Average — CMS composite of the measures below.
A standard survey is most likely before 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 Riverpoint Crest Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment was transported in a geriatric wheelchair by an OT who pulled the chair from behind, preventing the resident from seeing where he was going. This action did not respect the resident's dignity, as confirmed by staff interviews and facility training expectations.
A resident with severe cognitive impairment had a family member designated as their Resident Representative (RR), but there was no documentation of care plan meetings or attempts to contact the RR since admission. The RR reported not being invited to participate in care planning and expressed a desire to be included. The Administrator, responsible for sending care plan invitations after the Social Worker left, could not provide evidence that the RR had been contacted.
A resident with moderate cognitive impairment and chronic pain was found to be self-administering arthritis creams, antacid tablets, and cough drops kept at her bedside without a clinical assessment or physician orders. Facility staff, including nursing and administration, were unaware of the resident's possession and use of these medications, and no care plan or documentation addressed self-administration.
A nurse failed to provide privacy for a resident with severe cognitive impairment and an indwelling urinary catheter by leaving the door open and not pulling the privacy curtain during a catheter assessment, resulting in the resident being exposed and visible from the hallway while staff passed by.
A resident with Diabetes Mellitus II received daily insulin as ordered, but the MDS assessment did not accurately reflect the use of hypoglycemic medication during the required lookback period. Staff confirmed the omission was due to human oversight.
A resident with a diagnosis of PTSD did not have a person-centered care plan addressing this condition, despite a trauma-informed assessment and staff awareness of potential triggers. Nursing staff confirmed that no care plan was developed for PTSD because the resident had not exhibited related problems since admission, resulting in a deficiency.
Two residents prescribed psychotropic medications did not have comprehensive care plans developed within the required timeframe after their assessments. Both had diagnoses such as dementia, anxiety, and depression, and their assessments triggered the need for care planning related to psychotropic medication use. Staff interviews revealed that care plans were not created due to human error and unclear responsibility among staff for updating care plans.
A treatment cart containing wound care medications was left unlocked and unattended in a hallway, accessible to staff, visitors, and a resident. The cart contained topical medications that could be dangerous if accessed by residents. Additionally, Astelin nasal spray was found stored horizontally in two medication carts, contrary to manufacturer instructions requiring upright storage. Nursing staff were unaware of the proper storage requirements, and the DON confirmed expectations for compliance with manufacturer guidelines.
Two staff members failed to follow the facility's Enhanced Barrier Precautions policy by not wearing gowns while providing high-contact care to a resident with an indwelling urinary catheter. Both the nurse aide and the nurse performed catheter care and assessment using only gloves, despite the policy requiring both gowns and gloves for such procedures. Both staff later acknowledged the omission and recognized that gowns were required for this type of care.
The facility failed to accurately code MDS assessments for three residents, resulting in deficiencies related to falls, oxygen use, and discharge status. A resident with a fall was not recorded in the MDS, another resident's continuous oxygen use was omitted, and a third resident's discharge status was incorrectly coded. These errors were attributed to human error, despite daily discussions of resident conditions with the IDT.
A resident with diabetes mellitus was not provided with a comprehensive care plan addressing their condition and hypoglycemic medication. Despite having a physician's order for metformin, the care plan lacked focus areas, goals, or interventions related to diabetes. Interviews with the MDS Coordinator and DON confirmed the oversight, acknowledging it as a human error.
A resident with severe cognitive impairment and incontinence was not provided timely incontinence care, as required, during a shift at an LTC facility. The resident's incontinence pad was found wet, and the responsible nurse aide admitted to not checking or providing care due to being occupied with another resident. The DON confirmed the oversight, and other staff members were unaware of the situation as the aide did not seek assistance.
The facility failed to attempt alternatives before installing siderails for two residents. One resident with vascular dementia and COPD, and another with end-stage renal disease and a femur fracture, had siderails installed without prior attempts at alternative interventions. Observations and staff interviews confirmed that alternatives were not considered, and the facility's practice was to use siderails unless contraindicated or declined by the resident.
A facility failed to handle soiled linen properly, as observed when a nurse aide picked up soiled linen from the floor and placed it into a laundry hamper without bagging it first. This action was against the facility's policy, which requires soiled linen to be bagged to prevent microorganism transfer. Interviews with the DON and Administrator confirmed the non-compliance with infection control practices.
Resident Transported in Wheelchair Without Regard for Dignity
Penalty
Summary
A deficiency occurred when a resident, who was severely cognitively impaired, was transported in a geriatric wheelchair by an occupational therapist (OT) in a manner that did not honor the resident's right to dignity. The OT pulled the wheelchair from behind, positioning the resident so that he was unable to see where he was being taken. This action was observed by surveyors and was confirmed during interviews with the OT, who stated she was unaware that this method of transport was a dignity issue and explained she pulled the chair because it was difficult to push. The resident had an active order for occupational therapy evaluation and treatment. The incident was witnessed during a routine observation, and the OT involved was an agency staff member who had received facility training on treating residents with dignity and respect. The Rehabilitation Manager and the DON both acknowledged that staff should have known this method of transport was inappropriate and a concern for resident dignity.
Failure to Include Resident Representative in Care Planning
Penalty
Summary
The facility failed to include the Resident Representative (RR) of a severely cognitively impaired resident in the care planning process. The resident, who was admitted with severe cognitive impairment, had a family member designated as her RR. Review of the medical record showed that the care plan was last revised on 8/18/25, but there was no documentation of care plan meetings, attempts to contact, or conversations with the RR since admission. During a telephone interview, the RR stated he did not recall being invited to any care plan meetings and expressed a desire to be included. The Administrator confirmed that, following the departure of the Social Worker in June 2025, she was responsible for sending care plan meeting invitations but could not provide documentation that the RR had been invited for this resident.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to assess a resident's ability to self-administer medications, resulting in the resident keeping several medications at her bedside without clinical evaluation or physician orders. The resident, who was moderately cognitively impaired and had diagnoses including non-Alzheimer's dementia and chronic pain syndrome, stored and self-administered arthritis cream with 25% capsaicin, arthritis pain relief gel with 2% menthol, chewable antacid tablets, and cough drops. There was no documentation in the medical record of an assessment for self-administration, no physician orders for these medications, and no care plan addressing self-administration. Multiple staff members, including a nurse, unit manager, nurse aide, DON, and the administrator, were unaware that the resident kept and used these medications at her bedside. The nurse reported applying arthritis cream from the medication cart, but was unaware of the resident's personal supply. The DON and administrator confirmed that no assessment for self-administration had been conducted and were unsure how the facility would have known about the medications at the bedside. The lack of assessment and oversight led to the deficiency.
Failure to Provide Privacy During Catheter Assessment
Penalty
Summary
Nurse #2 failed to provide personal privacy for a resident with severe cognitive impairment and an indwelling urinary catheter during a catheter assessment. The nurse entered the resident's room, applied gloves, and proceeded to pull up the resident's gown and pull down his brief to assess the catheter insertion site without closing the door or pulling the privacy curtain. As a result, the resident's bare stomach and penis were visible from the hallway, and staff were observed passing by the open door during the assessment. Prior to this, a nurse aide had performed catheter care for the same resident, closing the door but not pulling the privacy curtain. The resident was in the bed closest to the door, with a roommate present whose privacy curtain was closed. After noticing bloody urine in the catheter tubing, the nurse aide informed Nurse #2, who then entered the room and conducted the assessment without ensuring privacy, leading to the resident's exposure.
Failure to Accurately Code MDS for Hypoglycemic Medication Use
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessment for one resident in the area of hypoglycemic medication use. The resident was admitted with a diagnosis of Diabetes Mellitus II and had active physician orders for both long-acting and sliding scale insulin, which were administered daily as documented in the Medication Administration Record. Despite this, the resident's admission MDS assessment did not reflect the use of hypoglycemic medications, including insulin, during the required 7-day lookback period. Staff interviews confirmed that the omission was due to human oversight and that the MDS should have been coded to indicate the resident's receipt of hypoglycemic medication. The deficiency was identified through record review and staff interviews, which established that the resident received insulin as ordered but the MDS assessment failed to accurately capture this information.
Failure to Develop Person-Centered Care Plan for PTSD Diagnosis
Penalty
Summary
The facility failed to develop and implement a person-centered care plan for a resident diagnosed with Post Traumatic Stress Disorder (PTSD), despite the resident having a documented history of PTSD, delusional disorders, mood disorder, and major depressive disorder. A trauma-informed assessment was completed, and the resident was found to be cognitively intact with no behaviors noted during the assessment period. However, review of the care plan revealed there was no plan of care addressing the resident's PTSD diagnosis. Staff interviews confirmed that while the resident had some behaviors such as refusal of care and paranoid behavior, these were care planned separately and not specifically linked to PTSD. Nursing staff, including the MDS Nurse and the Director of Nursing, acknowledged that a person-centered care plan should have been developed for the resident's PTSD, including identification of triggers such as loud noises. The MDS Nurse stated that a care plan was not created because the resident had not exhibited any PTSD-related problems since admission. Despite this, the expectation was that staff should be aware of appropriate interventions should a PTSD episode occur. The lack of a specific care plan for PTSD constituted the deficiency identified during the survey.
Failure to Timely Develop Comprehensive Care Plans for Psychotropic Medication Use
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days of completing the comprehensive assessment for two residents who were prescribed psychotropic medications. For one resident with non-Alzheimer's dementia, anxiety, and major depressive disorder, the admission MDS assessment indicated the use of antianxiety and antidepressant medications, and the Care Area Assessment (CAA) was triggered for psychotropic medication use. However, the comprehensive care plan created did not address psychotropic medication use. Staff interviews revealed that the care plan was not created due to human error, and there was confusion among staff regarding responsibility for care plan updates. Similarly, another resident with anxiety, depression, and Alzheimer's dementia was prescribed antianxiety medication, and the CAA was triggered for psychotropic medication use. The care plan for this resident also failed to address psychotropic medication use. Staff interviews indicated that the lack of a clearly identified person responsible for updating care plans after new medication orders contributed to the deficiency. Both the DON and Administrator acknowledged that psychotropic medication use should have been included in the care plans for these residents.
Unsecured Treatment Cart and Improper Medication Storage
Penalty
Summary
Surveyors observed that a treatment cart containing medications used for wound care was left unattended and unlocked in a hallway for 25 minutes. During this time, no staff were present with the cart, and several staff members, visitors, and a resident in a wheelchair passed by the unlocked cart. Upon inspection, the cart was found to contain several topical medications, including antiseptic solution, medical grade honey, hydrocortisone cream, corticosteroid cream, and a cream for skin conditions. The Wound Care Nurse acknowledged forgetting to lock the cart and confirmed that these medications could be dangerous if accessed by a cognitively impaired resident. Both the DON and the Administrator confirmed that the cart should have been locked at all times when not in use, as the medications could pose a danger if ingested. Additionally, surveyors found that Astelin nasal spray, which must be stored upright according to manufacturer instructions, was stored horizontally in two separate medication carts. Nurses responsible for these carts admitted they had not read the manufacturer's instructions and were unaware of the proper storage requirements. The DON stated that nursing staff are expected to check carts and follow all manufacturer guidelines for medication storage, including storing the nasal spray upright if indicated.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to adhere to its infection control policy regarding Enhanced Barrier Precautions (EBP) during high-contact care for a resident with an indwelling urinary catheter. During an observation, a nurse aide entered the resident's room, washed her hands, and applied gloves but did not don a gown, despite gowns being available and required by the facility's EBP policy for catheter care. The nurse aide proceeded to provide catheter care, noted the presence of bloody urine, and completed the task without ever applying a gown. Upon interview, the nurse aide acknowledged forgetting to put on the gown and recognized, after reviewing the posted signage, that a gown was required for this type of care. A similar observation occurred with a nurse who assessed the same resident's indwelling urinary catheter. The nurse entered the room, washed her hands, and applied gloves but did not wear a gown while lifting the resident's gown and lowering the brief to assess the catheter insertion site. After completing the assessment, the nurse disposed of her gloves and washed her hands. In an interview, the nurse admitted to forgetting to apply a gown and confirmed that it was required for catheter care. Both the Staff Development Coordinator and the Director of Nursing confirmed that the staff should have worn gowns during these high-contact care activities, as outlined in the facility's EBP policy.
Inaccurate MDS Coding for Falls, Oxygen Use, and Discharge Status
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the areas of falls, oxygen use, and discharge status. Resident #17, who was admitted with diagnoses including diabetes, chronic kidney disease, and hypertension, experienced a fall on 4/2/24, as documented in a nurse's progress note. However, this fall was not recorded in the Quarterly MDS assessment dated 6/20/24. Interviews with MDS Nurses #1 and #2 revealed that the omission was due to human error, despite the fact that changes in resident conditions were discussed with the interdisciplinary team (IDT) each morning. The Director of Nursing (DON) and the Administrator both acknowledged that the MDS should have accurately reflected the fall. Resident #56, diagnosed with Chronic Obstructive Pulmonary Disease (COPD), had a physician's order for continuous oxygen use at 2 liters per minute via nasal cannula. Despite this, the admission MDS did not indicate oxygen use, although the Medication Administration Record confirmed continuous oxygen delivery since admission. MDS Nurse #1 admitted the oversight was due to human error. Similarly, Resident #93, who was discharged home, was incorrectly coded in the discharge MDS as being discharged to a short-term general hospital. MDS Nurse #2 acknowledged the error, and the Administrator confirmed that the MDS should have accurately reflected the resident's discharge status.
Failure to Include Diabetes Management in Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan for a resident diagnosed with diabetes mellitus, who was taking hypoglycemic medication. The resident was admitted with this diagnosis, and a physician's order was in place for the administration of metformin, a hypoglycemic medication. However, upon review of the resident's comprehensive care plan, there was no mention of the diabetes diagnosis or the use of hypoglycemic medication, indicating a significant oversight in the care planning process. Interviews with facility staff, including the MDS Coordinator and the Director of Nursing, confirmed that the omission was an error. The MDS Coordinator acknowledged that it was her responsibility to include the resident's diabetes and medication in the care plan during the last review, but she missed it. The Director of Nursing and the Administrator both agreed that these elements should have been included in the comprehensive care plan, highlighting a lapse in the facility's care planning procedures.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a severely cognitively impaired resident, identified as Resident #45, who was dependent on staff for activities of daily living. Resident #45 was admitted with a diagnosis of cerebral infarction and was always incontinent of bowel and bladder. Despite having no pressure ulcers or skin conditions, the resident was at risk for skin integrity impairment due to the lack of incontinence care. Observations revealed that the resident's incontinence pad was wet, and there was a slight odor of urine, indicating that care had not been provided as required. On the day of the incident, Nurse Aide (NA) #1, who was responsible for Resident #45's care during the 7 AM to 3 PM shift, admitted to not checking or providing incontinence care since the start of her shift. She cited being occupied with another demanding resident and did not seek assistance from other staff members, such as the nurse or unit manager, who were available and willing to help. The Director of Nursing (DON) confirmed the resident's incontinence brief was saturated with urine and expressed disappointment in NA #1's failure to provide necessary care. Interviews with other staff members, including Nurse #4 and Unit Manager #2, revealed that they were unaware of the lack of care provided to Resident #45, as NA #1 did not communicate her inability to attend to the resident. Both Nurse #4 and Unit Manager #2 had been in the resident's room for other duties but did not check for incontinence or notice any issues. The facility's administrator stated that the resident should have received incontinence care every two hours, highlighting the oversight in care provision.
Failure to Attempt Alternatives Before Siderail Use
Penalty
Summary
The facility failed to attempt alternatives before installing siderails for two residents reviewed for accidents. Resident #27, who was admitted with vascular dementia and COPD, was found to have siderails installed without any prior attempts at alternative interventions. The physical device use evaluation completed by the Unit Manager indicated that no alternatives were tried before the use of one-quarter siderails. Observations revealed that the siderails were consistently in the raised position, and interviews with nursing staff confirmed that alternatives were not considered before siderail use. Similarly, Resident #56, admitted with end-stage renal disease, COPD, and a femur fracture, also had siderails installed without prior attempts at alternatives. The physical device use evaluation for this resident also showed no alternatives were attempted, and no medical symptom justified the use of siderails. Observations confirmed the siderails were in use, and interviews with nursing staff and the Director of Nursing revealed a lack of awareness regarding the requirement to try alternatives before siderail implementation. Interviews with the Director of Nursing and the Administrator further confirmed that the facility's practice was to use siderails unless they were contraindicated or declined by the resident or their representative. Both the DON and the Administrator were unaware that alternatives needed to be attempted before using siderails, indicating a systemic issue in the facility's approach to siderail use.
Improper Handling of Soiled Linen
Penalty
Summary
The facility failed to handle soiled linen in a manner that prevents the spread of infection, as observed during a bathing activity for a resident. Nurse Aide #1 was seen removing soiled gloves, performing hand hygiene, and applying clean gloves before picking up soiled linen from the floor. She then transported the linen out into the hallway and placed it into the soiled laundry hamper without bagging it first. This action was contrary to the facility's policy, which requires soiled linen to be bagged or placed in containers at the location where it is used to avoid the transfer of microorganisms. Interviews with the Director of Nursing, who also serves as the facility's Infection Preventionist, and the Administrator confirmed that the practice observed was not in compliance with the facility's infection control policy. The Director of Nursing stated that soiled linen should not be placed directly on the floor, as it could lead to cross-contamination of microorganisms. The Administrator also indicated that soiled linen should be bagged for transportation unless it can be placed directly into the soiled linen hamper.
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 11 citations issued within 25 miles in the last 12 months — including the 2 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 New Bern
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pruitthealth-trent | 4.3 mi | ★★★★★ | 6 | 2 |
| Pruitthealth-neuse | 4.5 mi | ★★★★★ | 2 | 0 |
| Bayview Nursing & Rehabilitation Center | 7.1 mi | ★★★★★ | 2 | 0 |
| Grantsbrook Nursing And Rehabilitation Center | 12.2 mi | ★★★★★ | 1 | 0 |
| Brook Stone Living Center | 12.6 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Riverpoint Crest Nursing And Rehabilitation Center.
100% money-back within 48 hours.
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.