Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Health & Rehabilitation during CMS and state inspections, most recent first.
Insufficient CNA staffing led to missed ADL care and repeated missed showers for dependent residents. A resident reported showers were often missed, and multiple residents said the facility was short-staffed and baths were missed. Staff described one-person coverage on halls, missed breaks, long shifts due to turnover, and tasks being missed on evenings. The Birch Hall schedule showed limited CNA coverage on day and evening shifts and one CNA on nights, despite the facility’s staffing plan calling for staffing based on census and resident needs.
A facility failed to provide bathing assistance for dependent residents, with showers missed for 4 of 9 sampled residents. One resident was observed with dry skin and dirty nails and stated showers were often missed, leaving the resident feeling dirty. Records showed limited or no showers completed for several residents despite care plans requiring bathing help or total assist. Staff said showers were often missed and were difficult to complete when only one person was working the hall.
A resident with a BIMS of 15 and clear speech reported that a CNA inserted a finger into his rectum while he was being changed. He said the event was humiliating, continued to bother him, and led him to decline baths and isolate more. The resident and family stated no one from the facility followed up with him or explained the outcome of the allegation, and the chart lacked additional documentation about the incident.
Incomplete Investigation of Alleged Sexual Abuse: A resident reported alleged sexual abuse by a staff member, but the facility’s investigation lacked documentation of key interviews, questions, dates, and findings. Staff stated the resident was interviewed and a police report was filed, yet there was no documented follow-up on the resident’s psychosocial status, and the care plan was not updated to reflect care in pairs or new interventions related to the incident.
A resident with chronic back pain consistently reported severe pain and said his pain was not controlled to his acceptable level. He was observed grimacing and shifting in bed while rating his pain 8/10, and pain meds and nonpharmacologic interventions were documented as ineffective. Staff noted the pain was not well controlled that day, and the resident’s pain summary showed severe pain was documented daily.
Menu substitutions were served without following the written menu or obtaining dietitian review for nutritional adequacy. Two residents reported ordering a chef salad alternate but receiving chicken tenders instead, and staff said the kitchen changed the menu without approval. The chef salad later served lacked the required meat portion, and staff confirmed it did not meet the protein requirement.
Food was served below required temperatures and was repeatedly described by residents as cold, bland, rubbery, dry, or having a bad taste. Staff said trays were delivered to halls and left for residents without checking temperatures or reheating food, and observations found hot items such as biscuits and gravy, eggs, and ground meat well below the facility’s policy standard of 135 degrees F.
Food items in the kitchen were not properly date-marked or monitored, including sauces, dressings, mayonnaise, cheese, cream cheese, strawberries, and foods brought in by family such as frozen pancakes, waffles, and donuts. Staff also found multiple expired spices and dry goods, and milk cases plus a bucket of pickles were stored on the floor in the walk-in refrigerator. Facility policy required use-by dating for opened foods and family-provided foods not in original containers.
A resident was found cold in bed while her room temperature measured far below the set thermostat level. Surveyors also found several nearby rooms in the 60s, and staff reported that heat had been turned off for repairs, temperatures were not checked afterward, and later issues included a faulty air handler component and multiple broken thermostats affecting several rooms.
A staff member misappropriated a cognitively intact resident’s funds by entering into a private agreement to provide travel assistance for medical appointments in exchange for $1000 plus expenses. The resident and staff member exchanged text messages discussing payment, hotel, food, airline tickets, and a rental car, and the staff member requested advance payment due to financial difficulties. The resident agreed to pay half of the fee in advance and wrote a personal check for $500 to the staff member, which was cashed, despite the staff member having prior training on professional boundaries and misappropriation of funds.
Unclean Nebulizer Equipment: A resident’s nebulizer mouthpiece and aerosol tubing were observed with white crust and buildup, and there was no date showing when the equipment had last been replaced. Staff gave conflicting accounts about who was responsible for weekly changes, and the resident said the nebulizer had been used since it was last replaced. The MAR/physician order summary did not show an order for changing the tubing, although facility policy stated the tubing was to be changed weekly or per protocol.
A resident with paraplegia and a history of wounds developed a new pressure wound, but the care plan was not updated to reflect this change or its management. Staff interviews and record reviews confirmed that the care plan did not include the new wound or note the resolution of a previous wound, resulting in incomplete documentation of the resident's current care needs.
A resident with a history of pressure wounds and paraplegia developed a new Stage II sacral ulcer, but staff failed to provide timely pressure-relieving interventions such as an air mattress, and did not consistently assess or document the wound as required by facility policy. Inconsistent staff awareness and incomplete documentation contributed to inadequate wound management.
The facility failed to respect residents' privacy by entering rooms without consent and going through personal items, causing distress. Additionally, two residents were unable to vote due to lack of assistance in obtaining absentee ballots, despite expressing a desire to participate in elections.
The facility did not ensure residents were informed about the grievance process and lacked an option for anonymous reporting. Several residents were unaware of how to file grievances and feared retaliation. Staff interviews and observations confirmed the absence of anonymous grievance options, and the grievance policy did not include instructions for anonymous submissions.
A resident at the facility lost her dentures and was not referred for dental services, resulting in her having to eat soft and pureed foods. Despite having dentures upon admission and sufficient funds to replace them, the facility did not schedule a dental appointment. Staff interviews confirmed the dentures were lost, and the facility's policy required them to assist with dental appointments, which they failed to do.
The facility failed to ensure call lights were within reach for three residents, as observed during a survey. One resident's call light was under the bed, another's was two feet away on a nightstand, and a third's was one and a half feet away. Staff were unaware of the call light locations and acknowledged they should be accessible. The facility's policy emphasizes the importance of communication and access to services, which was not maintained.
A facility failed to assess and accommodate the wheelchair positioning needs of a resident with one-sided weakness, who was frequently observed leaning dangerously forward in his wheelchair. Despite staff awareness of the issue, no positioning aids were assessed or provided, and the care plan lacked specific interventions for safe wheelchair use. The resident had a history of falls, and no prior therapy notes on positioning were available during the survey.
The facility failed to ensure accurate MDS assessments for two residents, one regarding hearing aid usage and the other concerning antibiotic medication. A resident's care plan indicated the use of hearing aids, but MDS assessments inaccurately showed no usage. Another resident's MDS record incorrectly listed antibiotic use, which was not supported by physician orders or the resident's statement. Staff acknowledged these errors.
A facility failed to develop a baseline care plan for a resident's foley catheter care within 48 hours of admission. The resident, who was discharged from the hospital with a foley catheter, did not have this need addressed in their care plan. A staff member indicated that the omission might have been due to a missed checkbox on the admission assessment.
A facility failed to include the use of Eliquis, an anticoagulant medication, in a resident's care plan, which is essential for monitoring potential side effects. Despite the interdisciplinary team's responsibility to keep care plans current, the resident's care plan did not reflect the prescribed medication or the need for monitoring, highlighting a deficiency in the care planning process.
A facility failed to update a resident's care plan regarding denture care. The resident was observed without dentures and stated they were missing, requiring her to eat soft foods. A staff member was unaware of the care plan's active intervention for denture care, which had not been revised since its last update.
A resident's ability to hear was compromised due to a missing hearing aid that was not replaced since July 2024. Despite the care plan indicating the need for two hearing aids, one was missing, and the grievance process was not initiated. The resident missed an ear cleaning appointment, and new appointments were scheduled for later months. The social services staff was unaware of the issue, highlighting a communication lapse.
The facility failed to properly document refrigerator temperatures and date opened medications, as observed with a vial of Tuberculin PPD in a medication refrigerator. A staff member indicated that logs were kept at the nurse's station, but a review showed significant gaps in documentation for October and November.
A resident in the facility was not provided with the necessary assistive utensils, as observed during a meal where she struggled to eat with regular silverware. Despite her tray card indicating a need for built-up utensils, staff were unaware of this requirement due to communication lapses. The resident's dietary progress note highlighted her need for adaptive utensils to manage weight loss, but this was not included in her care plan.
The facility failed to provide residents with access to their personal funds on weekends, affecting their ability to purchase items like soda from vending machines. Staff interviews revealed that weekend managers lacked access to petty cash, and the only person with access was unavailable unless it was an emergency. The facility's policy was not followed, and no residents had received personal funds on weekends in the past 12 months.
Insufficient CNA Staffing and Missed ADL Care
Penalty
Summary
The facility failed to provide sufficient nursing staff every day to meet resident needs and to have a licensed nurse in charge on each shift. Surveyors found that dependent residents did not receive scheduled ADL care, including missed showers for residents #1, #3, #5, #6, and #8. Resident #1 stated that staff seemed to assume the resident could shower independently despite needing assistance, and that showers were often missed. Staff member G stated evening shift showers were the task most often missed, and staff member P stated that when only one person was on the hall, staff were reluctant to leave the hall long enough to complete a bath or shower. Residents and staff also described ongoing low staffing on multiple halls. Resident #1, resident #4, resident #5, and resident #9 reported that there was not enough staff and that baths were missed when the facility was short-staffed. Staff member H stated that although CNA shifts were eight hours, some staff had been working 12- to 16-hour shifts because of turnover, and that the evening shift on Cedar Hall rarely had the expected two staff members. Staff member N stated tasks often got missed on the evening shift on Cedar Hall because only one staff member was on shift. Staff member G and staff member K stated that only one person was scheduled on Birch Hall during evening shifts, breaks were difficult to take, and staff were pulled from Birch Hall to assist with appointments. Review of the Birch Hall CNA schedule for 6/1/26 through 6/14/26 showed one CNA scheduled on day shift for 7 of 14 days, one CNA scheduled on evening shift for 12 of 14 days, and one CNA scheduled on night shift for all 14 days. The facility document on staffing resources stated the facility fills a complete schedule weeks in advance based on census and resident needs, with nurse manager/ED review, and listed nurse aide staffing at 142-145 hours per day.
Missed Bathing Assistance for Dependent Residents
Penalty
Summary
The facility failed to provide bathing assistance for dependent residents, with bathing/showers missed for 4 of 9 sampled residents. Resident #1 was observed lying in bed with long nails containing a brownish substance underneath and flakes of dry skin peeling from the arms. The resident stated a need for shower assistance, explained that the private bathroom gets wet during showers and that the resident might slip, and said showers are often missed, leaving the resident feeling dirty when a shower is missed. Resident #1's 30-day bathing lookback showed only two completed showers during the review period, despite a care plan noting bathing/shower assistance requiring physical help in part of the bathing activity. Resident #3's 30-day bathing lookback also showed only two completed showers during the review period, although the care plan stated the resident preferred to be showered once per week. Resident #6's bathing lookback showed no showers completed during the review period, and the care plan stated bathing/shower assistance required total assist from staff. Resident #8's bathing lookback showed no showers completed during the review period, and the care plan stated bathing/shower assistance required physical help in part of the bathing activity. Staff interviews indicated that the hall staff were responsible for completing scheduled baths and showers, that showers were often missed, and that it was difficult to complete showers when only one person was working the hall.
Failure to Protect Resident From Alleged Sexual Abuse and Provide Follow-Up Support
Penalty
Summary
The facility failed to protect a resident from non-consensual sexual contact by a CNA and failed to ensure the resident received necessary social services after the alleged event. The resident reported that while two CNAs were changing his brief, one CNA inserted a finger into his rectum. He later stated the finger went past the second knuckle and was moved around, and he said the event bothered him after he thought about it. The resident was cognitively intact, with a BIMS score of 15, clear speech, and the ability to understand and make himself understood. The resident stated he reported the incident to nursing staff and later to police, but he also stated that nobody from the facility followed up with him or provided him with the outcome of the investigation. He said the incident was humiliating, made him feel uncomfortable, and continued to bother him. He also stated he had declined baths because of the incident and was scared it would happen again. A family member stated the resident was upset, embarrassed, and still concerned about the matter, and another staff member stated the resident had become more withdrawn and had not come out of his room as much after the incident. Facility documentation showed the allegation was investigated and found unable to be verified, but the resident’s chart contained no other progress notes, assessments, or documentation about the incident. The resident stated staff member M no longer cared for him, but he also stated no staff had checked on how he was doing after the event. The facility policy stated that all residents have the right to be free from abuse, including sexual abuse, and that the facility would react to all allegations or questions from residents, family members, employees, or visitors.
Incomplete Investigation of Alleged Sexual Abuse
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of sexual abuse involving a staff member and one resident. The resident reported the incident to staff, and the facility later determined the allegation was unable to be verified. The investigation summary stated that the witnessing CNA was not in the room for all of the cares, the resident did not say anything at the time, and the ED interviewed five other residents on the same hallway. During interviews, staff described the abuse investigation process as involving interviews with the resident, other staff, and selected residents, with the focus on the area of concern. Staff member A stated she was responsible for reporting and investigating abuse allegations and said she talked to the resident, suspended the staff member involved, talked to other residents, obtained the witness statement, filed a police report, and contacted the family. However, she also stated she did not document the interviews she conducted with other residents or staff and did not have a copy of the police report. Staff member B stated staff member A conducted most of the investigation, and staff member E stated she did not follow up with the resident after the allegation and was not involved because a police report had been filed. The investigation file did not show which other residents were interviewed, the questions asked, all staff interviewed, the details from those interviews, the dates the interviews were conducted, follow-up with the resident for psychosocial outcome, or interventions for the resident if necessary. The resident stated no one from the facility had followed up with him about the investigation or how he was doing, and later stated staff only returned to ask whether police had called him. The resident's comprehensive care plan was not updated to reflect care in pairs or any new interventions related to his mental health and well-being after the incident.
Inadequate Pain Management for Resident with Chronic Back Pain
Penalty
Summary
The facility failed to provide pain management that was acceptable to a resident’s goals for 1 of 25 residents sampled. Resident #3 reported chronic back pain and stated the pain was “horrific,” rating it 8/10, while also saying he considered 5/10 to be an acceptable pain level. During observation, he was lying in bed, grimacing, wincing, and frequently shifting his weight. He stated he had taken pain medication at noon and wanted something more for the pain, but later reported he was still in pain and again rated it 8/10. Staff were notified of the resident’s pain, and one staff member stated nursing was responsible for notifying the provider if pain was not well managed, but did not know whether the provider had considered changes to the pain regimen. Another staff member stated she attempted to contact the provider, but the provider had not responded, and she felt the resident’s pain control had not been well controlled that day. The resident’s care plan directed staff to notify the MD if pain medication was ineffective and to observe effectiveness of pain interventions and need for additional measures. The MAR showed acetaminophen, a lidocaine patch, gabapentin, and hydrocodone/acetaminophen were given, with hydrocodone/acetaminophen marked ineffective. The TAR documented pain monitoring at 8/10 with repositioning, dim light/quiet environment, relaxation, and distraction marked not effective. The pain summary showed severe pain was documented daily and occurred 23 out of 49 times between 1/6/26 and 1/14/26.
Menu substitutions served without required nutritional review
Penalty
Summary
The facility failed to serve substituted menu items in accordance with the written menu and standardized recipe requirements, and failed to have the dietitian review menu changes for nutritional adequacy for two sampled residents. Resident #40 stated he ordered the chef salad alternate for lunch, but the kitchen served chicken tenders instead, and he reported that the kitchen often messed up the menus and that residents were told one item the night before only to receive something different the next day. Resident #69 also stated she wanted the salad but was served chicken tenders instead. Staff member L stated the night CNAs used the wrong menu day and residents were told they would receive chicken tenders, and staff member L said the kitchen decided to serve chicken tenders instead of the chef salad. Staff member D stated he did not get approval from the dietitian to change the menu and did not authorize the kitchen to change it. The menu for week two, day 3, listed chopped chef salad as the alternate for both lunch and dinner, but the dinner chef salad served on 1/13/26 did not include meat. Resident #40 and resident #69 both stated the chef salad did not have meat on it, and staff members H and I confirmed the dinner chef salad was served without meat and without any additional items. Staff member D stated the chef salad should have included two ounces of turkey and two ounces of ham, and staff member G stated that without the meat the chef salad would not meet the protein requirement for the meal. The facility's Dining Manager Chopped Chef's Salad recipe reflected a two-cup portion including turkey and ham, and the Food Preparation policy stated menu items shall be prepared following the facility's written menus and standardized recipes.
Food Served Cold and Unappetizing
Penalty
Summary
The facility failed to ensure food was served at a palatable, attractive, and safe appetizing temperature for 7 of 25 sampled residents, including residents 40, 41, 49, 56, 66, 69, and 79. Staff member R stated that when trays were delivered to the hall, floor staff passed them out immediately, and if a resident was not ready to eat, the tray was left on the bedside table until the resident was ready. Staff member R stated she did not check food temperatures before residents started eating, did not reheat food before it was eaten, and was unaware of anyone checking temperatures after meals were delivered to the halls. Resident interviews reflected dissatisfaction with the food, including reports that it tasted bad, had a funny or rancid taste, was bland, was served too often in the same form, and was frequently cold, dry, hard to chew, or rubbery. Observations showed trays sitting in the kitchen window and on hall delivery with temperatures below the facility’s policy standards. On one observation, biscuits and gravy were 100 degrees and eggs were 110 degrees while trays waited for residents who had not yet arrived to the dining room. On another observation, trays delivered to the halls for room residents included biscuits and gravy at 107 and 99 degrees, ground meat at 100 degrees, and eggs at 130 degrees. The facility policies stated hot foods should remain at or above 135 degrees F and that food and drinks shall be palatable, attractive, and at a safe and appetizing temperature.
Food Items Not Dated, Expired Dry Goods, and Food Stored on Floor
Penalty
Summary
Food items were not dated or monitored in the kitchen to ensure they were used by the use-by date or discarded. During an observation and interview, multiple refrigerated and dry food items were found without open or discard dates, including sauces, dressings, mayonnaise, mustard, honey, vanilla flavoring, sliced cheese, half a brick of cream cheese, and a bucket of strawberries in juice. Several items brought in by family were also found in the kitchen and freezer without dates, including frozen pancakes, waffles, and donuts labeled with a resident's name. Staff member D stated that open food items were only good for seven days and that anything without an open date should be thrown out, while staff member F stated there was no list to follow showing when to discard food items in the kitchen. The kitchen also contained multiple expired dry goods during a later observation, including ground ginger, ground coriander, ground allspice, pickling spice, open jars of ground marjoram, rubbed sage, ground mustard, caraway seed, and pork spice rub. In addition, milk carton cases and a five-gallon bucket of pickles were observed stored on the floor in the walk-in refrigerator. The facility's policy required food to be clearly marked with a use-by date and stated that food brought in by family or visitors and not in original containers must be labeled with a use-by date and consumed within 4 days.
Cold Resident Rooms Due to Heating System Problems
Penalty
Summary
The facility failed to maintain a comfortable environment for residents by allowing resident room temperatures to fall below the expected range, affecting 1 of 25 sampled residents, resident #64. During an observation, resident #64 was in bed with several blankets and stated she was cold. The thermostat in her room was set to 75 degrees, but the temperature reading was 65 degrees. Surveyor observations and staff interviews showed that multiple rooms on the unit were cold, with temperatures recorded at 63 to 67 degrees in several rooms. Staff member C stated a repair company had been in the building that morning to drain a heat system line and had turned off the heat for the repairs, which affected part of the hall. Staff member C also stated he had not checked temperatures after the repairs and had not been notified by floor staff of the cold conditions. Later interviews documented that the heating issue involved bleeding the water lines, a computer component in the air handler that was not working, and four faulty thermostats controlling multiple rooms. Resident #64 was later observed resting in bed with blankets, and she stated she was comfortable and no longer cold after the room temperature had risen.
Misappropriation of Resident Funds by Staff Through Private Travel Arrangement
Penalty
Summary
A staff member engaged in misappropriation of a resident’s funds by entering into a private financial arrangement for travel assistance. The cognitively intact resident, with a BIMS score of 15 and able to make his own decisions, reported that after becoming friendly with the staff member, the staff member offered to assist with travel to another city for medical appointments in exchange for $1000 plus expenses. Text messages on the resident’s phone showed ongoing discussions between the resident and the staff member about payment for services, hotel, food, airline tickets, and a rental car, and the staff member requested advance payment due to financial difficulties. The resident agreed to pay half of the $1000 fee in advance and wrote a personal check for $500 to the staff member, which was cashed. The deficiency occurred despite the staff member having previously completed education on professional boundaries and on abuse, neglect, misappropriation of funds, and abuse reporting. The staff member’s acceptance of $500 from the resident for personal services, as evidenced by the cashed check and corroborating text messages, constituted misappropriation of resident funds. The resident later expressed regret about the payment and a desire to get his money back and involve law enforcement, indicating that the financial transaction was not resolved as the resident had expected.
Unclean Nebulizer Equipment
Penalty
Summary
The facility failed to provide clean equipment for respiratory treatment for one resident, identified as resident #69. During observation, the resident’s nebulizer mouthpiece and corrugated aerosol tubing were noted to have a white crust and buildup. Staff member B stated that nursing staff were responsible for changing nebulizer equipment weekly and that an order was entered in the chart to alert staff to change the tubing each week. Staff member P stated she did not know when the resident’s nebulizer tubing or mouthpiece had last been changed and said the respiratory therapist was responsible for changing them weekly, but she was not sure why the equipment had not been changed. On later observation, the nebulizer still had the white crust and buildup, and there was no date on the tubing or mouthpiece to show when it had last been replaced. The resident was unable to state when it had last been replaced and said she had used the nebulizer since it was last replaced. The physician Order Summary Report did not show an order for changing the nebulizer tubing, while the facility policy stated nebulizer tubing was to be changed weekly or according to facility protocol.
Care Plan Not Updated for New Pressure Wound
Penalty
Summary
The facility failed to update the care plan for a resident with a new pressure wound. The resident, who has a history of wounds and is paraplegic, reported having a current buttock wound. Staff confirmed that care plans should be updated by the wound care nurse to reflect all current care concerns, including new wounds and interventions. Nursing progress notes documented the identification of a new pressure wound, but the care plan, last revised prior to the wound's development, did not include this new wound or its management. Additionally, the care plan was not updated to reflect the resolution of a previous sacral wound, nor was it revised to address the current wound identified in the nursing notes. This lack of care plan updates was confirmed through interviews and record review, showing a failure to ensure the care plan accurately reflected the resident's current condition and needs.
Failure to Implement and Document Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement appropriate wound prevention and management measures for a resident with a history of pressure wounds and an elevated risk for developing new ulcers. Despite the resident having a new Stage II sacral wound and a history of paraplegia, there was no pressure-relieving air mattress or overlay on the resident's bed. Staff interviews revealed inconsistent awareness and follow-up regarding the new wound, with some staff unaware of its presence and others only applying barrier cream for ongoing maceration and irritation. Documentation showed that a secure message about the new wound was sent to the nursing team, DON, and wound care nurse, who recommended barrier cream and an air mattress, but these interventions were not promptly implemented. Additionally, the facility failed to accurately assess and monitor the new wound. There was a lack of comprehensive wound assessment documentation, including weekly measurements and detailed wound characteristics, as required by facility policy. The care plan and weekly summary charting did not reflect compliance with recommended interventions, and there was no evidence of regular monitoring or modification of interventions based on the resident's condition. These failures in wound management placed the resident at risk for wound progression and infection.
Violation of Resident Privacy and Voting Rights
Penalty
Summary
The facility failed to honor residents' rights to privacy and self-determination, as evidenced by staff entering residents' rooms without consent and going through their personal items. Two residents reported that a staff member entered their rooms and searched through their drawers without permission, which led to distress and a lack of respect for their privacy. One resident found a staff member holding knives that were stored in a drawer, and both residents expressed dissatisfaction with the intrusion and lack of communication regarding a scheduled deep cleaning. The facility's training module emphasized the importance of notifying residents and obtaining consent before handling personal items, which was not adhered to in this instance. Additionally, the facility failed to ensure that residents had the opportunity to engage in political voting. Two residents expressed a desire to vote but did not receive the necessary absentee ballots. One resident reported informing the activities staff about the missing ballot, but no follow-up was conducted to assist her in voting. Another resident expressed disappointment at not receiving a ballot, despite wanting to vote. The facility's policy on resident rights included participation in community activities, such as voting, but the lack of follow-up and assistance resulted in these residents being unable to exercise their voting rights.
Failure to Inform Residents of Grievance Process and Provide Anonymous Reporting
Penalty
Summary
The facility failed to ensure that residents were informed about how to file grievances and did not provide an option for anonymous reporting. During interviews, several residents expressed that they were unaware of the grievance process and feared retaliation if they complained. One resident mentioned a complaint about an incident but did not know what a grievance was. Another resident had issues with staff respecting his privacy and accessing his trust account on weekends but was unaware of how to file a grievance or do so anonymously. A third resident also faced difficulties accessing her trust account and was similarly uninformed about the grievance process. Staff interviews revealed that there was no designated location for residents to file anonymous grievances, and the facility's grievance policy lacked instructions for anonymous submissions. Observations confirmed the absence of grievance boxes for anonymous reporting, and grievance forms were only available in a limited area of the facility. Additionally, a resident's missing dentures were reported to the previous administrator, but the individual was not aware of a formal grievance process. The facility's grievance log showed no records of grievances filed by the residents mentioned, indicating a lack of awareness and accessibility to the grievance process.
Failure to Provide Dental Services After Denture Loss
Penalty
Summary
The facility failed to ensure that a resident was referred for dental services after losing dentures while residing at the facility. This deficiency affected one of the sampled residents, who was required to eat soft and pureed foods due to the absence of dentures. During an observation and interview, the resident stated that her dentures were taken, and she had to find soft foods to eat. Despite the resident having dentures upon admission, the facility did not schedule a dental appointment to replace the lost dentures, even though the resident had sufficient funds to cover the cost. Interviews with staff revealed that the lower denture was lost in October 2021, but there was no record of when the upper denture went missing. The facility's policy required them to provide or obtain dental services to meet residents' needs, including assisting with making dental appointments. However, the facility did not adhere to this policy, as evidenced by the lack of action to replace the resident's dentures. The resident's care plan indicated she had upper and lower dentures and required assistance with oral care, but the facility failed to address the issue over an extended period, despite multiple opportunities to do so.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three of the 24 sampled residents, leading to a deficiency in resident care. During observations, it was noted that one resident's call light was under her bed, making it inaccessible, while another resident's call light was placed on a nightstand two feet away from the bed, and a third resident's call light was one and a half feet away on a nightstand. These residents were unable to reach or locate their call lights, which are essential for communication and requesting assistance. Interviews with staff revealed that they were unaware of the call light locations and acknowledged that call lights should always be within reach of residents. The facility's policy on Resident Rights emphasizes the importance of communication and access to services, which was not upheld in these instances.
Failure to Assess and Accommodate Wheelchair Positioning Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident with one-sided weakness who required a wheelchair for mobility. The resident was observed multiple times leaning forward in his wheelchair, often to the point where his head was almost touching his knees or the table. Despite these observations, there was no assessment conducted for positioning aids to help the resident maintain a safe and comfortable posture in his wheelchair. Staff members were aware of the resident's tendency to lean forward but did not know if any positioning equipment was required or available. The resident's care plan noted a potential for falls due to impaired mobility and balance, but it lacked specific interventions for wheelchair positioning. A nursing note indicated that the resident had previously been found on the floor next to his wheelchair, complaining of pain. Despite requests, no prior physical or occupational therapy notes regarding the resident's wheelchair positioning were provided during the survey, indicating a lack of documented assessment and intervention for the resident's needs.
Inaccurate MDS Assessments for Hearing and Medications
Penalty
Summary
The facility failed to ensure the accuracy of the Quarterly MDS assessment for two residents, specifically regarding medications and hearing. For one resident, there was a discrepancy in the documentation of hearing aid usage. During an observation, the resident was noted to have difficulty hearing, and a staff member provided a hearing aid, which did not improve the resident's hearing. The resident's care plan indicated the use of two hearing aids, but the MDS assessments inaccurately reflected that the resident did not use hearing aids and had highly impaired hearing. This inconsistency was acknowledged by a staff member who admitted the error in the assessment. For another resident, the MDS record inaccurately indicated that the resident was on an antibiotic for the last seven days. However, a review of the resident's EHR and physician orders showed no antibiotics were ordered or administered during that period. The resident confirmed not being on antibiotics, and a staff member verified the absence of any antibiotic orders in the resident's records. The staff member recognized the need to correct the MDS assessment to reflect the accurate medication status.
Failure to Implement Baseline Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident's foley catheter care within 48 hours of admission. During an observation and interview, the resident was noted to have been discharged from the hospital with a foley catheter, which was placed there, and expressed hope for its removal soon. A staff member confirmed that the resident was admitted to the facility on the same date as the baseline care plan, but the plan did not address the foley catheter. The staff member suggested that the omission might have been due to a missed checkbox on the admission assessment, which is supposed to trigger care areas for the baseline care plan.
Deficiency in Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident receiving anticoagulant medication. The resident, who was diagnosed with atrial fibrillation, was prescribed Eliquis, an anticoagulant medication. During an interview, a staff member stated that the interdisciplinary team was responsible for ensuring care plans remained current and that high-risk medications, such as anticoagulants, should be included in resident care plans for monitoring side effects. However, the review of the resident's current care plan, which was last revised on 10/25/24, did not reflect the use of Eliquis or the need to monitor for potential side effects, indicating a deficiency in the care planning process.
Failure to Update Care Plan for Denture Care
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident after Quarterly and Annual assessments. During an observation and interview, it was noted that the resident was without her dentures and stated that someone had taken them, leading her to find soft foods to eat. A staff member confirmed that the resident had not had dentures for as long as she had been living at the facility, despite the care plan indicating that she had upper and lower dentures and required assistance with oral/denture care twice daily. The care plan had not been updated since its last revision date, which was several months prior.
Failure to Replace Missing Hearing Aid for Resident
Penalty
Summary
The facility failed to replace a missing hearing aid for a resident who required hearing aids, affecting the resident's ability to hear since July 2024. During an observation and interview, it was noted that the resident was having difficulty hearing, and a staff member attempted to assist by providing one hearing aid, which did not improve the resident's hearing. The resident's care plan indicated the use of two hearing aids, but one had been missing since August 2024. A staff member admitted to neglecting to fill out a grievance form for the missing hearing aid, which is typically the first step in the replacement process. The resident had an appointment scheduled for ear cleaning in August 2024, which was missed due to illness, and a new appointment was set for November 2024. Additionally, a replacement appointment at Costco was scheduled for December 2024. The facility's policy requires employees to refer any need for hearing services to the social worker, who is responsible for assisting residents in obtaining necessary services. However, the new social services staff member was unaware of the resident's missing hearing aid, indicating a lapse in communication and follow-up on the resident's needs.
Deficient Medication Storage Practices
Penalty
Summary
The facility failed to maintain proper documentation and labeling practices for medication storage, specifically regarding the recording of refrigerator temperatures and the dating of opened medications. During an observation, a medication refrigerator on Hall B was found to contain a vial of Tuberculin Purified Protein Derivative (PPD) that was opened but not dated. Additionally, there were no temperature logs available to confirm that the refrigerator maintained a safe temperature range. An interview with a staff member revealed that refrigerator temperature logs were supposed to be kept at the nurse's station, and a new process had been implemented to address identified compliance issues. However, a review of the facility's Refrigerator Temperature Log for October and November 2024 showed significant gaps in documentation, with 27 out of 31 days in October and four out of seven days in November lacking records.
Failure to Provide Assistive Utensils for Resident
Penalty
Summary
The facility failed to provide assistive utensils for a resident who required them, impacting her ability to eat effectively and increasing her risk of weight loss. During an observation, the resident was seen struggling to use regular silverware, which was not in accordance with her dietary needs as indicated on her tray card. The tray card specified that she should receive built-up utensils, but these were not provided at the dining table. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for assistive utensils. Staff members were unaware of the resident's requirement for special utensils, and there was a breakdown in communication about dietary changes. The dietary progress note indicated that the resident had been followed by a dietician for weight loss, who noted that the resident could handle utensils more easily with adaptive utensils. However, this information was not reflected in the resident's care plan, which lacked details about the need for assistive utensils or the risk of weight loss if they were not used.
Failure to Provide Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their personal funds on weekends, which is a violation of their rights to manage their financial affairs. This deficiency affected three residents who were unable to access their funds for amounts less than $100 for Medicare residents or $50 for Medicaid residents. The residents reported being unable to purchase items such as soda from vending machines during weekends, as they had to wait until business hours on Monday to access their funds. Staff interviews revealed that the weekend managers did not have access to petty cash, and the only person with access was a staff member who was not available on weekends unless it was an emergency. The facility's policy stated that residents should have routine access to petty cash and be able to arrange for access to larger funds when needed. However, the policy was not being followed, as residents were not able to access their personal accounts on weekends. Staff members indicated that there was an attempt to train a weekend receptionist to manage resident trust accounts, but the training was incomplete due to the employee's termination. The facility was in the process of hiring a new weekend receptionist to address this issue, but at the time of the report, no residents had received personal funds on weekends in the past 12 months.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 12 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Missoula
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Missoula Health & Rehabilitation Center | 2 mi | ★★★★★ | 6 | 0 |
| Village Health & Rehabilitation | 3.5 mi | ★★★★★ | 1 | 0 |
| The Living Centre | 24.9 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.