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 Riverview Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to develop and implement person-centered care plans for residents, leading to deficiencies in monitoring medication side effects, range of motion exercises, and nail care. Residents on anticoagulant and psychotropic medications were not monitored for side effects as required. Additionally, residents needing nail care and range of motion exercises did not have appropriate interventions in their care plans. These deficiencies were confirmed by the DON and Care Plan Nurse.
The facility failed to monitor side effects and obtain stop dates for psychotropic medications for five residents. Despite the policy requiring documentation and monitoring for efficacy and adverse consequences, orders for monitoring side effects were absent. Interviews with the DON and LPNs confirmed the lack of monitoring and stop dates, attributed to a change in electronic medical record systems.
A resident with Multiple Sclerosis, dependent on assistance for eating, was left without help after a CNA delivered a meal tray out of reach. The CNA did not assist the resident, and staff walked past without helping. An RN later provided assistance, confirming the resident's need for help. Interviews revealed that while the facility has a list of residents needing assistance, no specific staff is assigned to help, and all nursing staff are responsible for assisting residents during meal delivery.
A cognitively intact resident was not allowed to sign his own advance directive form, which was instead signed by a family member. The resident was not consulted about his code status, despite facility policy requiring residents to be informed of their rights to make medical decisions. Staff interviews confirmed the resident's capability to make his own decisions.
The facility failed to maintain a safe and comfortable environment for two residents. One resident had an overbed table with exposed jagged wood, which was not reported by staff despite facility policy. Another resident experienced discomfort due to a sagging mattress and was given a raised perimeter mattress instead, which was difficult to use. The DON confirmed the issues but noted a lack of available regular mattresses.
A resident with dementia was found with full side rails on both sides of the bed, acting as a restraint without proper assessment, consent, or physician orders. The CNA was unaware of the reason for the side rails, while the LPN noted they were requested from hospice to prevent the resident from getting out of bed. The DON confirmed the lack of necessary documentation and assessments, violating the facility's policy on residents' rights.
A facility failed to accurately code the MDS for a resident with schizophrenia, marking them as not having a serious mental illness despite PASRR documentation indicating otherwise. This error was confirmed by the MDS Nurse, highlighting a deficiency in ensuring accurate resident assessments.
The facility failed to complete and discuss baseline care plans within 48 hours for two residents, as required by policy. Both residents, who were cognitively intact, reported that their care plans were not explained to them upon admission. Interviews with staff revealed a lack of awareness about the requirement to complete and discuss these plans within the specified timeframe.
The facility failed to provide adequate ADL care, resulting in several residents having long, jagged fingernails and one resident with unkempt, greasy hair and beard. The DON confirmed the absence of a routine task for nail care, and an LPN noted the need for bathing and grooming to prevent skin concerns. The facility lacked a direct policy on ADLs, contributing to these hygiene deficiencies.
The facility failed to provide necessary ROM services for four residents, leading to deficiencies in their care. A resident with hand contractures had no devices or orders for services, and staff confirmed no ROM exercises were performed. Another resident with finger contractures did not receive ROM exercises or bracing, and a third resident with arm contractures lacked therapy or bracing. A fourth resident with a left arm contracture was not receiving therapy services, and the facility lacked a restorative nursing program.
The facility failed to maintain sufficient nursing staffing during weekends in the third quarter of 2024, as indicated by the PBJ Staffing Data Report. The ADON and HR confirmed the low staffing levels due to excessive call-ins and staff clocking in late or out early. The Administrator, who started in May 2024, acknowledged the issue and was working on improving staffing levels.
A resident on anticoagulant medication was not adequately monitored for side effects such as bruising and bleeding, as required by the facility's policy. The Director of Nurses confirmed the absence of a monitoring tool in the resident's records, which placed the resident at risk for bleeding. The resident had a history of serious medical conditions, including Parkinson's disease and a history of pulmonary embolism.
A resident with moderate cognitive impairment did not receive condiments for her sandwich during a meal service, despite expressing a preference for mayonnaise and mustard. The Admission Nurse did not offer condiments, and the Dietary Manager confirmed they should have been included. Condiments were available in the dining room, but staff failed to provide them, potentially affecting the resident's meal consumption.
A facility failed to consistently offer snacks to residents, as required by its policy. A resident reported not receiving snacks on two survey days, despite being hungry, and noted that snacks were only available at the nurse's station. Staff interviews revealed confusion over snack distribution responsibilities, leading to inconsistent availability for residents.
A facility failed to follow infection control protocols during wound care for a resident with a Stage 4 pressure ulcer. The Treatment Nurse did not perform hand hygiene before gathering supplies, used contaminated gloves, and failed to follow Enhanced Barrier Precautions. The nurse also improperly cleaned the wound and placed contaminated items back into the treatment cart without sanitizing them, placing the resident at risk for infection.
Deficiencies in Care Planning and Implementation
Penalty
Summary
The facility failed to develop and implement person-centered care plans for several residents, leading to deficiencies in monitoring medication side effects, range of motion exercises, and nail care. For instance, Resident #4, who was on an anticoagulant medication, did not have a care plan that included monitoring for bleeding and bruising, which are critical side effects of such medication. Similarly, Resident #10's care plan required monitoring for side effects of psychotropic medications, but this was not being done, as confirmed by the Director of Nursing (DON) and the Care Plan Nurse. In addition to medication monitoring, the facility also failed to address the needs of residents requiring nail care and range of motion exercises. Resident #9 was observed with long, jagged nails, despite a care plan intervention to trim nails as needed. Resident #58, who is diabetic, also had long nails and expressed a desire to have them cut, yet no care plan was developed for nail care. Furthermore, residents with contractures, such as Resident #17 and Resident #19, did not have appropriate interventions like range of motion exercises included in their care plans to prevent worsening of their conditions. The lack of proper care planning extended to other residents as well, such as Resident #18, who was on multiple psychotropic medications but did not have orders to monitor for side effects. This oversight was consistent across several residents, including Resident #51, Resident #55, and Resident #44, whose care plans included interventions for monitoring side effects of psychotropic medications, but these were not being followed. The DON confirmed these deficiencies, highlighting a systemic issue in the facility's care planning and implementation processes.
Failure to Monitor Psychotropic Medication Side Effects and Obtain Stop Dates
Penalty
Summary
The facility failed to monitor for side effects and obtain a stop date for psychotropic medications for five residents. The policy titled 'Behavioral Assessment, Intervention and Monitoring' required documentation of rationale for use and monitoring for efficacy and adverse consequences when medications are prescribed for behavioral symptoms. However, the facility did not adhere to this policy, as evidenced by the lack of orders to monitor for side effects of multiple psychotropic medications for the residents involved. Resident #10 was prescribed Buspirone and Venlafaxine for anxiety disorder, but there was no order to monitor for side effects. Similarly, Resident #18, who was diagnosed with schizophrenia, bipolar disorder, and anxiety disorder, was prescribed Aripiprazole, Ativan, Olanzapine, and Venlafaxine without monitoring for side effects. Resident #51, diagnosed with mood disorder and anxiety, was prescribed Ativan and Zoloft without a stop date or monitoring for side effects. Resident #55, with bipolar disorder, anxiety disorder, borderline personality disorder, and psychotic disorder with delusions, was prescribed Buspirone and Risperidone without monitoring for side effects. Lastly, Resident #44, diagnosed with dementia, was prescribed Risperidone, Trazodone, Lexapro, and Lorazepam without a stop date or monitoring for side effects. Interviews with the Director of Nursing (DON) and Licensed Practical Nurses (LPNs) confirmed the lack of monitoring for side effects and the absence of stop dates for PRN orders. The DON acknowledged that the monitoring should have been included in the physician's orders and transferred to the Medication Administration Record (MAR) to ensure proper documentation. The failure to monitor for side effects and obtain stop dates for psychotropic medications was attributed to a change in electronic medical record systems, which resulted in the omission of necessary monitoring tools.
Failure to Assist Resident with Meal Delivery
Penalty
Summary
The facility failed to promote dignity for a resident who required assistance with eating. During an observation, a Certified Nursing Assistant (CNA) delivered a meal tray to a resident's room, placing it out of the resident's reach and leaving without providing assistance. The CNA informed the resident that someone would assist him shortly, but nursing staff were observed walking past the room without entering to help. A Registered Nurse (RN) later entered the room and assisted the resident, confirming that the resident could not feed himself and required staff assistance. The RN acknowledged that the CNA should have assisted the resident immediately upon delivering the meal tray. Interviews with the CNA, a Licensed Practical Nurse (LPN), and the Director of Nursing (DON) revealed that the facility has a list of residents who require assistance with eating, but no specific staff member is assigned to assist these residents. Instead, all nursing staff are responsible for passing trays and assisting residents as needed. The DON confirmed that staff are expected to assist residents requiring help at the time of tray delivery, rather than leaving the tray unattended. The resident involved had been admitted to the facility with a diagnosis of Multiple Sclerosis and was documented as dependent for eating in the Quarterly Minimum Data Set Assessment.
Failure to Honor Resident's Right to Make Health Care Decisions
Penalty
Summary
The facility failed to honor a resident's right to make health care decisions, specifically regarding the formulation of advance directives. The facility's policy requires that residents be provided with information about their rights to make medical decisions, including the right to accept or refuse treatment and to formulate advance directives. However, for one resident, the advance directive form was signed by a family member instead of the resident himself, despite the resident being cognitively intact and capable of making his own decisions. Interviews with the resident and facility staff confirmed that the resident was not involved in the discussion or signing of his advance directive form. The resident expressed that he had not been spoken to about his code status and emphasized the importance of making his own decisions. The Social Services staff and the Director of Nursing acknowledged that the resident should have been allowed to sign his own form, as he was capable of self-determination. The resident's cognitive status was confirmed by a Brief Interview for Mental Status score indicating he was cognitively intact.
Facility Fails to Maintain Safe and Comfortable Environment for Residents
Penalty
Summary
The facility failed to provide a safe, clean, and comfortable environment for its residents, as evidenced by two specific incidents. Resident #4 was observed with an overbed table that had missing edging, exposing chipped and jagged wood. This condition was confirmed by a Certified Nurse Aide (CNA) who admitted to not reporting the issue, despite the facility's policy requiring staff to notify the nurse or maintenance of such conditions. The Director of Nurses (DON) also confirmed the hazardous condition of the overbed table, acknowledging the potential risk of injury to the resident. Resident #4 had been admitted to the facility with a diagnosis of Parkinson's Disease with Dyskinesia. Resident #58 experienced discomfort due to a sagging mattress, which he had reported to various staff members. Despite his complaints, the issue remained unresolved, and he was observed lying on a raised perimeter mattress, which he found difficult to maneuver on. A Licensed Practical Nurse (LPN) was unaware of the resident's complaints and confirmed that the nursing staff was responsible for changing mattresses. The DON acknowledged that the resident should have had a regular mattress but stated that none were available. Resident #58, who was cognitively intact, had been admitted with a diagnosis of Nontraumatic Intracranial Hemorrhage.
Failure to Ensure Residents are Free from Physical Restraints
Penalty
Summary
The facility failed to ensure that residents were free from physical restraints, as evidenced by the use of full side rails on both sides of a resident's bed. The resident, who was admitted with a diagnosis of dementia, was observed with full side rails, which were implemented to prevent him from getting out of bed. The CNA was unaware of the reason for the full side rails, while the LPN stated that the full side rails were requested from hospice after the resident was observed climbing out of bed with half side rails. The Director of Nursing confirmed that the full side rails acted as a restraint and acknowledged the absence of a side rail or restraint assessment, consent, or physician orders for their use. The facility's policy on residents' rights emphasizes the right to be free from physical restraints unless required for medical symptoms, which was not adhered to in this case. The resident's medical record did not contain documentation of an assessment or consent for the use of full side rails, highlighting a deficiency in the facility's compliance with its own policies and regulatory requirements.
Inaccurate MDS Coding for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure the accurate coding of the Minimum Data Set Assessment (MDS) for one resident, leading to a deficiency. The resident, who was admitted with a diagnosis of schizophrenia, was incorrectly coded in the MDS as not having a serious mental illness, despite documentation from the PASRR Office indicating otherwise. This error was confirmed during an interview with the MDS Nurse, who acknowledged that the MDS should have been coded correctly to reflect the resident's mental health condition. The inaccurate coding could potentially impact the level of care the resident receives.
Failure to Complete and Discuss Baseline Care Plans Timely
Penalty
Summary
The facility failed to complete baseline care plans within the required 48-hour timeframe for two residents, as per their policy. Resident 59's baseline care plan was completed on the day of admission but lacked acknowledgment from the resident or their representative. The resident reported that no staff discussed her care plan upon admission. Similarly, Resident 166's baseline care plan was initiated on the day of admission but was not completed within 48 hours, and there was no acknowledgment from the resident or their representative. The resident also reported that no one explained his care plan upon admission. Interviews with facility staff, including the MDS nurse, Care Plan Nurse, and Director of Nursing, revealed a lack of awareness regarding the requirement to complete and discuss baseline care plans within 48 hours of admission. The MDS nurse and Care Plan Nurse confirmed that they had not been discussing the baseline care plan findings with new admissions or their representatives. Both residents involved were cognitively intact, as indicated by their BIMS scores, which underscores the importance of involving them in their care planning process.
Deficiency in ADL Care and Hygiene Maintenance
Penalty
Summary
The facility failed to provide adequate assistance with Activities of Daily Living (ADL) care, specifically in maintaining hygiene for several residents. Observations revealed that multiple residents had long, jagged fingernails, and one resident had unkempt and greasy hair along with an unkempt beard. The Director of Nursing (DON) confirmed that there was no routine task set up for nail care, and the treatment nurse was responsible for cutting and cleaning residents' nails. The lack of routine nail care could potentially lead to infections if residents scratched themselves. Additionally, a Licensed Practical Nurse (LPN) noted that a resident's oily hair and strong body odor indicated a need for bathing and grooming, which could lead to skin concerns if not addressed. The report highlights specific cases, including a resident with dementia who had long nails with a brown substance underneath, a resident with epilepsy who was dependent on personal hygiene care, and a resident with contractures who also had long, jagged nails. Another resident, who was diabetic and cognitively intact, expressed a desire to have his nails cut due to their length. The facility lacked a direct policy on ADLs, and staff interviews confirmed that there was no regular schedule for nail care, which contributed to the observed deficiencies in personal hygiene maintenance.
Failure to Provide ROM Services for Residents
Penalty
Summary
The facility failed to provide necessary services to maintain or improve the range of motion (ROM) and mobility for four residents, leading to deficiencies in their care. Resident #17 was observed with contractures in both hands without any devices in place, and there were no orders or documentation for services to address these contractures. Interviews with staff, including an LPN and CNAs, confirmed that no ROM exercises were being performed, and the facility lacked a restorative program. The resident had been admitted with a diagnosis of contractures, and the MDS indicated impairments in both upper and lower extremities. Resident #19 had limited ROM in the fingers of the left hand and did not receive any ROM exercises or bracing. The OT confirmed the presence of contractures and the potential benefit of ROM exercises. The resident was dependent on all care, and the CNA confirmed that no ROM exercises were performed. The resident's medical record showed a diagnosis of Multifocal Motor Neuropathy, and the MDS indicated impairments in one side of the upper and lower extremities. Resident #39 was observed with limited ROM in both arms without braces or splints. The OT confirmed contractures in the elbows and the potential benefit of ROM exercises and bracing. The resident's representative stated that the resident did not have contractures upon admission and had never received therapy or bracing. The MDS indicated impairments in both upper and lower extremities. Resident #22 was observed with a left arm contracture and was not receiving therapy services. The OT confirmed the need for PROM to prevent worsening contractures, and the DON acknowledged the absence of a restorative nursing program. The resident's medical record included a diagnosis of hemiplegia and hemiparesis following a cerebral infarction, with impairments noted in the MDS.
Insufficient Weekend Nursing Staffing in Q3 2024
Penalty
Summary
The facility failed to ensure sufficient nursing staffing during weekends for the third quarter of 2024, as revealed by the Payroll-Based Journal (PBJ) Staffing Data Report. The report indicated excessively low weekend staffing, which was confirmed by the Assistant Director of Nurses (ADON) and Human Resources (HR). The ADON, who was not in her current role during the third quarter but worked part-time, acknowledged the staffing issues during weekends due to low staffing levels. HR confirmed that the PBJ data for the third quarter was accurately entered and attributed the low staffing to excessive call-ins and staff clocking in late or out early. The Administrator, who assumed her role at the end of May 2024, also confirmed the staffing issues during weekends. She noted that the facility was actively working on improving staffing levels to ensure adequate care for residents. The deficiency was identified through staff interviews, record reviews, and facility policy reviews, which highlighted the facility's failure to maintain adequate staffing on each shift to meet residents' needs as per their policy revised in April 2007.
Inadequate Monitoring of Anticoagulant Medication
Penalty
Summary
The facility failed to adequately monitor a resident receiving anticoagulant medication for side effects, specifically for signs of bruising and bleeding. The facility's policy on anticoagulation, revised in September 2012, requires staff and physicians to monitor individuals on anticoagulation therapy for complications such as excessive bruising, hematuria, and hemoptysis. However, a review of the Order Summary Report and the Medication Administration Record for November 2024 revealed that there was no monitoring tool in place for staff to observe these side effects in a resident taking Xarelto, a blood thinner. The Director of Nurses confirmed that the resident, who was admitted to the facility in June 2020 with medical diagnoses including Parkinson's disease, a history of pulmonary embolism, transient ischemic attack, and cerebral infarction, was not being adequately monitored for the side effects of the anticoagulant medication. The lack of monitoring was acknowledged as a risk for bleeding, as the necessary documentation for monitoring was not included in the physician orders.
Failure to Accommodate Resident's Food Preferences
Penalty
Summary
The facility failed to accommodate a resident's food preference during a meal service. During a dining observation, it was noted that a resident's meal tray included a ham and cheese sandwich without any condiments, which the resident preferred. The Admission Nurse confirmed that condiments were not provided and stated that residents were given condiments only if they requested them. The resident expressed a preference for mayonnaise and mustard on her sandwiches, but staff did not offer these condiments during the meal. The Dietary Manager confirmed that condiments should have been included on the meal tray and that staff should have inquired about the resident's condiment preferences. An inspection of the dining room revealed that condiments were readily available in a drawer, accessible to staff. The Admission Nurse acknowledged that she should have asked the resident about her condiment preference but failed to do so. The Director of Nursing noted that not offering condiments could lead to the resident not eating the meal, potentially resulting in weight loss. The resident, who has a diagnosis of unspecified dementia and a moderate cognitive impairment, was admitted to the facility earlier in the year.
Inconsistent Snack Distribution
Penalty
Summary
The facility failed to ensure that snacks and nourishments were consistently offered to residents, as evidenced by observations and interviews conducted over four survey days. The facility's policy, revised in November 2015, states that snacks should be available to residents 24 hours a day, either upon request or scheduled between meals. However, Resident #10 reported not being offered snacks on two of the four survey days, despite expressing hunger, particularly at bedtime. The resident mentioned that snacks were placed at the nurse's station, requiring residents to go there to obtain them, and recounted an instance where a request for cheese and crackers was not fulfilled by a CNA. Interviews with staff revealed inconsistencies in the distribution of snacks. CNA #4 and CNA #6 indicated that they did not routinely offer snacks, as it was believed to be the responsibility of another CNA or dietary aide. CNA #5 mentioned a change in procedure several months prior, where a dietary aide instructed that snack trays be left at the nurse's station rather than distributed to residents' rooms. The Dietary Manager and Assistant Director of Nurses confirmed that snacks were intended to be offered three times daily, but acknowledged that the current practice resulted in only those residents near the nurse's station receiving snacks, unless specifically requested.
Infection Control Breach During Wound Care
Penalty
Summary
The facility failed to adhere to infection prevention and control protocols during wound care for a resident with a Stage 4 pressure ulcer on the right heel. The Treatment Nurse (TN) did not perform hand hygiene before gathering wound care supplies after assisting another resident. The TN placed wound care supplies on an unclean treatment cart and a soiled overbed table without cleaning them or using a barrier. During the wound care procedure, the TN used gloves that had been contaminated by the soiled table, failed to change gloves or perform hand hygiene after removing the old dressing, and did not follow Enhanced Barrier Precautions (EBP). The TN cleaned the wound improperly by wiping over the wound bed multiple times with the same gauze, and after completing the wound care, placed contaminated items back into the treatment cart without sanitizing them. The Assistant Director of Nursing/Infection Preventionist (ADON/IP) confirmed that these actions placed the resident at risk for infection. The resident involved had been admitted with a diagnosis of a Stage 4 pressure ulcer and hemiplegia following a cerebral infarction.
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Illustrative
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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 Greenwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Crystal Rehabilitation And Healthcare Center | 0 mi | ★★★★★ | 1 | 0 |
| Golden Age Nursing Home | 1.3 mi | ★★★★★ | 3 | 0 |
| Middleton Oaks Health And Rehabilitation | 24.3 mi | ★★★★★ | 4 | 0 |
| Vaiden Community Living Center | 25.8 mi | ★★★★★ | 1 | 0 |
| Grenada Living Center | 26.5 mi | ★★★★★ | 0 | 0 |
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