Below 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 Riverbend Heights Health & Rehabilitation during CMS and state inspections, most recent first.
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.
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.
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 94 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.
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 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
Built specifically for Riverbend Heights Health & Rehabilitation.
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.