Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
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 Riverways Manor during CMS and state inspections, most recent first.
The facility failed to limit PRN psychotropic medication orders to 14 days for one resident and failed to ensure an appropriate diagnosis supported Seroquel use for another resident. One resident with dementia with psychotic disturbance remained on Seroquel without documentation addressing the black box warning, diagnosis, or behaviors, while another resident on hospice had a PRN lorazepam order for anxiety/terminal restlessness without a 14-day stop date. The DON acknowledged PRN psychotropics should have a 14-day stop date, and the Administrator stated policy should be followed.
A resident with urinary retention and an indwelling Foley catheter was observed sitting in a wheelchair with the drainage bag hanging from the chair, covered by a privacy cover, and about eight inches of tubing on the floor on multiple occasions. The resident said staff had not assisted with the catheter bag or tubing since around lunch time, and staff, the DON, and the Administrator all stated the bag and tubing should be kept off the floor and covered in a dignity bag.
Unsafe Kitchen Range Maintenance: The facility failed to keep a commercial electric range in safe, operable condition. A kitchen range had no working burner elements, several burner elements were cracked and deformed, and staff reported the burners had not worked for about 6 months. Dietary staff warmed soup in the oven because the burners did not work, the oven did not heat properly, and the steam table was kept on low because it could over boil. The DM, MS, and Administrator all acknowledged the range problems and that repairs had been requested, but the equipment remained out of service.
A resident with multiple medical conditions was repeatedly observed with genitalia exposed to the public in a LTC facility. Despite the facility's policy on maintaining privacy, staff, including CNAs and the DON, failed to address the exposure. The resident, who required substantial assistance, was left uncovered for extended periods, and staff interviews revealed inconsistent actions to ensure privacy.
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents before discharging them from Medicare Part A services, despite providing a Notice of Medicare Non-Coverage (NOMNC). The Social Services Director and Administrator were unaware of the requirement to issue an SNF ABN, leading to this deficiency.
The facility failed to accurately document MDS assessments for three residents, leading to discrepancies with medical records and care plans. A resident's MDS incorrectly indicated side rail use, another's misclassified Plavix as an anticoagulant, and a third's omitted insulin and antidepressant administration. Staff interviews revealed issues with linking diagnoses and medications in the MDS.
The facility failed to ensure timely administration and availability of medications for several residents, leading to missed doses and delays. Residents experienced issues with anxiety, depression, pain management, diabetes, and nutritional support due to unavailable or late medications. Staff interviews highlighted inconsistencies in medication administration practices and a lack of clear policy on medication refills.
A facility failed to assess, care plan, and monitor the use of a wheelchair seatbelt for a resident with cerebral palsy and other conditions. Despite the resident's high fall risk and use of a battery-operated wheelchair with a seatbelt, there was no assessment or care plan documentation. Staff interviews revealed a lack of awareness and oversight, with the DON admitting to not considering the seatbelt due to the resident's ability to remove it independently.
The facility failed to maintain proper catheter care for two residents, resulting in catheter drainage bags touching the floor. One resident's bag dragged on the floor while in a wheelchair, and another's bag touched the floor while hooked on a bed frame. Staff interviews confirmed that catheter bags should not touch the floor, highlighting a lapse in adherence to facility policy.
The facility failed to maintain infection control practices during glucometer disinfection and catheter care. An LPN did not allow the glucometer to remain wet for the required time between resident uses, and a CNA did not perform hand hygiene or change gloves appropriately during catheter care. These actions were contrary to the facility's policies and expectations.
Psychotropic Medication Orders Lacked Required Limits and Supporting Diagnosis
Penalty
Summary
The facility failed to limit the use of PRN psychotropic medication orders to 14 days for one resident and failed to ensure an appropriate diagnosis supported the use of an antipsychotic medication for another resident. Facility policy stated that PRN psychotropic medications are limited to 14 days and that diagnosis alone does not necessarily warrant psychotropic use; if a psychiatric diagnosis is part of the rationale, there must be sufficient supporting documentation that the resident meets the criteria for that diagnosis. One resident with diagnoses including dementia with psychotic disturbance, depression, anxiety disorder, and insomnia had an order for Seroquel 50 mg in the morning and 100 mg at bedtime for unspecified dementia with psychotic disturbance. The record included a GDR note stating no changes should be made because the resident was not stable enough for dose reductions, with no mention of discrepancies with the black box warning, diagnosis, or behaviors. Another resident with dementia with psychotic disturbance and hospice care had a PRN lorazepam order for anxiety/terminal restlessness, but the facility did not provide a 14-day stop date. During interviews, the DON stated PRN psychotropics should have a 14-day stop date and acknowledged that dementia is not usually an acceptable diagnosis for Seroquel, while the Administrator stated she expected policy to be followed, including the 14-day stop date and appropriate documentation for behaviors and diagnosis.
Catheter Drainage Bag and Tubing Left on Floor
Penalty
Summary
The facility failed to ensure the urinary indwelling catheter drainage bag and tubing were maintained off the floor for one resident with urinary retention and an indwelling Foley catheter. The resident had an order for monthly Foley catheter and bag changes, was identified in the MDS as using an indwelling catheter, and had a care plan directing Foley catheter care every shift and as needed, monitoring of urinary output, and assistance to the bathroom every two hours and as needed. During observations on three occasions, the resident was sitting in a wheelchair with the catheter drainage bag hanging from the wheelchair, covered by a privacy cover, and approximately eight inches of tubing lying on the floor. The resident stated staff had not assisted with the catheter drainage bag or tubing since around lunch time. Staff interviews reflected that catheter drainage bags should be placed in a dignity bag and kept off the floor, and the DON and Administrator stated they expected staff to follow the facility policy requiring the catheter tubing and drainage bag to be kept off the floor.
Unsafe Kitchen Range Maintenance
Penalty
Summary
The facility failed to maintain essential equipment in a safe and operable working condition. The kitchen had one commercial electric range with no working burner elements, and the facility did not provide a policy for equipment maintenance or current invoices related to the range repairs. Review of electric range estimates showed that replacement estimates were obtained on 07/09/25 and 08/07/25, but no further action was taken. The facility census was 46, and the deficient practice had the potential to affect all residents. During observation on 01/19/26, the kitchen range was found with no working burner elements. Dietary staff reported that soup was being warmed in the oven because the top burners did not work. The Dietary Manager stated the stove top had not worked properly for approximately six months, three top burner elements were cracked and deformed, and a pot or skillet would not sit evenly on the burners. Staff had been told not to use the burners. The oven section did not heat properly, cakes and cornbread did not cook evenly, and the steam table was kept on low because it could over boil. The Maintenance Supervisor stated the range had been looked at by an outside contractor but not serviced, and the elements needed to be replaced. The Administrator stated the burners were out of service and there might be an issue with the oven, and that the range should be repaired or replaced.
Resident Privacy Violation
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident, identified as Resident #39, by allowing the resident's genitalia to be exposed to the public. This incident was observed multiple times throughout the day, with the resident's privacy curtain open and the genitalia visible from the hallway. Several staff members, including CNAs and the Director of Nursing, walked past the room without addressing the exposure, despite the facility's policy that mandates promoting and maintaining resident privacy. Resident #39, who was admitted with multiple medical conditions including diabetes mellitus, bladder-neck obstruction, and an indwelling catheter, was observed lying in bed with genitalia exposed. The resident required substantial assistance for personal care and hygiene, yet was left uncovered for extended periods. The resident's medical records indicated intact cognition and no behaviors that would suggest an inability to understand the need for privacy. Interviews with staff revealed a lack of consistent action to address the resident's exposure. CNA F mentioned that they would pull the privacy curtain and ask the resident to cover up, but this was not consistently done. The Director of Nursing acknowledged that staff should assist residents in maintaining privacy but admitted to not always checking the rooms for exposure. The Administrator noted the resident's preference for an open door and curtain but emphasized the need for staff to educate and ensure privacy.
Failure to Issue SNF ABN Prior to Medicare Part A Discharge
Penalty
Summary
The facility failed to issue a Skilled Nursing Facility Advanced Beneficiary Notice (SNF ABN) to two residents, which is required to inform them about potential non-coverage and the option to continue services with financial liability. This deficiency was identified during a review of the medical records of two residents. For Resident #20, Medicare Part A skilled services began on May 7, 2024, and ended on June 2, 2024, with the resident remaining in the facility after the discharge from Medicare Part A services. Although a Notice of Medicare Non-Coverage (NOMNC) was provided on May 31, 2024, there was no documentation of an SNF ABN being issued. Similarly, for Resident #43, Medicare Part A skilled services started on August 14, 2024, and ended on August 30, 2024, with the resident also remaining in the facility post-discharge. A NOMNC was provided on August 27, 2024, but again, no SNF ABN was documented. Interviews with the Social Services Director and the Administrator revealed a lack of awareness and understanding regarding the requirement to issue an SNF ABN alongside a NOMNC, contributing to the deficiency.
Inaccurate MDS Documentation for Residents
Penalty
Summary
The facility failed to document accurate Minimum Data Set (MDS) assessments for three residents, leading to discrepancies between the MDS and the residents' medical records, care plans, and observations. Resident #16's MDS inaccurately indicated the use of side rail restraints, despite observations and staff interviews confirming the absence of side rails on the resident's bed. Resident #29's MDS inaccurately coded Plavix, an antiplatelet medication, as an anticoagulant, and the care plan failed to accurately reflect the medication's use. Resident #39's MDS inaccurately documented the administration of insulin and antidepressant medications, and failed to include diagnoses of anxiety and depression, despite medical records and medication administration records indicating otherwise. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and the Administrator, revealed a lack of accurate linkage between diagnoses and medications in the MDS. The DON and Administrator acknowledged the expectation for MDS accuracy, including correct documentation of diagnoses, medications, and restraints. The discrepancies in the MDS assessments for these residents highlight a failure in the facility's processes to ensure accurate and consistent documentation, as required by their policy on resident assessments.
Medication Administration and Availability Deficiencies
Penalty
Summary
The facility failed to ensure medications were available and administered within the prescribed time frame for several residents. For Resident #7, the facility did not have the prescribed buspirone available, resulting in five missed doses over two days. Similarly, Resident #16 missed doses of fluoxetine and Xalatan due to the medications being on hold while awaiting delivery from the pharmacy. Resident #17 experienced a delay in receiving hydrocodone-acetaminophen for pain management, missing four doses over two days, which was only resolved by using the emergency medication kit. Resident #25's insulin glargine was consistently administered late, with five out of eight doses given outside the prescribed time frame. This resulted in the resident being woken up after bedtime to receive the medication. Resident #29 also faced issues with medication availability, missing doses of furosemide and trazodone due to the medications being out of stock and on hold while awaiting pharmacy delivery. Resident #41 experienced delays in receiving scheduled g-tube feedings, residual checks, and flushes, with several instances of late administration or lack of documentation. The resident expressed frustration over the delays, and staff interviews revealed inconsistencies in medication administration practices. The facility's policy did not adequately address the time frame for ordering medication refills, contributing to these deficiencies.
Failure to Assess and Document Wheelchair Seatbelt Use
Penalty
Summary
The facility failed to assess, care plan, and monitor the use of a wheelchair seatbelt for a resident with cerebral palsy, muscle spasm, psychosis, and convulsions. The resident, who was admitted with these diagnoses, was observed using a battery-operated wheelchair with a seatbelt, but there was no documentation of an assessment for its use. The resident's quarterly Minimum Data Set (MDS) indicated intact cognition, impairment in both upper and lower extremities, and dependency on staff for various activities of daily living. Despite being considered high risk for falls, the care plan did not address the use of the seatbelt. Interviews with facility staff revealed a lack of awareness and oversight regarding the seatbelt's assessment and documentation. The MDS Coordinator and the Director of Nursing acknowledged that assessments for seatbelt use should be completed quarterly and reflected in the care plan. However, the Director of Nursing admitted to not considering the seatbelt for this resident because the resident could remove it independently. The facility also lacked a seatbelt policy, contributing to the oversight in assessing and documenting the seatbelt's use for the resident.
Improper Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to ensure proper care for urinary indwelling catheter drainage bags for two residents, resulting in the bags touching the floor. Resident #29, who was admitted with a diagnosis of neurogenic bladder, had a physician's order for Foley catheter care every shift and a monthly catheter change. Observations revealed that the resident's catheter drainage bag was hanging from the wheelchair and dragging on the floor while being pushed to the dining room. The dignity bag covering the catheter was inadequate, leaving the drainage bag exposed and in contact with the floor. Similarly, Resident #39, admitted with diagnoses of bladder neck obstruction and unspecified hydronephrosis, had orders for monthly catheter changes and irrigation as needed. Observations showed the resident's catheter drainage bag touching the floor while hooked on the bed frame. Interviews with facility staff, including an LPN, RN, CNA, the Director of Nursing, and the Administrator, confirmed that catheter drainage bags should not touch the floor, indicating a lapse in adherence to facility policy and proper catheter care procedures.
Infection Control Deficiencies in Glucometer Disinfection and Catheter Care
Penalty
Summary
The facility failed to maintain proper infection control practices during the disinfection of a glucometer used for glucose monitoring for three residents. Observations revealed that the Licensed Practical Nurse (LPN) did not allow the glucometer to remain wet for the required two minutes with a disinfectant wipe between each resident use. This was contrary to the manufacturer's disinfection directions and the facility's expectations as stated by the Director of Nursing (DON) and other nursing staff. The facility also did not provide a policy on cleaning and disinfecting the glucometer. Additionally, the facility failed to maintain infection control practices during catheter care for one resident. The Certified Nursing Assistant (CNA) did not perform hand hygiene or change gloves appropriately during the catheter care process. The CNA touched various surfaces and items without changing gloves or performing hand hygiene, which is against the facility's hand hygiene policy. The CNA also did not follow proper procedure for cleaning the catheter tubing, particularly for an uncircumcised resident, as described by the DON and other nursing staff. Interviews with the staff, including the LPN, RN, and DON, confirmed the expected procedures for both glucometer disinfection and catheter care, which were not followed during the observed incidents. The facility's failure to adhere to these infection control practices poses a risk of cross-contamination and infection among residents.
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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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Nursing homes near Van Buren
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brent B Tinnin Manor | 16.7 mi | ★★★★★ | 0 | 0 |
| Clark's Mountain Nursing Center | 20.3 mi | ★★★★★ | 0 | 0 |
| Current River Nursing Center, Inc | 27.3 mi | ★★★★★ | 9 | 0 |
| Rock Point Nursing Center | 28.1 mi | ★★★★★ | 11 | 0 |
| Greenville Health Care Center | 30.8 mi | ★★★★★ | 0 | 0 |
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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 July 2026) and official state health department websites.