Below average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Trace Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Nurses and nurse aides lacked the appropriate competencies to provide care that maximizes each resident's well-being, resulting in care that did not meet regulatory standards.
Staff failed to properly disinfect a shared glucometer between residents by using alcohol wipes instead of an EPA-registered germicidal wipe, did not perform required hand hygiene and glove changes during wound care, and placed soiled linen directly on the floor rather than bagging it, all in violation of facility infection control policies.
The facility did not ensure pharmaceutical services were provided to meet each resident's needs and failed to employ or obtain a licensed pharmacist, resulting in a lack of required pharmaceutical oversight.
A cook was observed preparing food with facial hair not fully covered by a beard restraint, contrary to facility policy and professional standards. Staff interviews confirmed that all kitchen staff are expected to use beard restraints that cover all facial hair, but this was not followed during the observed food preparation.
A resident was not protected from the wrongful use of their belongings or money, as facility staff failed to safeguard personal property or funds, resulting in unauthorized use.
A resident with multiple diagnoses was not assessed for the ability to self-administer medications, and no care plan was in place. A medication aide routinely left medications at the bedside for the resident to take unsupervised, and the resident was unaware of the medications' purpose. Facility leadership confirmed that medications should not be left unattended and staff should observe administration.
A resident with dementia, who was cognitively intact, had a family member designated as medical POA and Responsible Party in multiple records, but the facility failed to obtain and include the actual POA document in the medical record. Interviews with the resident, her RP, and various staff revealed confusion and lack of clarity regarding the process for handling advanced directive documents, resulting in the absence of the required documentation.
Two residents with high-risk conditions—one on anticoagulant therapy and another with diabetes mellitus type II—did not have individualized, person-centered care plans addressing these needs. Both residents were severely cognitively impaired and required specific interventions, but staff responsible for care planning did not include the necessary diagnoses or medications in their care plans at admission. Key nursing and administrative staff were unaware of these omissions.
A resident with dementia had a care plan indicating 'Full Code' status, but after a physician's order for DNR was entered by the ADON, the care plan was not updated to reflect this change. The ADON acknowledged responsibility for updating the care plan and could not explain the omission, and the Administrator confirmed the care plan should have been revised.
Two residents were not treated with dignity when a staff member entered a room without knocking or announcing their presence, and another resident with a urinary catheter was observed in public areas with an uncovered drainage bag, making urine visible to others. Staff interviews revealed inconsistent understanding and use of privacy practices, despite facility expectations for maintaining resident dignity.
A resident with multiple chronic conditions had a BMP ordered by an NP, but the facility failed to notify the ordering provider of abnormal lab results. The results were reviewed internally but not communicated to the NP, and staff interviews revealed confusion about responsibility for reporting lab findings.
A deficiency was cited when a facility area was found to contain accident hazards and lacked adequate supervision to prevent accidents, compromising resident safety.
The facility failed to conduct timely care plan meetings for two residents, one with severe cognitive impairment and another with moderate impairment. The care plans were not reviewed quarterly as required, with the last meetings held several months prior. Staff, including the Social Worker and Administrator, were unaware of the missed meetings, which should have been scheduled and conducted regularly.
The facility was found to have expired thickened orange juice cartons in dry storage, available for resident use, and a scoop improperly stored inside a sugar bin, risking cross-contamination. The Assistant Dietary Manager and Administrator acknowledged these deficiencies, confirming that expired items should be discarded and scoops stored outside ingredient bins.
A resident with chronic obstructive uropathy had their urinary catheter drainage bag resting on the floor, increasing infection risk. During a bathing activity, the bag was observed on the floor due to the bed's low position. Staff, including a nurse aide and medication aide, failed to notice or correct the issue initially. The Infection Preventionist and DON confirmed the infection control concern, although the resident did not suffer any ill effects.
A medication cart on the 400 hall was left unlocked and unattended, observed from 4:27 PM to 4:32 PM. The cart was visible from the nurse's station, but no staff were present. Medication Aide #1 admitted to leaving it unlocked, and both the DON and Administrator confirmed that carts should be secured unless in use.
A resident on anticoagulant medication experienced an unwitnessed fall and subsequent changes in condition, including lethargy and altered mental status. Despite these signs, the facility did not continue neurological checks as per protocol or seek immediate medical intervention. The resident was later found to have significant intracranial hemorrhages and passed away after being transferred to the hospital.
Lack of Staff Competency in Resident Care
Penalty
Summary
Nurses and nurse aides did not demonstrate the necessary competencies to provide care that maximizes each resident's well-being. The deficiency was identified based on observations and findings that staff lacked appropriate skills or knowledge required to meet the individualized needs of residents. This failure resulted in care that did not support the highest possible level of well-being for each resident, as required by regulatory standards.
Failure to Follow Infection Control Procedures for Glucometer Disinfection, Hand Hygiene, and Linen Handling
Penalty
Summary
Nurse #1 failed to follow the manufacturer's instructions and facility policy for cleaning and disinfecting a shared blood glucose meter (glucometer) after checking a resident's blood glucose level. Instead of using an EPA-registered germicidal wipe as required, Nurse #1 used an alcohol wipe, which was not approved for this purpose. This practice was observed during a blood glucose check, and Nurse #1 stated she had always used alcohol wipes and was unaware of the need for an EPA-registered disinfectant. The shared glucometer was used for multiple residents on the unit, and the improper cleaning method was used between each resident. Additionally, the Wound Care Nurse did not adhere to the facility's hand hygiene policy during wound care for a resident. After cleansing a sacral wound, the nurse failed to change gloves and perform hand hygiene before applying a new dressing, instead using the same gloves to handle both the wound and the dressing materials. The nurse later acknowledged that hand hygiene and glove change should have occurred between these steps to prevent cross-contamination but did not perform them during the observed procedure. A separate incident involved a nurse aide who placed soiled linen, including towels and a gown, directly on the floor of a resident's room after providing a bath, rather than bagging the items as required by facility policy. The aide admitted to being aware of the correct procedure and having bags available but did not use them. The Director of Nursing confirmed that soiled linen should never be placed on the floor and should always be bagged immediately to prevent the spread of germs.
Removal Plan
- The Facility Consultant completed a medical record audit of all residents, including Resident #34, Resident #92, and Resident #97, who received blood glucose checks to identify any diagnosed blood-borne pathogen infections.
- The unit managers and the treatment nurse completed the cleaning and disinfecting of all resident glucometers in accordance with the manufacturer’s instructions.
- The Director of Nursing, Assistant Director of Nursing, Treatment Nurse and Unit Managers initiated, in person, education with all nurses and medication aides regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- Any nurse or medication aide who has not worked or received the in-service will receive the education prior to the next scheduled work shift.
- All newly hired nurses or medication aides including agency, will be in-serviced by the Director of Nursing, Assistant Director of Nursing or Unit Managers during orientation regarding the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- The Director of Nursing (DON), Assistant Director of Nursing (ADON), and Unit Managers initiated in-person return demonstrations of properly cleaning and disinfecting glucometers with all nurses and medication aides including agency.
- Any nurse or medication aide who does not successfully pass the return demonstration will be immediately re-educated and will be required to repeat the return demonstration until successful demonstration is achieved.
- Staff who have not completed the return demonstrations will complete it prior to their next scheduled work shift.
- The Director of Nursing, Assistant Director of Nursing and Unit Managers initiated in person quizzes with all nurses and medication aides, including agency to validate knowledge and understanding of the importance of following facility and manufacturer’s instructions for cleaning and disinfecting a shared glucometer.
- Any nurse or medication aide that does not successfully pass the quiz will be immediately re-educated and will be required to retake the quiz at the time of administration until a successful passing score is achieved.
- Any nurse or medication aide who has not completed the quiz will complete it prior to their next scheduled work shift.
Failure to Provide Pharmaceutical Services and Licensed Pharmacist Oversight
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident and did not employ or obtain the services of a licensed pharmacist. This deficiency was identified during the survey process, indicating that the required pharmaceutical oversight and services were not in place for residents as mandated.
Failure to Ensure Proper Beard Restraint During Food Preparation
Penalty
Summary
During an observation in the facility's kitchen, a cook was seen preparing and cutting food while wearing a facial covering that did not fully cover his mustache and the sides of his beard. This observation was confirmed through staff interviews, including with the Dietary Manager Consultant, who stated that all staff are required to use beard restraints that cover all facial hair. The Administrator also confirmed that she was unaware that proper beard restraint practices were not being followed in the kitchen, despite the expectation that all staff wear appropriate hair restraints covering all facial hair during food preparation.
Failure to Protect Resident's Belongings or Money
Penalty
Summary
A deficiency was identified regarding the protection of residents from the wrongful use of their belongings or money. The report notes that there was a failure to safeguard a resident's personal property or funds, resulting in unauthorized or inappropriate use. Specific actions or omissions by facility staff led to this breach, directly impacting the resident's rights and property. No additional details about the resident's medical history or condition at the time of the deficiency are provided in the report.
Failure to Assess and Supervise Self-Administration of Medications
Penalty
Summary
A resident with chronic kidney disease, anxiety, depression, and insomnia was admitted to the facility and assessed as cognitively intact with no behavioral issues. Despite this, there was no documentation in the resident's medical record indicating that an assessment had been conducted to determine the resident's ability to self-administer medications. Additionally, there was no care plan in place for self-administration of medications for this resident. During an observation, a medication aide was seen leaving a cup containing eight different medications on the resident's overbed tray, allowing the resident to take them at her discretion. The resident reported not knowing what the medications were or why she was taking them. The medication aide admitted to routinely leaving medications at the bedside without confirming if the resident had been assessed for self-administration and acknowledged this was not good practice. Both the DON and the Administrator stated their expectation that staff should remain with residents until all medications are consumed and that medications should not be left unattended.
Failure to Maintain Medical Power of Attorney Documentation in Resident Record
Penalty
Summary
The facility failed to ensure that a copy of a resident's Medical Power of Attorney (POA) advanced directive document was obtained and included in the resident's medical record. The resident, who was admitted with a diagnosis of dementia and assessed as cognitively intact, had her family member listed as her medical POA and Responsible Party (RP) in multiple facility records, including the physician's progress note, care conference record, and face sheet. Despite this, there was no evidence in the medical record of the actual POA document. The resident's RP confirmed that a POA document had been executed and stated he had brought a copy to the facility, though he could not recall when or to whom it was given. Interviews with facility staff revealed confusion and lack of clarity regarding the process for obtaining and filing advanced directive documents. The Medical Records Director reported not having the POA document and explained that such documents would typically be provided by the Social Worker or Admissions Director. Both social workers interviewed denied responsibility for obtaining or receiving POA documents, while the Admissions Director stated he would forward such documents to the Medical Records Director but did not recall receiving one for this resident. The Director of Nursing was unsure of the facility's process for ensuring advanced directives were present in the medical record, and the Administrator confirmed that a copy of the POA should be obtained and scanned into the record, but acknowledged there was no current plan of correction for this issue.
Failure to Develop Comprehensive Care Plans for High-Risk Conditions
Penalty
Summary
The facility failed to develop individualized, person-centered comprehensive care plans for two residents with high-risk conditions. One resident, admitted with atrial fibrillation and coronary artery disease, was prescribed an anticoagulant medication and was severely cognitively impaired. Despite these factors, the resident's care plan did not include any indication of anticoagulant use. Interviews with the MDS nurse, admitting nurse, ADON, DON, and Administrator revealed that the admitting nurse did not add high-risk medications to care plans during admission and was unaware that this was required. The ADON, DON, and Administrator all stated that high-risk medications should be included in care plans upon admission, but were unaware that this had not occurred for this resident. Another resident, admitted with diabetes mellitus type II and also severely cognitively impaired, was receiving sliding scale insulin, oral hypoglycemic medication, blood glucose checks, and a consistent carbohydrate diet. However, the resident's comprehensive care plan did not address diabetes mellitus type II. Similar to the first case, the admitting nurse did not add the diagnosis to the care plan and was unaware that this was part of the admission process. The ADON, DON, and Administrator each indicated that high-risk diagnoses such as diabetes should be included in care plans upon admission, but were unaware that this had not been done for this resident.
Failure to Update Care Plan Following Change in Code Status
Penalty
Summary
The facility failed to revise the comprehensive care plan to accurately reflect a resident's code status after a change in advanced directives. A resident with dementia was admitted with a care plan indicating a 'Full Code' status for CPR, while a physician's order was later entered into the electronic medical record by the Assistant Director of Nursing (ADON) changing the code status to Do Not Resuscitate (DNR). Despite entering the DNR order, the ADON did not update the resident's care plan to reflect this change. During interviews, the ADON acknowledged responsibility for updating the care plan and was unable to explain why it was not done. The Administrator confirmed that the care plan should have been updated when the DNR order was entered.
Failure to Maintain Resident Dignity and Privacy
Penalty
Summary
A deficiency was identified when a staff member failed to treat a resident with dignity and respect by not knocking or announcing their presence before entering the resident's room. The resident, who was cognitively intact, expressed a preference for staff to knock or announce themselves before entering, as she liked to know who was in her room and what they were doing. The housekeeper involved stated she did not knock if residents were already awake, but both the housekeeping supervisor and the administrator confirmed that staff are always expected to announce their presence regardless of the resident's state. Another deficiency was observed when a resident with an indwelling urinary catheter was seen in common areas with an uncovered catheter drainage bag, making the urine visible to other residents, staff, and visitors. The resident, who was moderately cognitively impaired, was observed multiple times with the visible catheter bag. Interviews with nursing staff revealed a lack of awareness regarding the need for privacy covers, and staff indicated that privacy bags were not readily available or seen on the unit. However, both the DON and the administrator stated that privacy covers were provided by the facility and should be used to maintain resident dignity.
Failure to Notify Ordering Practitioner of Abnormal Lab Results
Penalty
Summary
The facility failed to notify the ordering practitioner of abnormal laboratory test results for one resident. The resident, who had multiple diagnoses including obstructive sleep apnea, chronic kidney disease, chronic atrial fibrillation, and congestive heart failure, was admitted with a telephone order from a nurse practitioner for a basic metabolic panel (BMP) to be drawn at the facility. The order was signed off by a nurse, and the blood specimen was collected and reported to the facility. The lab results, which included several out-of-range values, were reviewed by the Medical Director several days later, but the results were not communicated to the nurse practitioner who ordered the test. Interviews with facility staff and the Medical Director revealed confusion and lack of clarity regarding who was responsible for reporting lab results to the ordering provider. The patient access representative at the cardiology office confirmed that the results were never received, and additional blood work had to be ordered and completed at an offsite provider. The Assistant Director of Nursing stated that the nurse assigned to the resident's hall should have reported the results, while the Director of Nursing and Administrator were unsure of the policy. The Regional Nurse Consultant indicated that typically the unit manager would notify the prescribing provider, but anyone could communicate the results.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which resulted in the presence of accident hazards and insufficient oversight to protect residents from potential harm. No additional details regarding the specific hazards, the number of residents affected, or their medical conditions at the time of the deficiency are provided in the report.
Failure to Conduct Timely Care Plan Meetings
Penalty
Summary
The facility failed to incorporate residents and/or their representatives in the care planning process for two residents. Resident #9, who was admitted with heart disease and Alzheimer's dementia, had not had an Interdisciplinary (IDT) care plan meeting since November 23, 2022, despite being severely cognitively impaired. The Social Worker and Director of Nursing (DON) were unaware of the lapse in care plan meetings, which should have been held quarterly. The Administrator also confirmed the oversight, stating that Social Work was responsible for scheduling these meetings. Similarly, Resident #24, assessed as moderately cognitively impaired, had not had a care plan review or meeting since September 21, 2023. The resident himself noted the absence of a recent care plan meeting. Both the Administrator and Social Worker acknowledged the missed care plan meetings, with the Social Worker unable to explain why the meetings were omitted from the schedule. The facility's policy requires care plans to be reviewed and updated quarterly or with any significant changes.
Improper Food Storage and Handling in Kitchen
Penalty
Summary
The facility failed to adhere to proper food storage and handling protocols, as observed during a kitchen inspection. Forty-three cartons of thickened orange juice with expired use-by dates were found in the kitchen's dry storage, available for resident use. The Assistant Dietary Manager confirmed that these expired cartons should have been discarded, acknowledging that residents on thickened liquid diets were present in the facility. Additionally, a scoop was improperly stored inside a dry sugar ingredient bin, with its handle in contact with the sugar, posing a risk of cross-contamination. The Assistant Dietary Manager admitted that the scoop should have been stored outside the bin to prevent contamination. The Administrator also confirmed that outdated food should be discarded and that the scoop should not have been stored inside the sugar bin.
Catheter Bag Mismanagement Leads to Infection Risk
Penalty
Summary
The facility failed to ensure that an indwelling urinary catheter drainage bag did not rest on the floor, which placed a resident at increased risk for infection. Resident #51, who was admitted with chronic obstructive uropathy and had an indwelling urinary catheter, was observed with his catheter drainage bag partially resting on the floor during a bathing activity. Despite having a privacy cover, the bag's position on the floor was noted when the resident's bed was in a low position. Nurse Aide #1 raised the bed during the activity, lifting the bag off the floor, but lowered it afterward, causing the bag to rest on the floor again. Medication Aide #1, who administered medication to the resident, did not notice the bag's position, and her foot brushed against it as she left the room. Further observations and interviews revealed that Nurse #1, who was supervising Medication Aide #1, confirmed the bag should not be on the floor and adjusted the bed to lift the bag. Nurse Aide #1 mistakenly believed the privacy cover made it acceptable for the bag to rest on the floor. The Infection Preventionist and the Director of Nursing both stated that catheter bags should never contact the floor due to infection control concerns. Physician #1 indicated that the resident did not experience any ill effects or urinary tract infection from the incident. The Administrator also confirmed that catheter bags should not rest on the floor for infection control purposes.
Unattended and Unlocked Medication Cart
Penalty
Summary
The facility failed to secure resident medications stored in an unattended medication cart on the 400 hall, as observed during a survey. The incident involved one of five medication carts, specifically the Wing D cart, which was left unlocked and unattended from 4:27 PM to 4:32 PM. The cart was parked midway down the hall near a resident's room, visible from the nurse's station, but no staff were present at the station. The red dot on the push lock was visible, indicating that the lock was not engaged. During this time, two nurse aides, a cognitively intact resident, and two visitors walked past the unlocked cart. Medication Aide #1 returned to the cart at 4:32 PM and opened the top drawer without unlocking it. Interviews with staff confirmed the deficiency. Medication Aide #1 admitted to leaving the cart unlocked and acknowledged that it should be locked whenever not in use. The Director of Nursing (DON) stated that the medication cart should be secured and locked unless a nurse is present. The DON emphasized that the Medication Aide or Nurse assigned to the cart is responsible for ensuring it is secured. The Administrator reiterated that medication carts should remain locked unless actively in use by the assigned staff member.
Failure to Monitor Neurological Status After Fall
Penalty
Summary
The facility failed to adequately monitor and assess a resident's neurological status following an unwitnessed fall, particularly given the resident's use of anticoagulant medication. The resident, who had a history of severe cognitive impairment, hypertension, and was on Coumadin, was found on the floor in her room and was unable to explain what had happened. Initial neurological checks were conducted and reported as normal, except for limited movement in the hips, which was consistent with the resident's existing condition. However, the facility did not continue these checks as per protocol, and the seriousness of the resident's change in condition was not recognized in a timely manner. As the day progressed, the resident exhibited signs of lethargy and altered mental status, which were initially attributed to the administration of pain medication. Despite these changes, the facility staff did not seek immediate medical intervention. The Physician Assistant was informed of the resident's condition but was under the impression that the lethargy was due to the pain medication. The resident's condition continued to deteriorate, with unclear speech and further lethargy noted, yet the facility did not escalate the situation until the family insisted on a transfer to the emergency room. Upon arrival at the hospital, a CT scan revealed significant intracranial hemorrhages, which were deemed life-ending. The resident was subsequently placed on comfort care and passed away. The facility's failure to adhere to its protocol for neurological assessments and to recognize the urgency of the resident's condition after the fall contributed to the deficient practice identified by the surveyors.
Removal Plan
- Address how corrective action will be accomplished for those residents found to have been affected by the deficient practice.
- Address how the facility will identify other residents having the potential to be affected by the same deficient practice.
- The Assistant Director of Nursing initiated a head-to-toe assessment of all residents including residents with recent falls who are on blood thinners for signs and symptoms of acute change in condition.
- The Assistant Director of Nursing reviewed all progress notes to identify any resident with an acute change including residents with recent falls who are on blood thinners.
- The Assistant Director of Nursing reviewed fall incident reports to include residents on blood thinners.
- Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.
- The Assistant Director of Nursing initiated an in-service with all nurses to include the agency regarding Acute change with emphasis on assessing changes in condition to include neurological checks, obtaining vital signs, initiating interventions for the acute change, notification of the physician for further recommendations and notifying the resident representative with documentation in the electronic record.
- The Assistant Director of Nursing initiated an in-service with all CNAs to include agency staff regarding Notification of Acute Changes with emphasis on immediately reporting to the nurse any change in condition to include but not limited to a decreased level of consciousness.
- The ADON initiated an in-service with all nurses regarding Incidents with emphasis on investigating all incidents thoroughly including obtaining statements and completion of investigative folder, assessment of the resident to include neuro checks for suspected head trauma to include residents prescribed blood thinners, initiating intervention based on root cause, updating care plans for new safety interventions and notification of MD/RR.
- Indicate how the facility plans to monitor its performance to make sure that solutions are sustained.
- The facility's interdisciplinary team including the Administrator, Director of Nursing, Assistant Director of Nursing, and Unit Managers will review progress notes and incident reports to identify residents with an acute change including residents with falls prescribed blood thinners utilizing the Acute Change Audit Tool.
- The Director of Nursing or Assistant Director of Nursing will review the Change in Condition audits to ensure all areas of concern were addressed appropriately.
- The Administrator or Director of Nursing will present the findings of the Acute Change Audit Tools to the Quality Assurance Performance Improvement committee to review and to determine trends and/or issues that may need further interventions and the need for additional monitoring.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 38 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Washington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ridgewood Living & Rehabilitation Center | 0.9 mi | ★★★★★ | 11 | 0 |
| The Carrolton Of Williamston | 13.3 mi | ★★★★★ | 4 | 0 |
| Cypress Glen Retirement Community | 17.9 mi | ★★★★★ | 0 | 0 |
| Greenville Health And Rehabilitation Center | 21.5 mi | ★★★★★ | 0 | 0 |
| East Carolina Health And Rehabilitation Center | 21.7 mi | ★★★★★ | 14 | 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 July 2026) and official state health department websites.