Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Rest Home during CMS and state inspections, most recent first.
An LPN administered 14 units of Novolog FlexPen to a resident without priming the pen with 2 units as directed by the manufacturer. Surveyors observed the medication pass, reviewed the manufacturer’s instructions, and confirmed the omission with the LPN. The resident had an order for daily subcutaneous Novolog.
The facility failed to provide and implement an infection prevention and control program because it did not have a water management plan to assess areas where Legionella and other opportunistic waterborne pathogens could grow and spread or to define control measures and monitoring. The IP stated empty rooms were flushed weekly but could not provide a water management plan, and the Maintenance Director confirmed the facility lacked an assessment and control measures. The facility policy on Legionnaires' disease included general maintenance and boiler temp monitoring, but it did not include an assessment or established interventions when control limits were not met.
A facility failed to follow professional standards for medication administration when an LPN left a cognitively impaired resident unattended with a drink containing their morning medications. The resident, with a BIMS score indicating severe cognitive impairment, was left alone in the dining room to take medications mixed in a chocolate drink, including a laxative solution, laxative powder, antidepressant, and analgesic.
The facility did not remove expired medications from stock in one of the medication rooms. An open bottle of Lantus Insulin with a past discard date was found in the Unit 4 medication room's refrigerator. This was confirmed by an RN during an interview. The facility's policy requires medications to be maintained only until their expiration dates, which was not followed.
A facility failed to follow physician orders for timely lab services for a resident on psychotropic medication. The resident's orders for LFT and CBC were not obtained as scheduled, despite being placed in advance. The facility's policy schedules blood draws twice weekly, but there were two missed opportunities to conduct the tests.
The facility failed to implement contact precautions for two residents under transmission-based precautions. Staff entered rooms without wearing required PPE, such as gowns, despite signage and policy requirements. Interviews revealed a lack of awareness among staff about the need for gowns, contributing to the deficiency during a suspected norovirus outbreak.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
The facility failed to follow the manufacturer’s instructions for administering Novolog insulin in 1 of 2 observed insulin administrations involving Resident #111. During medication administration observation, Staff A, an LPN, administered 14 units of Novolog FlexPen subcutaneously but did not prime the insulin pen with 2 units before giving the dose. The manufacturer’s instructions reviewed by surveyors stated that the pen should be primed by selecting 2 units, holding the pen with the needle pointing up, tapping the cartridge to move air bubbles to the top, and pressing the push-button until the dose selector returns to 0. Staff A confirmed the observation findings during interview, and the resident’s record showed an order for Novolog FlexPen, 14 units subcutaneously once daily.
Missing Water Management Plan for Legionella Prevention
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program because it did not have a water management plan that included an assessment and control measures to identify and prevent the growth and spread of Legionella and other opportunistic waterborne pathogens. During interview, the Infection Preventionist stated that empty rooms were flushed weekly but was unable to provide a water management plan. The Maintenance Director stated that the facility did not have a water management plan that assessed areas where opportunistic waterborne pathogens could grow and spread or included control measures to prevent their growth and how to monitor them. Review of the facility policy titled Legionnaires' Disease showed general prevention language about maintaining water systems, following manufacturer guidelines, and monitoring boiler temperatures twice daily, but it did not include an assessment identifying areas where opportunistic waterborne pathogens could grow and spread or control measures with established ways to intervene when control limits were not met.
Failure in Medication Administration Supervision
Penalty
Summary
The facility failed to adhere to professional standards of quality in medication administration for one resident. During an observation, a Licensed Practical Nurse (LPN) was seen preparing a resident's morning medications by mixing them into a chocolate drink. The LPN then instructed the resident to drink the chocolate milk and left the drink on the dining room table with the resident, who was unattended. The resident, identified as having severe cognitive impairment with a BIMS score of 2, was left alone to take the medication without supervision. The medications included a laxative solution, a laxative powder, an antidepressant, and an analgesic. The LPN confirmed the observation during an interview, indicating a failure to stay with the resident until the medication was taken, as required by professional standards.
Expired Medication Not Removed from Stock
Penalty
Summary
The facility failed to ensure the removal of expired medications from stock in one of the three medication rooms observed. During an observation of the Unit 4 medication room, an open bottle of Lantus Insulin was found in the medication refrigerator with a discard date of 2/7/25, indicating it was expired. This finding was confirmed through an interview with a Registered Nurse, Staff A, at the time of the observation. A review of the facility's policy on the care, cleaning, and storage of medication rooms, dated June 2023, revealed that medications should be maintained only up until their expiration dates, and proper storage and expiration dates should be checked, which was not adhered to in this instance.
Failure to Conduct Timely Laboratory Tests for Resident
Penalty
Summary
The facility failed to follow physician orders for timely laboratory services for a resident reviewed for psychotropic medication side effects. The resident had active physician's orders for a Liver Function Test (LFT) and Complete Blood Count (CBC) with differential to be conducted on February 6, 2025. However, interviews with staff revealed that these laboratory tests were not obtained as ordered. The facility's policy indicated that blood draws are scheduled twice weekly, on Tuesdays and Thursdays, and there were two missed opportunities for the blood work to be obtained. The Assistant Director of Nursing confirmed that the labs had not been conducted, despite the orders being placed on February 5, 2025.
Failure to Implement Contact Precautions for Residents
Penalty
Summary
The facility failed to implement its infection control policies regarding contact precautions for two residents who were under transmission-based precautions. Resident #113 was on contact precautions for norovirus, yet multiple staff members, including a unit aide and licensed nursing assistants, entered the resident's room without wearing the required personal protective equipment (PPE), such as gowns. Observations revealed that staff members either wore only masks and gloves or, in some cases, only a mask, failing to adhere to the facility's policy and CDC guidelines that require gowns and gloves upon entry into a room with contact precautions. Similarly, for Resident #13, who was also under contact precautions, staff entered the room without donning the necessary gown, despite signage indicating the requirement. Interviews with staff revealed a lack of awareness regarding the need for gowns when entering rooms with contact precautions. The facility was experiencing an outbreak of suspected norovirus or gastrointestinal illness, and the infection preventionist confirmed that the facility had modified CDC guidance for their infection control procedures. However, the observations and interviews indicated a failure to consistently implement these modified procedures.
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Illustrative
What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Dover
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Dover Center For Health & Rehabilitation | 2.6 mi | ★★★★★ | 0 | 0 |
| Langdon Place Of Dover | 4.8 mi | ★★★★★ | 0 | 0 |
| Birch Healthcare Center | 5.2 mi | ★★★★★ | 7 | 0 |
| Rochester Manor | 5.5 mi | ★★★★★ | 4 | 0 |
| Saint Ann Rehabilitation And Nursing Center | 6.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.