DON confirmed that staff were expected to monitor and document psychotropic side effects, yet this was not occurring.
Failure to provide individualized activities: A resident with severe visual impairment and cognitive decline, a resident with Alzheimer’s disease, and a resident with dementia and mood disturbance did not receive consistent, preference-based activity programming. Records and staff interviews showed limited or absent 1:1 engagement, activity calendars that were not tailored to the residents’ abilities, missed opportunities for music, sensory, and small-group activities, and inaccurate or inconsistently shared calendars on the memory care unit.
Surveyors observed unclean floors in the dry storage room, walk-in refrigerator, and walk-in freezer, with plastic, foil, cardboard, tape, and a hair net left under baker’s racks on repeated checks. They also found excessive crumbs in the conveyor toaster, yellow splatters in the microwave, overly scored cutting boards, and a plastic food cover with flaking plastic. The DM stated food should be free from foreign substances and that worn cutting boards and plastic domes should be replaced when no longer serviceable.
A resident admitted with MDD later developed additional psychiatric diagnoses, including schizoaffective disorder, bipolar type, along with ongoing delusions, paranoia, and behavioral issues such as threats, aggression, and fixed false beliefs about bullets in the body. The record showed no PASRR Level II evaluation and no documentation of referral to the State mental health authority after the serious mental illness diagnosis was identified, and no care plan incorporated PASRR Level II recommendations.
Behavioral Care Plan Lacked Person-Centered Interventions: A resident with schizoaffective disorder, anxiety, cognitive impairment, and movement disorder had care plans for yelling, disrobing, throwing items, and aggression, but the documented interventions were generic and did not include the individualized calming approaches staff described. Staff reported the resident responded to music, snacks, showers, touch, hand massages, folding towels, writing, and 1:1 attention, yet observations showed repeated episodes of loud yelling and throwing items with no calming intervention in place, while the DON stated behavioral interventions should be resident-centered and reflect the resident’s preferences and needs.
A resident admitted with severe protein-calorie malnutrition had IV fluids running through a PICC line, but the order summary did not identify the PICC or its location and did not include PICC site care or monitoring orders. Although the care plan later listed central line/PICC interventions, observations confirmed the PICC in the left upper arm with IV fluids infusing, and RN and DON interviews stated the orders should have accurately reflected the access type, assessment frequency, dressing changes, and complication monitoring.
A resident with multiple serious respiratory infections, MRSA, sepsis, tracheostomy, and gastrostomy was discharged from the hospital with an order for Zerbaxa IV every eight hours, with no oral alternative due to NPO status. After readmission, the resident returned without IV access, staff were unable to start an IV, and the resident was sent to the hospital where a PICC line was placed and one dose of Zerbaxa was given, with instructions to continue the course. Back at the facility, Zerbaxa was not entered on the MAR or TAR, pharmacy reported delays, and the resident missed multiple scheduled doses while remaining in the facility. Interviews showed staff and providers knew Zerbaxa was the only effective antibiotic, that payment issues and the high cost delayed obtaining it, and that the resident ultimately did not receive any Zerbaxa doses at the facility during this period.
The facility failed to maintain cleanliness and proper food storage, with grease buildup, dust, and unlabeled items in the kitchen. Milk was stored at unsafe temperatures, and there was a shortage of dishes, affecting meal service. Cutting boards were not easily cleanable, and staff did not sanitize thermometer probes. The Maintenance Director was not informed about cleaning needs, and the Administrator noted delays in dish collection.
The facility failed to maintain the walk-in fridge and automated dishwasher in proper working order. The fridge was operating above the required temperature due to a broken control knob, and the dishwasher failed to spray on the first cycle due to a malfunctioning motor and calcium buildup. These issues persisted for weeks without resolution.
The facility failed to maintain a clean and safe environment, with rust on a commode riser, dust buildup in ceiling vents and fans, and indentations on a commode seat. The Maintenance and Housekeeping Directors indicated a lack of communication and coordination in addressing these issues.
The facility failed to include necessary dosage parameters in medication orders for Acetaminophen for three residents. The orders lacked the specification of not exceeding three grams in 24 hours, which is crucial to prevent toxicity. Staff interviews confirmed the absence of these parameters, and the DON was unaware of the issue despite having expectations for such parameters to be included.
The facility failed to maintain proper drainage, resulting in backups and odors in storage areas, and did not ensure cleanliness in the Serenity Unit dining room and laundry room. Additionally, a restroom ceiling vent in a resident room was found to be loose due to missing screws.
The facility failed to maintain cleanliness in the kitchen, leading to an ant infestation. Observations revealed unwashed dishes from the previous night and ants around the soiled dishes. The Dietary Manager acknowledged that the dishes should have been washed earlier. This affected the kitchen area with a census of 92 residents.
A resident with cognitive impairments and specific activity preferences was not provided with individualized or adapted activities in a LTC facility. Despite interests in music, animals, and religious services, the resident primarily attended BINGO and food-related activities. Observations showed a lack of engagement and interaction, and activity calendars lacked specific times or locations for activities. Interviews revealed inconsistent activity offerings and a lack of 1:1 attention to the resident's preferences.
A resident with PTSD did not receive a meal during lunch service, despite being in full view of staff, triggering feelings of anxiety and isolation. The facility's new meal service process failed to ensure the resident received a meal, as the meal card was not properly managed. The oversight highlighted a deficiency in the facility's trauma-informed care and meal service process.
The facility failed to ensure dietary staff followed the recipe for pureed eggs, leading to unpalatable food. During breakfast preparation, a disorganized recipe book was found, and a staff member prepared eggs without consulting it, omitting salt, pepper, and margarine. The eggs were bland, and the staff member did not taste them before serving. This affected two residents on pureed diets.
A resident with intellectual disabilities and behavioral issues accessed a sharps container on a medication cart and poked their finger with an insulin pen needle while left unsupervised by an LPN. The sharps container was overfilled, and the resident lifted the lid to access the needle.
Infection Control Program, Surveillance Logs, and EBP Failures
Penalty
Summary
The facility failed to establish and maintain a comprehensive infection prevention and control program for Legionella and other water-borne pathogens. The facility’s water-borne pathogen prevention binder showed no facility-specific risk assessment based on ASHRAE standard 188, a CDC toolkit assessment with eight unanswered questions, no CDC Legionella Environmental Assessment Form, and an incomplete Water Management Program workbook with blank or unanswered sections for facility information, water safety program details, narrative description, control measures, and validation techniques. The facility’s water flow chart showed three separate water mains serving different sections of the building, and the DOM stated he and the Administrator coordinated the Legionella program while taking water temperatures and spot-checking sinks and showers on a rotating schedule. The facility also failed to maintain complete infection surveillance logs for twelve months. Review of the Infection Control Log from April 2025 through March 2026 showed inaccurate information in multiple months and missing or incomplete information in several others. Corporate nursing staff stated the prior IP had lost the 2025 infection tracking log/book, the current IP had rebuilt it, and the current IP was also completing the 2026 log/book. The current IP stated he/she had only been in the role for about three weeks, had not been given time to fix the logs, and was unsure whether the prior IP had tracked infections correctly. Facility staff, including a CMT, LPN, DON, and the IP, identified the IP as responsible for tracking infections and monitoring trends. The facility failed to ensure Enhanced Barrier Precautions were followed for a resident with chronic wounds. The resident had Alzheimer’s disease with moderately impaired cognition and had a care plan directing EBP for wound care to the right dorsal second toe and right back leg, with gown and gloves required for wound care and other high-contact care activities. Observation on multiple days showed no EBP sign on the resident’s door and no PPE organizer or readily available PPE in the room until staff placed them on the morning of 3/26/26. CNA A, Bath Aide A, and LPN A stated they had not been following EBP for the resident before that morning, and LPN B confirmed the sign and PPE organizer were placed that morning. The IP and DON stated the resident should have had EBP in place because of the wounds.
Incomplete Antibiotic Stewardship Surveillance
Penalty
Summary
The facility failed to ensure an antibiotic stewardship program was in place to monitor how antibiotics were prescribed and used by residents. The facility’s policy required antibiotic usage and outcome data to be collected on a facility-approved surveillance tracking form, with all clinical infections treated with antibiotics reviewed by the Infection Preventionist (IP) or designee. The policy also required each resident’s antibiotic regimen to be documented with information including the resident name and medical record number, unit and room number, date symptoms appeared, antibiotic name, start date, pathogen identified, site of infection, culture date, stop date, total days of therapy, outcome, and adverse events. Review of the Infection Control Log from April 2025 through March 2026 showed missing or incomplete antibiotic stewardship surveillance data for multiple months, including April through September 2025, November and December 2025, and January and February 2026. During interviews, Corporate Nurse A stated the facility had recently terminated the prior IP for not fulfilling job duties, the prior IP had lost the 2025 infection tracking log/book that included antibiotic surveillance, and the current IP had been in place for about three weeks and was rebuilding the log/book. The current IP stated he/she had not been given time to fix or verify the accuracy of the 2025 and 2026 infection tracking logs and was unsure whether the prior IP had completed antibiotic surveillance correctly. Staff interviews showed uncertainty about antibiotic stewardship, with a CMT unsure the program existed and an LPN describing it as resident education rather than surveillance, while the DON stated all staff were educated but could not explain what the program entailed.
Psychotropic Medication Side Effect Monitoring Not Documented
Penalty
Summary
The facility failed to ensure psychotropic medication side effect monitoring was in place for five sampled residents who were receiving antipsychotic, antianxiety, and/or antidepressant medications. Review of facility policies showed that residents should only receive antipsychotic medication when necessary, and nursing staff and the interdisciplinary team were expected to monitor and report side effects and adverse consequences of psychotropic medications. The deficiency was identified through observation, interview, and record review for residents with diagnoses including depression, schizophrenia, bipolar disorder, delusional disorder, generalized anxiety disorder, schizoaffective disorder, vascular dementia, and major depressive disorder. For one resident, the record showed multiple scheduled psychotropic medications, including alprazolam, buspirone, mirtazapine, quetiapine, and sertraline, but there were no orders for monitoring target symptoms or potential side effects. During interview, the resident stated staff did not ask about mood or medication side effects. For another resident with delusional disorder, recurrent major depressive disorder, and generalized anxiety disorder, the record showed buspirone, lamotrigine, and risperidone, but there was no order or documentation for psychotropic side effect monitoring, despite a care plan intervention to monitor, document, and report adverse reactions. A third resident with generalized anxiety disorder, schizoaffective disorder, and recurrent major depressive disorder had orders for aripiprazole and sertraline, but no order or documentation for antipsychotic side effect monitoring. Another resident with vascular dementia, bipolar disorder, and major depressive disorder had orders for aripiprazole and citalopram, and although the care plan included monitoring for psychotropic complications, the MAR and TAR for three months showed no monitoring documentation. A fifth resident with bipolar disorder had escitalopram and quetiapine ordered through a PEG tube, with care plan interventions calling for monitoring every shift, but the MAR and TAR showed no side effect monitoring documentation. Interviews with CMT, LPN, and the DON confirmed that psychotropic side effect monitoring should be documented and that specific orders were needed for staff to document it.
Failure to Provide Individualized Activities
Penalty
Summary
The facility failed to provide individualized activities that matched residents’ preferences and abilities for three sampled residents. The Activities Program policy stated that activities were to be based on resident-centered assessments and preferences, scheduled seven days a week, and designed to meet each resident’s interests and psychosocial needs. However, the record showed that the activity calendars and activity offerings on multiple units were largely geared toward residents with better eyesight, hand dexterity, mobility, and cognition than some of the sampled residents, and that group activities were scheduled back-to-back with very limited time for 1:1 activities. One resident with schizoaffective disorder, anxiety, glaucoma, movement disorder, and progressive cognitive decline was severely visually impaired, used a wheelchair, and liked music, snacks, folding laundry, and sitting near the nurses’ station. Although the care plan and evaluations identified these preferences, the quarterly activity notes did not show what 1:1 activities were actually offered or whether repeated attempts were made to engage the resident when he/she was napping. Documentation for late February and March showed participation in only a few food-related events, with no documentation explaining why the resident did not participate in multiple scheduled music, food, or sensory activities. Observations showed the resident hollering in the common area without soothing activity such as music, and later screaming alone in the room while other residents were in BINGO, with no staff attempt documented to provide calming activity. Staff interviews described the resident as someone who would benefit from adapted, sensory, and 1:1 activities such as music, hand massages, nail care, hair care, and other tactile experiences, but activities staff reported they did not provide 1:1 activities on the unit and that staffing and scheduling made it difficult to do so. A resident with Alzheimer’s disease and cognitive communication deficit had an activity evaluation identifying preferences for family visits, movies, music, talk radio, parties, television, and small group or 1:1 activities in the afternoon. The care plan included 1:1 activities because the resident preferred to stay in the room and not socialize, but the resident stated he/she was unaware of when activities occurred and had not been offered an activity on one date reviewed. The 1:1 activity record showed only 18 documented activities over several months, including multiple entries where the resident was asleep when staff visited and a month-long gap with no recorded 1:1 activities. A resident with unspecified dementia and mood disturbance had an MDS showing music, groups, favorite activities, and religious services were important, and the resident said he/she liked bingo, crafts, audiobooks, shopping, and games. The activity evaluation noted the resident liked bingo but was unwilling to provide preferred activity information, and the care plan stated the resident preferred to stay in bed most days but attended bingo when he/she felt like it. Staff reported the memory care unit was not invited to activities outside the unit, calendars were not always provided, the monthly calendar for the memory care unit was inaccurate, and residents often slept through activities. The Activities Director acknowledged the calendar had been copied from another unit without editing, that the memory care unit was not consistently given calendars in recent months, and that residents on the memory care unit were typically not invited off the unit because it confused them.
Unsanitary kitchen floors and worn food service equipment
Penalty
Summary
The kitchen, dry storage room, walk-in refrigerator, and walk-in freezer floors were not kept clean during repeated surveyor observations. On 3/23/26, surveyors observed plastic, foil, cardboard, tape, and a hair net on the floors under baker’s racks in the walk-in refrigerator, dry storage room, and walk-in freezer. The same miscellaneous trash was still present on 3/24/26. The Dietary Manager stated the floors in these areas were swept twice a week, while the Administrator stated they should be swept daily. Surveyors also observed food preparation equipment and items that were not maintained in sanitary or serviceable condition. The conveyor toaster had excessive crumbs under the belt and in the bottom landing area, and the microwave had yellow splatters on its ceiling and around a plate during multiple observations. Light blue and red cutting boards were overly scored, and a breakfast test plate cover had flaking plastic around the inside rim. The Dietary Manager stated food should be free from foreign substances, and that cutting boards and plastic food domes should have been replaced when no longer serviceable; the Administrator also stated cutting boards should be replaced when excessively scored and plastic food covers when worn and flaking.
Failure to Refer Resident With New Serious Mental Illness for PASRR Level II Review
Penalty
Summary
The facility failed to refer one resident with a serious mental disorder to the State-designated authority for a PASRR Level II review after the resident developed new psychiatric diagnoses following admission. The resident was admitted with a diagnosis of major depressive disorder, but the Level I PASRR completed at admission did not identify a current or historical major mental illness and did not identify major depressive disorder as a current diagnosis. The facility’s PASRR policy stated that the nursing facility must notify the state mental health/intellectual disability authority of significant changes in residents with mental disorders or ID, and that referral should be made as soon as criteria indicative of a significant change is evident. The resident’s record showed multiple behavioral and psychiatric concerns over time, including scratching self and saying staff did it, threatening staff with eating utensils, believing the guardian murdered people, asking other residents to buy snacks and accusing them of stealing money, cursing at and threatening staff, and being verbally aggressive with other residents related to hallucinations. A psychiatric progress note later added generalized anxiety disorder and schizoaffective disorder, bipolar type, and the medical record showed both diagnoses with an onset date of 5/13/24. The annual MDS later documented anxiety disorder, depression, and schizoaffective disorder, along with antidepressant, antianxiety, and later antipsychotic medication use. On review of the electronic medical record, there was no PASRR Level II evaluation after the resident was diagnosed with a serious mental illness and no documentation of referral to the state mental health authority for such an evaluation. There was also no care plan that referred to or incorporated PASRR Level II recommendations. During interviews, the resident described fixed beliefs about bullets in the body and became agitated when discussing them, and staff reported ongoing delusional and paranoid thoughts. The MDS Coordinator stated the new serious mental illness diagnosis should have triggered a PASRR Level II referral, and the Administrator stated that a resident diagnosed with a serious mental disorder should be referred to the State authority for a PASRR Level II evaluation.
Behavioral Care Plan Lacked Person-Centered Interventions
Penalty
Summary
The facility failed to develop a behavioral care plan that incorporated person-centered interventions for one resident with significant behavioral symptoms. The resident had diagnoses including schizoaffective disorder, extrapyramidal and movement disorder, glaucoma, anxiety disorder, and senile degeneration of the brain. The resident’s care plans addressed refusal of care, verbal and physical aggression, yelling, disrobing, throwing items, and placing self on the floor, but the documented interventions were largely generic, such as explaining procedures, monitoring circumstances, diverting attention, and talking with the resident while passing by. The resident’s records showed that he/she was severely cognitively impaired and valued showers, snacks, and music. Staff interviews identified multiple individualized calming approaches that were not reflected in the behavioral care plans, including giving the resident pen and paper to write, folding clothes or towels, listening to music or a radio, warm showers, head or hand massages, fragrant lotion, holding hands, soft touch, a stuffed ladybug massager, a blanket for texture and warmth, snacks, soda, quiet 1:1 attention, and sitting with the resident while watching TV. Staff also stated the resident was more lucid and smiled when family visited, and that connection with others was important to the resident. Observations showed the resident yelling loudly in common areas and in his/her room with no staff intervention or calming activity taking place. On one occasion, the resident threw shoes and sunglasses while continuing to holler, and another resident left the area because of the yelling. On another occasion, the resident screamed non-stop in the room while no music was playing and no staff were present to soothe him/her. In contrast, a later observation showed the resident becoming calm and focused when a CNA softly talked to him/her while giving Jello and lightly touching the resident’s shoulder. The DON stated that behavioral interventions should be resident-centered and reflect the resident’s preferences and needs, and staff were responsible for knowing and implementing the care plan interventions.
Missing PICC Line Orders and Care Plan
Penalty
Summary
The facility failed to ensure one sampled resident had orders and a plan of care in place for a PICC line. The resident was admitted with unspecified severe protein-calorie malnutrition and had orders for IV fluids at 83 ml/hour and for an IV or implanted port dressing change, but the order summary did not identify that the resident had a PICC line or its location, and there were no orders for PICC site care or monitoring. The resident's significant change MDS did not indicate the resident had a PICC line or received IV medications, although the care plan later included interventions for a central line IV/PICC line such as flushing per policy, inspecting the site, monitoring catheter length, and monitoring for complications. Observations showed the resident had a PICC line in the left upper arm with IV fluids infusing at 83 ml/hour on multiple dates. During interview, RN A stated the resident had a PICC line access, the port had been removed during the last hospitalization, and the PICC line was being used for IV fluids; RN A also stated the orders should have identified the PICC line, included measurements, site assessment frequency, and dressing change frequency. The DON stated the IV access type orders should have been accurate, should have included assessment every shift, complications to monitor for, who to notify, and when to flush and change the dressing, and said the ADON was responsible for checking and verifying that orders were correct on admission or readmission.
Failure to Administer Ordered IV Antibiotic for Medically Complex Resident
Penalty
Summary
The deficiency involves the facility’s failure to provide a prescribed IV antibiotic, Zerbaxa, to a resident as ordered following readmission from the hospital. The resident had multiple serious diagnoses, including ventilator-associated pneumonia, COPD, acute respiratory failure, MRSA pneumonia and sepsis, bronchopneumonia, traumatic brain injury, tracheostomy status, and gastrostomy status, and was not cognitively intact per the reentry MDS. Hospital discharge instructions ordered Zerbaxa IV every eight hours through a specified completion date, and the facility’s physician order sheet reflected Zerbaxa 3000 mg IV every eight hours for six days. The resident was NPO and dependent on a feeding tube, and Zerbaxa was only available as an IV medication, making IV access and timely administration essential to follow the ordered regimen. Upon the resident’s return to the facility, nursing staff documented that the resident arrived without IV access. On the following day, nursing staff attempted twice to place an IV line without success and then sent the resident to a nearby hospital for vascular access. At the hospital, a PICC line was placed, and one dose of Zerbaxa was administered, with instructions that staff were to continue the antibiotic through the previously prescribed end date. The resident returned to the facility the same day with the PICC line in place. However, the medication administration records (MAR and TAR) for December did not contain any order entries for Zerbaxa, and there is no documentation that any doses of Zerbaxa were administered at the facility. Nursing notes indicated that on one day the pharmacy reported being backed up and would send the antibiotic later that evening, and the DON later stated the resident missed multiple scheduled doses over two days. Interviews with the RN, physician, NP, and DON revealed that the facility was aware of difficulties obtaining the specialty compounded medication, including that Medicaid had denied payment and that the facility owner was reportedly unwilling to pay for it. The physician and an infectious disease physician had agreed that there was no substitute for Zerbaxa and that it was the only appropriate antibiotic for the resident’s infection. Despite this, the medication was not available and not administered at the facility, and the resident went without the ordered doses while remaining in the facility. The NP and physician both stated they were unaware during this period that the resident was not receiving the ordered Zerbaxa at the facility.
Facility Fails to Maintain Cleanliness and Food Safety Standards
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage practices in the kitchen and dining areas, as observed during multiple inspections. There was a significant buildup of grease and grime under the deep fat fryer and the six-burner stove, as well as dust on the wall-mounted fan and ceilings, including the sprinkler heads. Unidentified items were found in the reach-in fridge, and several food items, such as beef paste, chicken base, and lemon juice, were not refrigerated as required by their labels. Utensils were stored in containers with food debris, and two containers of a white powdery substance were not labeled. Additionally, the lower spray wand of the dishwasher was clogged with debris, and the floor of the walk-in fridge had a buildup of grime. During the breakfast meal preparation, further issues were noted, including the absence of a thermometer in the Serenity Court kitchenette and milk being stored at an unsafe temperature of 53.2°F. The facility also lacked sufficient dishes, such as coffee cups and silverware, to serve residents, leading to delays in meal service. Cutting boards were found to be in poor condition, with numerous indentations and stains that rendered them not easily cleanable. The dietary staff did not sanitize the thermometer probe before use, and the chicken in the walk-in fridge was not dated when removed from the freezer. Interviews with staff revealed that the dietary department was short on essential items like plate covers and that the cleaning of certain areas, such as the dishwasher nozzles and the walk-in fridge floor, was not performed regularly. The facility's Maintenance Director was not informed about the need to clean the kitchen ceilings and sprinkler heads. The Administrator acknowledged that the shortage of dishes might be due to delays in collecting them after meals, leading to increased use of disposable plates.
Failure to Maintain Kitchen Equipment
Penalty
Summary
The facility failed to maintain essential kitchen equipment, specifically the walk-in fridge and the automated dishwasher, in proper working order. Observations on multiple occasions revealed that the walk-in fridge was operating at temperatures above the required 41 degrees Fahrenheit, with readings of 46.5 and 46.4 degrees Fahrenheit. Interviews with the Maintenance Director and Dietary Manager indicated that the temperature control knob was broken, preventing adjustments. The issue had persisted for about three weeks, and the Maintenance Director was unaware of the problem until it was pointed out by a state surveyor. The Administrator was also not informed about the improper temperature settings. The automated dishwasher was also not functioning correctly, as it failed to spray on the first cycle. The Dietary Manager reported that the dishwasher had been delimed, but the problem persisted. The Maintenance Director was informed about the issue but had not yet inspected the dishwasher, acknowledging that the repair might require a service professional. A subsequent phone interview revealed that the dishwasher's motor was malfunctioning, and there was a calcium buildup in the pump, which contributed to its improper operation.
Facility Fails to Maintain Clean and Safe Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, as evidenced by several observations and interviews. In one instance, a commode riser in a resident's room was found to have rust spots, making it not easily cleanable. The Maintenance Director was unaware of this issue until it was pointed out during the survey. Additionally, there was a heavy buildup of dust in the restroom ceiling vents of multiple resident rooms, as well as in the Greystone shower room and the resident smoke room. The Maintenance Director indicated that the housekeeping department was responsible for cleaning these areas, but the issue persisted. Further observations revealed numerous indentations on the commode seat in the Greystone shower room, rendering it not easily cleanable. A personal fan in a resident's room also had a heavy buildup of dust. Interviews with the Housekeeping Director and Supervisor indicated that while the housekeeping department had tools to clean these areas, there was a lack of communication and coordination between departments, leading to the deficiencies observed. The facility census at the time was 92 residents.
Failure to Include Acetaminophen Dosage Parameters
Penalty
Summary
The facility failed to include necessary parameters in medication orders for medications containing Acetaminophen for three residents. Specifically, the orders did not specify the maximum allowable dosage of three grams of Acetaminophen in 24 hours from all sources. This oversight was identified in the medication orders for three residents, who were prescribed various dosages of Acetaminophen for pain management. The absence of these parameters was confirmed through interviews with staff, including Certified Medication Technicians and a Licensed Practical Nurse, who acknowledged the importance of these parameters to prevent potential toxicity. The Director of Nursing (DON) expressed an expectation that all orders containing Acetaminophen should include the parameter of not exceeding three grams in 24 hours. The DON also expected nurses to ensure this parameter was added to all relevant orders and to contact the doctor if it was missing. Despite these expectations, the DON was unaware of the missing parameters, and it was noted that the Assistant Director of Nursing was responsible for auditing new orders. The deficiency was highlighted during interviews with staff, who confirmed the absence of the necessary parameters in the medication orders for the affected residents.
Facility Maintenance and Cleanliness Deficiencies
Penalty
Summary
The facility failed to maintain several areas in good repair, leading to potential health and safety issues for residents and staff. Observations revealed a brownish substance with particles backing up through the drains in the dry goods storage room and the walk-in refrigerator, accompanied by a pungent smell of standing water. The Maintenance Director confirmed that the drainage pipes were collapsed, causing improper drainage. The Dietary Manager noted that the drainage issue had persisted for at least four years, and the Administrator was aware of the backup but believed it was a one-time occurrence. Additionally, the facility did not maintain cleanliness in several areas. There was a heavy buildup of dust under the vending machines in the Serenity Unit dining room, which the Housekeeping Director attributed to not requesting the vending machine company to move the machines for cleaning. In the laundry room, fans had a heavy buildup of dust, and the Housekeeping Director admitted they had not been cleaned since December 2023. Furthermore, a restroom ceiling vent in a resident room was found to be loose due to missing screws, as noted by the Maintenance Director.
Ant Infestation Due to Unwashed Dishes in Kitchen
Penalty
Summary
The facility failed to maintain cleanliness in the kitchen area, specifically near the window and the two-compartment sink, which resulted in an ant infestation. Observations made on June 13, 2024, at various times in the morning, revealed numerous unwashed dishes from the previous night and the presence of ants around the soiled dishes. During an interview, the Dietary Manager acknowledged that the dishes left at the window sill area should have been washed the previous night. This deficiency affected the kitchen area of the facility, which had a census of 92 residents.
Failure to Provide Individualized Activities for Resident
Penalty
Summary
The facility failed to ensure that activities identified as being of interest to a resident with Huntington's disease, major depression, and anxiety disorder were offered daily on a 1:1 basis or adapted to meet the resident's cognitive and physical limitations. The resident, who was significantly cognitively impaired and required assistance with activities of daily living, had expressed interests in activities such as listening to music, being around animals, and participating in religious services. However, the facility did not provide individualized or bedside activities, and there was no documentation explaining why the resident did not engage in these activities. Observations over several months revealed that the resident was often not engaged in any group or 1:1 activities, and there was a lack of interaction with staff. The activity calendars for the resident's unit did not include specific times or locations for activities, and there were no designated 1:1 or bedside activity times. Despite the resident's interest in music and religious activities, participation logs showed that the resident primarily attended BINGO and food-related activities, with no participation in music, pet/animal, or religious activities. Interviews with activity assistants and the Director of Nursing indicated that activities were not consistently offered on the resident's unit, and there was a lack of individualized attention to the resident's preferences. The activity staff acknowledged that they had not conducted 1:1 activities with the resident, despite the resident's capability to engage in simple activities with assistance. The facility's failure to provide appropriate activities and document the resident's participation or lack thereof contributed to the deficiency.
Failure to Provide Trauma-Informed Care During Meal Service
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with Post-Traumatic Stress Disorder (PTSD), resulting in the resident not receiving a meal during lunch service. The resident, who had a history of trauma related to homelessness and brain tumor surgery, was seated in an open area in full view of staff during meal service. Despite being visible, the staff passed by the resident multiple times without serving a meal, and the kitchen window was closed after meal service without the resident receiving lunch. The resident expressed feelings of anxiety and isolation due to not receiving a meal, which triggered memories of past trauma, including being bullied as a child and experiencing homelessness. The resident reported that this oversight happened often, and staff ignored him/her, making him/her feel invisible. The Social Services Director acknowledged the resident's PTSD and the potential for not receiving a meal to trigger an emotional response related to past trauma. The facility had recently implemented a new meal service process involving laminated meal cards, which were intended to ensure all residents received their meals. However, the system failed in this instance, as the resident's meal card was not placed back with the others, leading to the oversight. The Director of Nursing expected staff to notice if a resident did not receive a meal and to address the issue, but this did not occur, highlighting a deficiency in the facility's meal service process.
Failure to Follow Recipe for Pureed Eggs
Penalty
Summary
The facility failed to ensure that dietary staff followed the recipe for pureed eggs, resulting in the eggs being unpalatable. This deficiency was observed during a breakfast meal preparation, where a disorganized recipe book was found, and the dietary staff member, referred to as DC A, prepared pureed eggs without consulting the recipe. DC A added cold milk and an unmeasured amount of thickener to the eggs, without adding salt, pepper, or margarine as specified in the recipe. The state surveyor noted that the eggs had a bland taste, and DC A did not taste the eggs before serving them. Interviews revealed that DC A was not properly trained in making pureed foods and was instructed by a previous Dietary Manager not to add salt. Another dietary staff member, DC B, mentioned tasting all pureed foods except those containing eggs and onions, relying on dietary aides to taste those items. The current Dietary Manager expected cooks to taste everything they prepared, but acknowledged that DC A was following previous instructions not to add salt. This practice potentially affected two residents on pureed diets in a facility with a census of 92 residents.
Resident Accesses Sharps Container and Pokes Finger
Penalty
Summary
The facility failed to provide adequate protective oversight for a resident who accessed a sharps container on the medication cart, found the tip/needle portion of an insulin pen, and poked their finger. The resident, who had intellectual disabilities and a history of behavioral and mental disorders, was left unsupervised when an LPN left the nurse's station to use the restroom. Upon returning, the LPN found the resident with the insulin pen needle in their hand, having poked their finger. The sharps container was found to be filled just above the fill line, and the resident had lifted the protective lid to access the needle. The resident's care plan indicated that they were not cognitively intact and had severe mood issues and behaviors that put them and others at risk. Despite this, the resident was left unsupervised, leading to the incident. The LPN acknowledged that they should have arranged for another staff member to watch the resident, given the resident's impulsivity and curious nature. The facility's policy for sharps disposal required that containers be sealed and replaced when 75% to 80% full, but this was not adhered to in this case. The facility's follow-up investigation confirmed that the resident was monitored for any adverse reactions and that there were no changes in their health status. The Administrator and ADON stated that they would have expected the sharps container to be emptied once it was half full and the lid to be completely closed after placing the insulin pen needle in the box. They also expected staff to notify another staff member to watch the resident while the LPN was away.
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What surveyors actually found near you
We read the 96 citations issued within 25 miles in the last 12 months — 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.
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lexington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Shirkey Nursing And Rehabilitation Center | 8.5 mi | ★★★★★ | 0 | 0 |
| Meyer Care Center | 9.6 mi | ★★★★★ | 1 | 0 |
| Odessa Health Care Center | 12.3 mi | ★★★★★ | 34 | 0 |
| Aspire Senior Living Oak Grove | 17.7 mi | ★★★★★ | 0 | 0 |
| Apple Ridge Care Center | 19.7 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release October 2026) and official state health department websites.