Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Heights Healthcare Center during CMS and state inspections, most recent first.
Residents reported that an LPN was rude, pushy, snappy, and condescending during medication passes and other interactions, with one resident saying the nurse refused to let him take meds after eating and stayed in his room until he complied. Six cognitively intact residents raised the same concern, and the Resident Council President said residents believed reporting the issue would not help because staff would side with the nurse. The DON stated this behavior was a serious violation of resident dignity and respect, and the Administrator acknowledged prior reports about the LPN.
Restriction of Resident Congregation in Activity Area: Cognitively intact residents reported they were not allowed to gather in the activity/dining area in the evening to play dominoes or socialize unless a staff member was present to monitor them. An LPN acknowledged the restriction was due to lack of available staff, and the Administrator stated residents were not permitted to congregate unsupervised because of past allegations between residents. The affected residents said the practice treated them like children and violated their rights.
The facility failed to develop and implement comprehensive person-centered care plans for two residents. One resident had EBP care planned for PEG tube-related close contact care, but an LPN administered medication without wearing the required gown and admitted she did not follow the care plan. Another resident had orders for staff to perform colostomy and suprapubic catheter care, but staff stated the resident was doing the care himself, no physician order or assessment supported self-care, and nurses were signing the ETAR as if the ordered care had been completed.
Failure to follow ordered colostomy and suprapubic catheter care for a cognitively intact resident. The resident stated he performed his own care, while the DON confirmed there was no physician order or assessment allowing self-care and that nurses had been signing the ETAR as if they completed the care. An RN also confirmed she knew the resident was doing the care himself and had still signed the ETAR.
A resident with chronic pain, including pain in both legs, the feet, and back, repeatedly reported pain at a level of 6 or higher and said his current pain meds were not strong enough. Nursing staff documented the ongoing complaints and said they were reported to the NP, but the regimen was not adjusted. The NP stated she normally evaluates frequent pain complaints and may change meds or refer to Pain Mgmt, but in this case she missed the repeated pain reports and did not modify the treatment.
Failure to submit accurate PBJ staffing data on time. The facility did not ensure complete and accurate direct care staffing information was electronically submitted to CMS within the required PBJ deadline. The COO, who handled submissions for multiple facilities, submitted the data late in the reporting window and did not recheck it after submission, later receiving fatal CMS warnings. The DON stated that staffing numbers were emailed to the COO by herself and an RN for use in the PBJ report.
An LPN entered a resident’s room and administered medication via PEG tube without donning a gown, despite EBP signage and facility policy requiring gowns and gloves before high-contact care. The LPN confirmed she forgot the gown and acknowledged the resident was placed at risk for infection. The IP nurse stated the gown should have been worn during direct care.
F880 was cited after the facility failed to sustain QAPI oversight for infection control related to EBP use. A CNA was found performing catheter care without the required EBP gown, the same deficient practice previously cited in a prior survey. The Administrator stated the QAPI committee met monthly and that CNA compliance had been audited for 12 weeks after the earlier citation, but monitoring was later stopped when staff were considered compliant, and the same concern recurred on the current survey.
A resident with moderate cognitive impairment was observed by a CNA inappropriately touching another moderately impaired resident in the day room. The incident was witnessed, reported, and confirmed by the DON as abuse. The resident who committed the act had a prior history of inappropriate behavior toward staff but not other residents. The facility's policy guarantees residents' right to be free from abuse, which was not upheld in this case.
A resident with an indwelling urinary catheter was observed on multiple occasions with the catheter bag and tubing uncovered and visible from the hallway, contrary to facility policy and staff expectations. Interviews with CNAs and the DON confirmed that catheter bags are required to be kept inside privacy bags to protect resident dignity. The resident had a history of Multiple Sclerosis, neuromuscular bladder dysfunction, and moderate cognitive impairment.
A resident with Alzheimer's disease exhibiting combative behavior was prescribed Rexulti, but the resident's representative was not informed of the medication's risks, benefits, or alternative treatments, nor was informed consent obtained, as required by facility policy. The DON confirmed that the representative was only notified of the new order and its purpose.
A shared bathroom used by four male residents was repeatedly found to have a strong urine odor and a thick black substance around the base of the toilet. Multiple staff, including nursing, housekeeping, and maintenance, confirmed the ongoing unsanitary conditions, which were documented over several days and discussed in daily rounds but not effectively addressed.
Quarterly MDS assessments for a resident with epilepsy and vascular dementia were not submitted within the required timeframe because the MDS Nurse was absent for personal health reasons and no coverage was provided, resulting in late completion and submission of the assessments.
Several residents did not receive care as outlined in their individualized care plans, including assistance with eating, nail and oral hygiene, trauma-informed care, and fall prevention. Staff failed to provide required interventions, leaving residents with unmet needs such as unattended meals, untrimmed nails, poor oral hygiene, unaddressed PTSD triggers, and missing fall prevention equipment.
Three residents with moderate cognitive impairment and significant physical limitations did not receive timely assistance with meals or personal hygiene. One resident's meal tray was left unattended for an extended period before staff provided feeding assistance, while two other residents were observed with unaddressed oral care needs and poor personal hygiene, including long, dirty fingernails and unshaven facial hair. Staff interviews confirmed these lapses were contrary to facility policy and expectations.
A resident with a history of callosities and other medical conditions did not receive appropriate foot care, resulting in excessively long toenails, untreated calluses, and an open wound on the heel. Staff failed to identify or document these issues during routine skin checks, and the resident was not seen by the podiatrist as needed. Multiple staff interviews confirmed lapses in assessment and documentation, with no treatment orders in place for the observed wound.
A resident with hemiplegia and communication limitations was observed without a required fall mat on the floor and without a wedge cushion between the thighs, despite facility policy and staff confirmation that these interventions were necessary to prevent injury. The fall mat was found folded and propped against the wall, and no wedge was present in the room.
A resident with a history of military service, PTSD, and traumatic injury did not receive an accurate trauma-informed care assessment. Staff failed to identify the resident's trauma history, symptoms, and triggers, relying instead on incomplete information from a family member. The resident's PTSD diagnosis and experiences were not reflected in his assessment, and assigned staff were unaware of his condition or triggers.
The facility did not update its Facility Assessment to include detailed documentation of staffing levels and competencies needed for each shift and emergency situations. Instead, sufficiency was marked as 'evaluated' without specific calculations or analysis, as confirmed by the Administrator during interviews and record reviews.
Staff did not adhere to infection control protocols during catheter care for a resident with a urinary catheter, as both a CNA and a Lead CNA failed to wear gowns as required by Enhanced Barrier Precautions. Additionally, an LPN did not properly disinfect a multi-use glucometer between uses, wiping it for only a few seconds instead of following the manufacturer's required contact time. These actions were confirmed by staff interviews and policy review.
A cognitively intact resident admitted to inappropriately touching two other residents, one of whom was severely cognitively impaired. The incidents were witnessed and reported by another resident and a maintenance staff member, but there was a delay in notifying the facility's administration. The facility's abuse prevention policy was not effectively implemented, allowing the behavior to continue.
A resident with a history of cerebral vascular accident and impaired mobility suffered a dislocated shoulder after a CNA used a sit-to-stand lift instead of the prescribed full body mechanical lift. The care plan and physician's order for the total lift were not followed, and staff interviews revealed a lack of access to or consultation of care plans.
A resident suffered a dislocated shoulder after a CNA used a sit-to-stand lift instead of the ordered full-body mechanical lift with a two-person assist. Interviews and record reviews revealed inconsistencies in staff knowledge and application of lifting protocols, leading to the injury.
Residents Reported Rude and Demeaning Treatment by an LPN
Penalty
Summary
The facility failed to ensure residents were treated with respect and dignity when multiple cognitively intact residents reported that an LPN was rude, pushy, snappy, and spoke to them as though they were children during medication administration and other interactions. A review of the facility’s Resident Rights policy stated that employees shall treat all residents with kindness, respect, and dignity. However, grievance logs and Resident Council meeting minutes for 2026 contained no documented concerns related to staff conduct or resident dignity, despite the residents’ reports during the survey process. During a Resident Council meeting, 11 residents were present and all had BIMS scores of 15. Six residents specifically identified the same LPN as often being rude during medication administration and general interactions. They stated they had not previously reported the concern because they believed staff sided with one another and that reporting would not help. The Resident Council President and another resident stated they believed the Administrator would take the nurse’s side and that reporting would do no good. Individual interviews confirmed the concern. One resident said the LPN was rude when administering medications and talked to him like a child. Another resident reported the nurse refused his request to take medications after eating and responded in a confrontational manner, staying in his room until he took them. Additional residents described the nurse’s tone as condescending, rude, snappy, and disrespectful, and said the behavior made them feel hopeless, vulnerable, rejected, angry, helpless, and sad. The DON stated that six residents reporting a nurse as rude and speaking down to them was a very serious situation and a violation of residents’ dignity and respect. The Administrator stated she had received prior reports regarding the LPN and had completed some corrective counseling, but residents reported the behavior continued.
Restriction of Resident Congregation in Activity Area
Penalty
Summary
The facility failed to promote and facilitate resident self-determination by restricting cognitively intact residents from freely congregating in the activity room during evening hours. During a Resident Council meeting, residents stated they were not permitted to use the activity room, which also served as the dining area, after administrative staff left for the day to play cards, play dominoes, or socialize. They reported that the nurse on duty would not allow them in the area unless a staff member was present to monitor them, and that they had raised the concern with the Activity Director without change. Resident #2, Resident #20, and Resident #40 each voiced that they wanted to remain in the activity area in the evening and felt the restriction treated them like children. Resident #2 stated that LPN #1 was rude when telling residents they could not sit in the dining area to play dominoes or socialize and said he believed it was his right to be there anytime he wanted. Resident #20 stated staff required residents to leave because no staff were available to supervise them, and he believed this violated his rights as a resident. Resident #40 stated he liked to play dominoes with other residents around 8:00 PM or later but was told by the nurse that he and others were not allowed in the area because no one was there to sit with them. Record review showed each of these residents had a BIMS score of 15, indicating they were cognitively intact. Resident #2 was admitted with diagnoses including COPD with acute exacerbation and hypokalemia; Resident #20 was admitted with abdominal distension (gaseous); and Resident #40 was admitted with generalized muscle weakness. The Activities Director stated residents wanted to gather in the dining and activity room area, but the Administrator said residents were not allowed there when staff were not present. LPN #1 acknowledged residents were not allowed in the dining area in the evening because the facility did not have staff available to sit with them, and the Administrator stated residents were not permitted to congregate unsupervised in the activity area due to past allegations between residents.
Incomplete Care Planning and Failure to Follow Ordered Care
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan with measurable, objective interventions and timetables for two residents. For Resident #7, the care plan included Enhanced Barrier Precautions (EBP) for close contact care, including hand hygiene, gown, and glove use. During observation, an LPN administered medication via the resident’s PEG tube without wearing a gown, and the LPN later confirmed she forgot to put it on and did not follow the care plan. The resident had been admitted with dysphagia and had a BIMS score of 15, indicating cognitive intactness. For Resident #9, the care plan and orders directed staff to clean the suprapubic catheter and stoma, and to apply the wafer and bag as needed, with the assigned position listed as LPN and RN. However, staff stated the resident performed his own colostomy and suprapubic catheter care, and the DON confirmed there was no physician order or assessment in place for the resident to perform his own care. The DON also stated nurses had been signing the ETAR as if the care was completed per order, and RN #3 confirmed she knew the resident was doing the care himself while still signing the ETAR. The resident had diagnoses including urinary tract infection, uninhibited neuropathic bladder, colostomy complications, and urinary retention, and his BIMS score was 15.
Failure to Follow Ordered Colostomy and Suprapubic Catheter Care
Penalty
Summary
The facility failed to implement physician orders related to colostomy care and suprapubic catheter care for one resident. The resident was admitted with diagnoses including urinary tract infection, uninhibited neuropathic bladder, colostomy complications, and urinary retention, and had a BIMS score of 15, indicating cognitive intactness. The resident stated he performed his own catheter care and colostomy care, and described how he completed the care himself. A clean colostomy bag was observed on the bedside table during the survey. The DON confirmed she was aware the resident performed his own colostomy and suprapubic catheter care and stated there was no physician order or assessment in place for the resident to perform his own care. She also stated nurses had been signing the ETAR as if the care had been completed by order. RN #3 confirmed she knew the resident was doing his own care and stated she had been signing the ETAR, explaining that she cut the wafer and provided supplies while the resident completed the care. The order summary showed orders for suprapubic catheter care every shift and stoma care with wafer and bag application as needed, and the ETAR contained numerous nurse signatures indicating the care was documented as completed by nursing staff.
Ineffective Pain Management for Resident with Chronic Pain
Penalty
Summary
Safe, appropriate pain management was not provided for a resident with chronic pain. The resident was admitted with diagnoses including pain in both lower legs, pain in the right foot, muscle spasm of the back, chronic pain syndrome, and other chronic pain. The resident, who was cognitively intact with a BIMS score of 15, reported consistent pain at a level of 6 for the last couple of years and stated his current pain medication regimen was not strong enough. He also reported that he had told nursing staff and the NP about the ongoing pain, but was told it would get better eventually or that there was nothing that could be done. He stated the pain affected his daily walking exercise and involved his legs, feet, and back. Facility staff acknowledged that the resident repeatedly reported pain levels of 6 or higher in nursing documentation from March through May 2026. An LPN stated the resident consistently said his pain medications were not enough and that this was reported to the NP months earlier. RN staff stated that standard procedure is to notify the NP when a resident reports ineffective pain control. The NP stated she normally evaluates residents who report frequent pain more than two times and may order x-rays, change medications, or refer to Pain Management if pain affects daily activities, but for this resident she did not adjust the regimen because she did not see a reason to do so and later acknowledged she missed the frequency of the documented pain reports.
Failure to Submit Accurate PBJ Staffing Data on Time
Penalty
Summary
The facility failed to ensure that complete and accurate direct care staffing information was electronically submitted to CMS through the Payroll-Based Journal (PBJ) system within the required timeframe for FY Quarter 1 2026. The facility policy stated that direct care staffing information is to be reported electronically through PBJ in a uniform CMS format and submitted no later than 45 days after the end of the reporting quarter, with the Quarter 1 deadline listed as February 14th. During interviews, the Administrator stated that the COO was responsible for submitting PBJ data and that she believed he had submitted it, but she was unaware that the submission had not been accepted. The COO stated that he was out of town during the week of the submission, submitted the data on Day 44, and did not recheck it on Day 45 because he had not previously experienced issues. He later received fatal warnings from CMS after returning to the office. The DON stated that she and RN #1 emailed daily staffing numbers to the COO, who stored the information and used it to submit the facility’s PBJ report to CMS.
Failure to Follow Enhanced Barrier Precautions During PEG Tube Medication Administration
Penalty
Summary
The facility failed to ensure staff followed Enhanced Barrier Precautions during high-contact resident care for Resident #7. The facility policy stated that gowns and gloves are to be applied prior to performing the high-contact resident care activity, and EBP signage was posted on the resident’s door. During an observation, an LPN entered the room and administered medication via PEG tube without donning a gown before providing the care. During interview, the LPN confirmed she forgot to put on a gown and acknowledged that she placed the resident at risk for infection by not wearing one. The Infection Prevention Nurse later stated the LPN should have worn a gown and that not doing so placed the resident at high risk of infection.
QAPI Failed to Sustain EBP Infection Control Compliance
Penalty
Summary
F880 was cited because the facility’s QAPI program did not sustain corrective action after a prior infection control deficiency involving Enhanced Barrier Precautions (EBP). Record review showed the facility had been cited in June 2025 for failing to ensure infection control practices when a CNA performed catheter care without wearing the required EBP gown. On the current survey, the same deficient practice was identified again, showing that the prior QAPI interventions did not prevent recurrence of the same infection control concern. The facility policy stated that the QAPI program is to be ongoing, facility-wide, and data-driven. During interview, the Administrator stated that the QAPI committee meets monthly and includes department heads such as the DON, ADON, Medical Director, Social Worker, Dietary, Activity Coordinator, Maintenance Supervisor, Treatment Nurse, Business Manager, and Head CNA. She reported that after the June 2025 survey, the facility discussed the citation in July 2025 and implemented weekly audits of CNA compliance with EBP for 12 weeks, after which monitoring was stopped when administration considered staff compliant. She acknowledged that staff may have become complacent after monitoring ended and that the same EBP concern was again identified during the current survey cycle.
Failure to Protect Resident from Sexual Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from sexual abuse by another resident. On the early morning of 2/20/2025, a CNA observed one resident with his hand underneath another resident's blouse, rubbing her breasts in the day room. The CNA immediately separated the residents and notified the nurse. The resident who was touched was assessed and found to have no injuries. Interviews and documentation confirmed that the incident occurred, with the resident who was touched indicating she was touched, while the other resident denied the action, claiming he was trying to cover her. The Director of Nursing confirmed that the investigation substantiated the abuse. Both residents involved were moderately cognitively impaired, as indicated by their BIMS scores of 11. The resident who committed the act had a history of inappropriately touching staff but had not previously touched another resident. The incident was witnessed by staff, and the facility's own policy states that residents have the right to be free from abuse, neglect, and corporal punishment. The failure to prevent this incident constituted a violation of the facility's abuse prevention policy.
Failure to Maintain Resident Dignity by Not Covering Urinary Catheter Bag
Penalty
Summary
Staff failed to maintain the dignity of a resident by not ensuring that an indwelling urinary catheter bag and tubing were covered. Observations on two separate occasions showed the resident lying in bed with the catheter bag, containing visible urine, hanging from the bed and visible from the hallway, without a privacy bag in place. Facility policy specifically prohibits practices that compromise dignity and requires staff to help residents keep urinary catheter bags covered. Interviews with CNAs and the DON confirmed that the expectation is for all urinary catheter bags to be kept inside privacy bags to prevent urine from being visible to others, acknowledging that the uncovered catheter bag was a dignity issue. The resident involved had a history of Multiple Sclerosis and neuromuscular dysfunction of the bladder, with moderate cognitive impairment as indicated by a BIMS score of 12.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to notify a resident representative of the risks and benefits associated with the initiation of a new psychotropic medication for one resident. According to the facility's policy, staff and the physician are required to review the indications, rationale, potential risks and benefits, and alternative treatment options with the resident or their representative prior to obtaining documented consent or refusal. In this case, a psychiatric nurse practitioner recommended starting Rexulti 0.5 mg for a resident diagnosed with Alzheimer's disease due to recent combative behavior. The staff contacted the resident's representative to inform her of the new medication order and explained that the medication was for Alzheimer's and to treat agitation. However, there was no documentation that the representative was informed of the potential risks and benefits of Rexulti, alternative treatment options, or that informed consent was obtained. The Director of Nursing confirmed during an interview that the representative was not provided with this information or the opportunity to consent or refuse the treatment. The resident involved had a history of dysphagia following cerebral infarction and Alzheimer's disease, and was rarely or never understood, as indicated by the Minimum Data Set assessment.
Unsanitary Shared Bathroom with Persistent Odor and Black Corrosion
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in a shared resident bathroom, as evidenced by repeated observations of a strong urine odor and a thick black substance around the base of the toilet. Multiple staff members, including nursing, housekeeping, and maintenance, confirmed the ongoing presence of these unsanitary conditions. Documentation from Grand Rounds over several days indicated that the bathroom was not free from urine odors and was not cleaned adequately, with these issues being consistently reported but not resolved. Interviews revealed that the bathroom was shared by four male residents and that both housekeeping and maintenance staff were aware of the persistent odor and cleanliness issues. Despite daily rounds and reporting during stand-up meetings, the black substance and odor remained unaddressed. Staff acknowledged the problem, with maintenance and housekeeping directors confirming the conditions and attributing the odor to missed toileting and the need for tile replacement. The ongoing nature of the issue was further corroborated by the staff responsible for daily rounds, who reported the problem repeatedly without effective resolution.
Failure to Timely Submit MDS Assessments Due to Staff Absence
Penalty
Summary
The facility failed to submit quarterly Minimum Data Set (MDS) assessments within the required 14-day timeframe for one resident. Specifically, the MDS assessments for a resident with an Assessment Reference Date (ARD) of 10/21/2024 and another with an ARD of 4/18/2025 were both completed and signed by the RN Assessment Coordinator well after the mandated submission period. The facility's policy requires timely completion and submission of MDS assessments in accordance with federal and state guidelines. Interviews with the MDS Nurse revealed that the delays occurred because she was absent due to a family illness and surgery during the relevant periods, and no staff member was assigned to cover her responsibilities. The Director of Nursing confirmed the expectation for timely MDS submissions. The resident involved had medical diagnoses including epilepsy and vascular dementia, and was noted to have moderate cognitive impairment based on a Brief Interview for Mental Status (BIMS) score of 7.
Failure to Implement Individualized Care Plans for Multiple Residents
Penalty
Summary
Multiple residents experienced deficiencies in care due to the facility's failure to implement individualized, comprehensive care plans as documented. One resident with a history of traumatic brain injury and moderate cognitive impairment required total assistance with eating, but was left unattended with her meal tray for 30 minutes without staff assistance. Another resident, who was cognitively intact and had diagnoses including intellectual disabilities and schizophrenia, was observed with excessively long and thick toenails, despite a care plan intervention for nail care. Staff interviews confirmed that the care plans for these residents were not followed. A resident with a diagnosis of PTSD and a history of military service and trauma had an inaccurately completed trauma assessment, which failed to identify his symptoms and triggers, such as distress caused by helicopters. This led to the care plan not addressing his specific psychosocial needs. Additional deficiencies were observed in residents requiring assistance with oral hygiene and personal care. One resident with hemiplegia and moderate cognitive impairment had visible dental buildup and reported infrequent mouth care, while another dependent resident had long, dirty fingernails and facial hair, indicating a lack of daily hygiene assistance as outlined in their care plans. Further, a resident at risk for falls due to impaired mobility was found without required safety interventions, such as a bedside fall mat and a wedge cushion, despite these being specified in the care plan. Staff interviews and record reviews consistently confirmed that while care plans were fully developed and individualized, they were not implemented by staff, resulting in unmet physical, psychosocial, and functional needs for several residents.
Failure to Provide Timely ADL Assistance and Personal Hygiene Care
Penalty
Summary
Staff failed to provide necessary assistance with activities of daily living (ADLs) for three residents who were unable to perform these tasks independently. One resident's breakfast tray was left unopened on her bedside table for 30 minutes before staff arrived to assist, despite her documented need for help with meals due to moderate cognitive impairment and a history of traumatic brain injury. Multiple staff interviews confirmed that facility policy requires residents needing assistance to be fed immediately when the tray is delivered, and that leaving the tray unattended could result in the food becoming cold and unappetizing. Another resident was observed with a significant buildup of brown/yellow substance on his teeth during two separate observations. The resident expressed a desire for oral care and stated it had been a while since anyone had offered to clean his teeth. Staff confirmed that oral care should be provided daily and acknowledged the presence of buildup, which could lead to dental issues. This resident also had moderate cognitive impairment and required assistance with personal care due to hemiplegia, muscle contractures, and generalized muscle weakness. A third resident was found with long, jagged, and dirty fingernails, as well as visible facial hair on the cheeks, chin, and upper lip. Staff confirmed that the resident's nails and facial hair should have been trimmed and cleaned, noting that long nails could harbor bacteria and cause skin tears, and that facial hair should be shaved regularly. This resident was dependent on staff for personal hygiene and had moderate cognitive impairment related to vascular dementia and epilepsy.
Failure to Provide Necessary Foot Care and Timely Assessment
Penalty
Summary
A deficiency occurred when a resident who required assistance with foot care did not receive necessary interventions to maintain skin integrity and prevent complications. The resident reported that her toenails were excessively long and thick, and that she was not seen by the podiatrist during the most recent visit. She also complained of left heel pain, which upon observation, revealed a circular area with thick, dry, peeling skin, dark redness, and a small open wound with dark purple edges. The resident stated she had been self-applying lotion, but staff were not providing any treatment. Multiple calluses and overgrown toenails were observed on both feet. Review of the resident's records showed no documentation of skin concerns, no treatment orders for the left heel, and repeated skin checks that failed to identify any issues. Interviews with facility staff, including the wound care nurse, ADON, and an LPN, confirmed that the resident's foot issues were not identified or documented during routine skin checks and audits. The wound care nurse was unaware of the wound and acknowledged that the resident's foot concerns should have been discovered earlier. The LPN admitted to not accurately documenting the resident's skin condition and had no record of applying lotion, despite doing so. The DON confirmed the resident had excessively long toenails and had not been seen by the podiatrist since February, placing the resident at risk for further complications. The resident was cognitively intact and had a history of callosities and other medical diagnoses.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards by not implementing required fall prevention interventions for one resident. Observations on two separate occasions revealed that the resident was lying in bed without a fall mat placed on the floor as required, and the mat was instead folded and propped against the wall. Additionally, the resident did not have a wedge cushion between his thighs, nor was one present in his room. Multiple staff members, including a CNA, an LPN, and the Director of Nursing, confirmed that the fall mat should have been on the floor to help prevent injury in the event of a fall, and that the wedge cushion was also required but missing. The resident involved had a medical history including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side, as well as unspecified convulsions. According to the most recent quarterly MDS assessment, the resident was rarely or never understood, indicating significant communication limitations. The facility's own policy emphasized the importance of making the environment as free from accident hazards as possible and specifically addressed fall prevention, but these interventions were not in place at the time of the observations.
Failure to Complete Accurate Trauma-Informed Assessment for Resident with PTSD
Penalty
Summary
The facility failed to ensure an accurate trauma-informed care assessment was completed for a resident with a known history of Post-Traumatic Stress Disorder (PTSD). The resident, who served as a sniper in the military during wartime and had been run over by an automobile prior to admission, reported experiencing PTSD symptoms such as nightmares and identified specific triggers, including the sound of helicopters. Despite these disclosures, the trauma-informed care assessment documented that the resident had not experienced traumatic events, and his PTSD symptoms and triggers were not identified in his records. Interviews with facility staff revealed that the social services staff relied solely on information from a family member and was unaware of the resident's military background and war experience. The LPN assigned to the resident was also unaware of his PTSD diagnosis or triggers. The Director of Nursing confirmed that the expectation was for an accurate trauma-informed assessment to be completed to identify triggers and prevent re-traumatization. The resident's admission record and MDS confirmed a diagnosis of PTSD and cognitive intactness, yet the assessment failed to reflect his trauma history and symptoms.
Facility Assessment Lacked Comprehensive Staffing and Resource Evaluation
Penalty
Summary
The facility failed to update its Facility Assessment to include a comprehensive evaluation of the resident population and the necessary resources, such as staffing levels and competencies, required to meet resident needs during both routine operations and emergencies. Review of the facility's policy indicated that the assessment should be conducted annually and used to inform staffing decisions for all shifts, including nights and weekends, and should be adjusted based on changes in the resident population. However, the Facility Assessment document only marked sufficiency analysis categories as 'Evaluated' without documenting specific staffing levels for each shift or addressing the specific skills and competencies needed for the current resident population. During an interview, the Administrator confirmed that the assessment process involved marking staffing as 'evaluated' or 'sufficient' without actually calculating or addressing the staffing and skills required for specific shifts, including night shifts, weekends, and emergencies. This lack of detailed documentation and analysis was observed over three survey days, and the deficiency was identified through interviews, record reviews, and policy reviews. No specific residents or their medical conditions were mentioned in relation to this deficiency.
Failure to Follow Infection Control Protocols During Catheter Care and Glucometer Use
Penalty
Summary
Staff failed to follow infection prevention and control protocols during two observed care activities. During catheter care for a resident with multiple sclerosis and neuromuscular dysfunction of the bladder, both a CNA and a Lead CNA did not wear gowns as required by Enhanced Barrier Precautions (EBP), despite signage and facility policy indicating the need for both gloves and gowns. The Lead CNA's clothing came into contact with the resident's bed, further breaching protocol. Both staff members acknowledged their failure to use gowns, and interviews with the Infection Preventionist and Director of Nursing confirmed that EBP, including gown use, was expected for residents with urinary catheters. Additionally, during medication administration, an LPN did not properly clean and disinfect a multi-use glucometer according to the manufacturer's instructions. The LPN wiped the glucometer for only a few seconds before allowing it to dry for two minutes, rather than ensuring the required contact time with the germicidal wipe. The DON confirmed that staff misunderstood the cleaning directions, and both acknowledged that not following the manufacturer's guidelines could result in the spread of infection.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to prevent resident-to-resident sexual abuse involving two residents. The incidents involved a resident with a BIMS score indicating cognitive intactness, who admitted to touching two other residents without their permission. One of the victims had a BIMS score indicating severe cognitive impairment, while the other was cognitively intact. The incidents were witnessed by another resident and a maintenance staff member, who reported the occurrences to the nursing staff and social services, respectively. However, there was a delay in notifying the facility's administration about the incidents. The facility's policy on abuse prevention was not effectively implemented, as evidenced by the repeated inappropriate touching by the same resident. The social services staff failed to document and promptly report the incident involving the cognitively intact resident to the administrator or the Director of Nursing. This lack of timely communication and intervention allowed the abusive behavior to continue, compromising the safety and well-being of the residents involved.
Failure to Follow Care Plan Results in Resident Injury
Penalty
Summary
The facility failed to follow the person-centered care plan for Resident #1, resulting in a dislocated shoulder. Resident #1's care plan, dated 3/8/23, indicated the use of a full body mechanical lift with two-person assistance due to generalized weakness and impaired mobility following a cerebral vascular accident. However, on 3/21/24, CNA #5 used a sit-to-stand lift by herself, leaving the resident in the lift too long without assistance, which led to the injury. Interviews with the resident and staff confirmed that the resident was previously using a sit-to-stand lift but was changed to a total lift due to her inability to bear weight consistently. The care plan and physician's order for the total lift had been in place since early March 2023, but staff failed to adhere to these directives. Further interviews revealed that some CNAs did not have access to or were not consulting the care plans as required. The Director of Nursing and Assistant Director of Nursing confirmed that the incident occurred because the care plan was not followed, and the resident's care needs were not met as specified. The facility's investigation report corroborated that the improper use of the sit-to-stand lift by CNA #5 resulted in the resident's shoulder dislocation. The administrator acknowledged that staff were not reviewing the care plans as they should, leading to the deficiency in care provided to Resident #1.
Failure to Follow Lift Protocols Resulting in Resident Injury
Penalty
Summary
The facility failed to prevent an accident that resulted in an injury to a resident. A staff member used a lift that was not ordered by the physician, leading to the resident being left in a sit-to-stand lift too long without assistance, which resulted in a dislocated right shoulder. The resident had an order for a full-body mechanical lift with a two-person assist, but this was not followed by the staff member, who was an agency CNA. The incident was confirmed through interviews, observations, and record reviews, including the resident's radiology report and departmental notes. Interviews with various CNAs and the RN revealed inconsistencies in the knowledge and application of the facility's lifting protocols. Some CNAs were unaware of the care guide that indicated the type of lift to be used for each resident, and there was a lack of colored dots on the resident's room door to indicate the appropriate lift. The DON and ADON confirmed that the CNA used the wrong lift and did not follow the physician's orders, which was against the facility's policy. The Administrator and DON acknowledged that the staff did not follow the care guides and that the CNA used the sit-to-stand lift without assistance, which was not permitted. The facility's investigation revealed that the resident's shoulder injury was due to the improper use of the lift. The resident's care plan indicated total dependence for transfer, but this was not adhered to by the staff, leading to the injury.
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What surveyors actually found near you
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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 Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Manor Nursing And Rehabilitation Center | 0.9 mi | ★★★★★ | 2 | 0 |
| Ms Care Center Of Greenville | 0.9 mi | ★★★★★ | 0 | 0 |
| Arbor Walk Healthcare Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Washington Care Center | 2.2 mi | ★★★★★ | 6 | 0 |
| Lake Village Rehabilitation And Care Center | 15.1 mi | ★★★★★ | 6 | 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.