Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
Surveyors found that meals were not consistently prepared or served according to standardized recipes or the posted menu, resulting in unappealing and unpalatable food. A resident reported not receiving the food listed on their meal ticket and described small portions, while all resident council attendees stated the food was not appealing or palatable. During a sampled lunch, the alternate entrée was missing the listed roasted beets and instead included broccoli, a hair was found in the fish entrée, and the smothered turkey patty was deemed not palatable by surveyors. The FSD confirmed the hair in the fish, had not tasted the turkey patty before service, and stated the patty was premade with gravy prepared from powdered mix, and the facility lacked a policy on food flavor or preparation.
A Social Worker Assistant did not receive required annual in-service training on abuse and neglect, as evidenced by a lack of documentation in her employee file and confirmation from both the Social Worker and Assistant Director of Nursing. The facility's policy mandates annual education for all staff, but records showed only initial orientation training for the SWA, resulting in noncompliance with regulatory requirements.
A resident with multiple medical conditions and intact cognition alleged verbal abuse by the ADON. Although staff reported the incident to the Social Worker, no immediate investigation was initiated, and the event was not reported to facility leadership, contrary to the facility's abuse policy.
The facility failed to handle potentially hazardous food and maintain sanitation, as observed by a surveyor. Egg salad sandwiches lacked a made-on date, and expired marshmallows and water were found in storage. Staff, including a Speech Therapist and an Administrator, were seen in the kitchen without required hair restraints, indicating a need for reeducation.
The facility's call bell system was found to be deficient, with issues including inaudible notifications and non-functioning devices, affecting all residents. Observations revealed that call bell activations did not register at the nurse's station, and visual notifications were obstructed. In one instance, a call bell did not function due to broken pins, as confirmed by the DOM, with residents present during testing.
Surveyors identified multiple deficiencies in the facility, including unclean and unsafe environments, non-functional equipment, and inadequate resident care. Observations included dirty washcloths, worn mattresses, non-working lights and televisions, missing furniture, and improper meal service. Staff interviews revealed a lack of communication and reporting, contributing to unresolved issues.
Facility staff failed to follow infection control practices during wound care and meal service. A resident on Enhanced Barrier Precautions did not receive proper gown use by the Unit Manager during wound care. Additionally, CNAs on the 4th floor did not perform or assist with hand hygiene during meal service. These actions were contrary to the facility's policies on Enhanced Barrier Precautions and hand hygiene.
A resident's privacy and personal property rights were violated when a housekeeper accessed their bedside drawer without permission. The resident, who is cognitively intact, expressed distress over the intrusion. Facility staff, including the DON and LNHA, confirmed that such actions were against policy, which emphasizes respect and dignity for residents.
A resident's call bell was repeatedly found on the floor, out of reach, despite their care plan and facility policy requiring it to be accessible. Staff interviews confirmed the expectation for call bells to be within reach, yet the deficiency persisted, as acknowledged by the facility's administration.
A resident with a history of stroke and dementia experienced a witnessed fall in the facility, but the investigation was incomplete. The assigned nurse failed to provide a statement, and there was no documentation in the progress notes. The facility's policy lacked specific guidance on conducting thorough investigations, leading to the deficiency.
The facility failed to accurately assess two residents in the MDS. One resident with a Wander guard was incorrectly coded as having no wander alarm, and another resident using continuous oxygen was incorrectly coded as not using oxygen. These errors were confirmed by the MDS Coordinator and other staff.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. One resident's care plan lacked specific details on mood impairment and medication use, while another resident's care plan did not address significant weight loss. The Registered Dietitian and Director of Nursing acknowledged the omissions, which were contrary to the facility's policy on comprehensive care plans.
A resident with severe cognitive impairment experienced a fall in the facility, which was witnessed by a CNA. Despite the incident, there was no documentation in the resident's medical record, violating the facility's protocol for documenting falls. The lack of documentation was confirmed by multiple staff members, including an LPN Supervisor and the DON.
Two residents with indwelling urinary catheters were not provided appropriate care, leading to potential infection risks. A resident's catheter bag was found on the floor and unsecured, with missing documentation for catheter care. Another resident's catheter bag was improperly positioned above the bladder and lacked a privacy cover. Staff interviews confirmed these practices were against facility policy.
The facility failed to properly store respiratory equipment for two residents, leaving nebulizer masks and nasal cannulas unsecured and exposed to air. One resident's equipment was found in an open drawer and another's on a nightstand and floor. Staff acknowledged that equipment should be stored in bags, as confirmed by the Infection Preventionist and Director of Nursing.
A facility failed to timely address a CP's recommendation to clarify a resident's medication order for liquid Colace, despite repeated notices. The ADON and DON acknowledged the delay, which contradicted the facility's policy for timely communication and response to CP recommendations.
Failure to Provide Palatable, Menu-Compliant Meals Using Standardized Recipes
Penalty
Summary
The facility failed to ensure that standardized recipes were utilized to prepare food in a manner that conserved nutritive value and flavor, and failed to provide palatable and appealing meals as listed on the menu. A resident reported dissatisfaction with the food, stating they did not receive the items listed on their meal ticket and that portion sizes were small. During a resident council meeting, all five members present stated that the food was not appealing and not palatable. The facility’s Food Service Director (FSD) explained that the menu was a set daily menu with a main and alternate entrée, and that the computer system generated resident meal tickets based on diet orders, with any changes or alternates requested through the resident’s nurse. The posted menu for the observed week specified particular items for the main and alternate lunch meals. When surveyors obtained a sample lunch tray containing both the main entrée and the alternate entrée, they observed that the alternate meal did not match the posted menu: the roasted beets listed were not served and broccoli florets were substituted instead. While tasting the main entrée of lemon butter baked fish filet, a surveyor observed a small black curled hair in the fish. Two surveyors tasted the smothered turkey patty and were unable to consume it, noting that the flavor profile did not meet expected standards of palatability. In a subsequent interview, the FSD confirmed the presence of hair in the fish and acknowledged that hair should not be in the food. The FSD also stated she had not tasted the smothered turkey patty prior to service and, upon tasting it at the surveyors’ request, stated she thought it was good. She reported that the turkey patty was premade and the gravy was made from a powdered mix with added water. The facility did not provide a policy related to the flavor or preparation of foods.
Failure to Provide Annual Abuse and Neglect Training to Social Services Staff
Penalty
Summary
The facility failed to implement its Abuse, Neglect, and Exploitation policy by not ensuring that all existing staff received annual education on abuse and neglect. Specifically, the Social Worker Assistant's (SWA) employee file only contained documentation of an in-service on resident neglect and abuse from her orientation in 2009, with no evidence of any additional or annual in-services on this topic. During interviews, the SWA could not recall the last time she received such training, and the Social Worker (SW) confirmed she had never provided or reviewed any in-services on abuse and neglect for the SWA. The Assistant Director of Nursing (ADON) stated that while she maintained in-service records for the nursing department, other department heads were responsible for their own staff, and she was unable to locate any recent training records for the SWA. The facility's undated Abuse, Neglect, and Exploitation policy requires that existing staff receive annual education through planned in-services. The SW's job description also assigns responsibility for checking the competence of social services personnel. Despite these requirements, there was no documentation of annual abuse and neglect training for the SWA, indicating a failure to follow facility policy and regulatory requirements for staff education on this critical topic.
Failure to Investigate Alleged Verbal Abuse and Implement Abuse Policy
Penalty
Summary
The facility failed to immediately initiate an investigation into an allegation of verbal abuse and did not implement its Abuse, Neglect and Exploitation policy as required. A resident with diagnoses including paraplegia, acute pyelonephritis, anxiety, and depression, and who was cognitively intact, was involved in an incident where the Assistant Director of Nursing (ADON) was alleged to have been verbally abusive. Documentation showed that the resident accused the ADON of speaking inappropriately to them. Despite this, there was no immediate investigation initiated at the time of the allegation. Interviews revealed that the Social Worker (SW) was informed by multiple staff members that there had been a verbal altercation between the resident and the ADON, and that the ADON later apologized to the resident. However, the SW did not follow up with either party or report the incident to the Administrator or Director of Nursing. The facility's policy required immediate investigation of any suspected or reported abuse, but this was not followed in this case.
Food Handling and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by the surveyor. In the reach-in cooler, two egg salad sandwiches were found without a made-on date, only a use-by date, which the Dietary Director (DD) acknowledged should be discarded due to the risk of causing illness. Additionally, in the dry storage area, four bags of unopened marshmallows were found with an expired manufacturer's date, and the DD confirmed they should be discarded. Furthermore, in the overstock storage area, 70 cases of water were found with an expired manufacturer's date, and the DD noted that the Licensed Nursing Home Administrator (LNHA) was aware and working on obtaining a new supply. The surveyor also observed sanitation issues related to staff not wearing hair restraints in the kitchen area. The Speech Therapist (SP) and the Administrator of Pediatric Medical Daycare (APMC) were both seen without hairnets, despite acknowledging the requirement to wear them. The District Dietary Director (DDD) confirmed that staff should wear hair restraints and mentioned that the APMC frequently enters the kitchen without a hairnet, indicating a need for reeducation. The facility's policy on labeling food requires all products to be marked with a made-on and use-by date, which was not adhered to in the observed instances.
Deficient Call Bell System Functionality
Penalty
Summary
The facility failed to ensure the proper functioning of the resident call bell system, which had the potential to affect all residents. During observations and interviews conducted in the presence of the Director of Maintenance (DOM), it was found that the call bell system's volume was not set to a level that could be heard, and the devices used to identify call bell notifications were not functioning properly. Specifically, in two separate rooms, the call bell light turned on when tested, but there was no audible notification, and the activation did not register at the nurse's station call bell annunciator. Additionally, visual notification of the activation was obstructed by a hallway wall. In another room, the call bell did not function at all due to broken pins in the call bell box, as confirmed by the DOM. Residents were present in the rooms during these tests, highlighting the immediate impact of the deficiency.
Deficiencies in Environmental Safety and Resident Care
Penalty
Summary
The facility failed to maintain a safe, sanitary, and homelike environment for its residents, as evidenced by several observations made by surveyors. On the Fourth Floor, a surveyor found dirty washcloths and a hairbrush in a central bath, a worn mattress in a resident's room, and a non-functional bathroom light and television in another resident's room. Interviews with staff revealed that these issues were known but not addressed, with the CNA and RN responsible for reporting such deficiencies to the unit manager, who in turn would use a computerized system to log maintenance requests. However, the system was not accessible to CNAs, and the issues remained unresolved. On the Third Floor, a surveyor noted a missing drawer in a resident's wardrobe, which had not been reported to maintenance. The Unit Manager was unaware of the missing drawer, and the Maintenance Director stated that room rounds were conducted every three to six months, with the last one in July 2024. The Director of Nursing confirmed that there should be no broken furniture in resident rooms, and the Licensed Nursing Home Administrator acknowledged the oversight after it was brought to their attention. On the Second Floor, a surveyor observed a trash can without a liner, disposable gloves in a whirlpool tub, and a full sharps bin that had not been emptied. Additionally, hair was found tangled in the wheels of medication carts, and residual stains and wrappers were present in the glove holder. During meal service observations, staff served residents on meal trays without removing items or inquiring about preferences, contrary to the facility's policy on providing a homelike environment and treating residents with dignity and respect.
Infection Control Deficiencies in Wound Care and Meal Service
Penalty
Summary
The facility staff failed to adhere to appropriate infection control practices in two specific instances. Firstly, during the provision of wound care to a resident with a sacral pressure ulcer, the Unit Manager did not wear a gown despite the resident being on Enhanced Barrier Precautions, which required gown and glove use for high-contact activities such as wound care. The absence of a bin containing personal protective equipment outside the resident's room was noted, and the Unit Manager acknowledged the oversight. The facility's policy on Enhanced Barrier Precautions, which mandates gown and glove use for residents with wounds or indwelling medical devices, was not followed. Secondly, during meal service on the 4th floor, three CNAs distributed meal trays to residents without performing hand hygiene beforehand, nor did they assist residents with hand hygiene before, during, or after the meal. Interviews with the CNAs, the Registered Nurse Unit Manager, the Infection Preventionist, and the Licensed Nursing Home Administrator confirmed that hand hygiene should have been performed by staff and assisted for residents. The facility's policies on hand hygiene and assistance with meals, which emphasize the importance of hand hygiene to prevent infection, were not adhered to.
Violation of Resident Privacy and Personal Property Rights
Penalty
Summary
The facility failed to maintain an environment that protected and valued a resident's private space and personal property, as observed during a survey. A housekeeper was seen wiping the inside of a resident's bedside drawer without permission, which was confirmed by the Registered Nurse Unit Manager (RN/UM#1) and the Housekeeping Director (HD) as inappropriate since the room was not scheduled for terminal cleaning. The resident, who was cognitively intact with a BIMS score of 15 out of 15, expressed distress and did not give permission for the drawer to be accessed. The Director of Nursing (DON) and the Licensed Nursing Home Administrator (LNHA) acknowledged that residents have an expectation of privacy regarding their personal property. The facility's Environmental Services Operational Manual and Resident Rights policy emphasize treating residents with kindness, respect, and dignity, which was not upheld in this instance. The incident involved a resident with diagnoses including paranoid schizophrenia, anxiety disorder, and bipolar disorder, highlighting the importance of respecting their personal space and belongings.
Failure to Maintain Call Bell Accessibility for Resident
Penalty
Summary
The facility failed to maintain the call bell within reach for a resident, leading to a deficiency. During a survey, it was observed multiple times that the resident's call bell was on the floor under the bed, and the resident was unaware of its location. The resident had a BIMS score indicating intact cognition and was at risk for falls due to impaired balance and mobility. The resident's care plan specified that the call bell should be within reach at all times, yet this was not adhered to. Interviews with facility staff, including a CNA, RN, RN Unit Manager, and the DON, confirmed that call bells should be within reach and secured to the bed. The facility's policy also required staff to ensure call lights are accessible to residents. Despite these guidelines, the call bell was repeatedly found on the floor, indicating a failure to follow established procedures and policies, as acknowledged by the Licensed Nursing Home Administrator.
Incomplete Investigation of Resident Fall
Penalty
Summary
The facility failed to maintain proper documentation and conduct a thorough investigation following a witnessed fall involving a resident. The incident occurred when a resident, who had a history of cerebral infarction, hemiplegia, hemiparesis, and dementia, fell after their shoe came off while walking. The fall was witnessed by a certified nursing assistant, and the resident was found sitting on the floor with the back of their head having hit the wall. Despite the fall being witnessed, the facility did not complete a comprehensive investigation as required. The investigation was incomplete because the assigned nurse did not provide a statement detailing the fall, and there was no nurse's note in the electronic medical record progress notes regarding the incident. Interviews with the LPN Supervisor and LPN Unit Manager confirmed that the necessary documentation and witness statements were not gathered, and the Director of Nursing acknowledged the lack of a thorough investigation. Additionally, the facility's Accidents and Supervision policy did not offer specific guidance on conducting a thorough investigation, contributing to the deficiency.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to accurately assess the status of two residents in the Minimum Data Set (MDS), an essential assessment tool for facilitating care. For Resident #98, the surveyor observed a Wander guard on the resident's left ankle, which was ordered by a physician and documented in the Medication Administration Record. However, both the Quarterly and Annual MDS assessments incorrectly indicated that there was no wander/elopement alarm. The MDS Coordinator and the Director of Nursing confirmed the coding errors during interviews. For Resident #41, the surveyor observed the resident using oxygen via nasal cannula, which was consistent with the resident's medical history of Chronic Obstructive Pulmonary Disorder (COPD) and a physician order for continuous oxygen use. Despite this, the most recent Quarterly MDS assessment incorrectly coded the resident as not using oxygen. The MDS Coordinator and the Licensed Nursing Home Administrator acknowledged the error, confirming that the resident's oxygen use should have been accurately reflected in the MDS.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, which led to deficiencies in addressing their medical, nursing, mental, and psychosocial needs. For one resident, the care plan did not specify the focus areas related to their risk for mood impairment, use of psychotropic medications, anti-anxiety medications, and antidepressant medications. The care plan lacked details on what the mood impairment was related to and did not specify the medications involved. Additionally, the resident could not recall if the facility had ever discussed their care plan with them, indicating a lack of communication and involvement in the care planning process. For another resident, the facility failed to include a care plan focus area or interventions for significant weight loss, despite the resident experiencing a weight loss greater than 5% in a month or 10% in six months. The Registered Dietitian acknowledged that a focus should have been added to the care plan for the significant weight change, and the Director of Nursing confirmed that the dietitian should have been responsible for updating the care plan. The facility's policy on comprehensive care plans emphasized the need for measurable objectives and timeframes to meet residents' needs, which was not adhered to in these cases.
Failure to Document Resident Fall
Penalty
Summary
The facility failed to maintain thorough documentation following a witnessed fall, which is a deficiency in meeting professional standards of clinical practice. This issue was identified for one resident who experienced a fall without injury. The fall occurred when the resident's shoe came off while walking, causing them to fall and hit the back of their head against the wall. Despite the incident being witnessed by a certified nursing assistant, there was no documentation in the resident's medical record regarding the fall. The resident involved in the incident had a medical history that included cerebral infarction, hemiplegia, hemiparesis, and dementia. The resident's cognitive function was severely impaired, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. The lack of documentation was confirmed by multiple staff members, including a Licensed Practical Nurse Supervisor, a Registered Nurse, and a Licensed Nurse Unit Manager, all of whom acknowledged that the assigned nurse was responsible for entering the assessment into the progress notes. The facility's protocol required detailed documentation of falls, including vital signs, range of motion, and any injuries or changes in condition. However, the surveyor found that there was no progress note or electronic medical documentation from the assigned nurse detailing the fall. The Director of Nursing and the Licensed Nursing Home Administrator both acknowledged the absence of necessary documentation, which was a clear deviation from the facility's established protocols for assessing and documenting falls.
Inadequate Catheter Care and Documentation
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. For Resident #120, the catheter drainage bag was observed resting on the floor and unsecured to the bed, contrary to the physician's order to document catheter output every shift. The Treatment Administration Record for Resident #120 showed blank sections on multiple dates, indicating a lack of documentation for catheter care. During an interview, the Licensed Practical Nurse acknowledged that the bag should not be on the floor, and the Director of Nursing confirmed that the bag should be secured to the bed frame and not in contact with the floor for infection control reasons. Resident #21 was observed with a urinary catheter drainage bag laying on top of the bed without a privacy bag and visible from the hallway. The bag was also hooked onto the right arm of the resident's wheelchair, positioned above the bladder, which is against the facility's policy. The Treatment Administration Record for Resident #21 also showed blanks for monitoring Foley catheter output. Interviews with the Unit Manager and Infection Preventionist confirmed that the catheter bags should be below the bladder level and covered with privacy bags to prevent infection. The facility's policy on catheter care emphasizes the importance of maintaining the drainage bag below the bladder level and ensuring privacy.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to properly store respiratory equipment, specifically nebulizer masks and nasal cannulas, in accordance with professional standards of practice. For Resident #72, a nebulizer mask was observed unsecured and exposed to air in an open drawer, and nebulizer tubing was found extending into a closed drawer without a date label. The Registered Nurse/Unit Manager acknowledged that the equipment should normally be stored in a bag, and the Infection Preventionist confirmed that all equipment should be stored in a bag with the resident's name and date on it. Similarly, for Resident #19, a nebulizer mask and nasal cannula were observed unsecured and exposed to air on a nightstand and hanging from an oxygen concentrator. The nasal cannula was also found on the floor and hanging from the back of the resident's chair. Resident #19 had a medical history of acute respiratory failure and chronic obstructive pulmonary disease (COPD), with orders for nebulization and continuous oxygen therapy. The Unit Manager and Infection Preventionist both stated that the equipment should be stored in bags when not in use, and the Director of Nursing confirmed that it should not be left open to air or on the floor.
Delayed Response to Pharmacist's Medication Recommendation
Penalty
Summary
The facility failed to address the recommendations made by the Consultant Pharmacist (CP) in a timely manner for a resident admitted with Alzheimer's Disease and Protein-Calorie Malnutrition. The CP had recommended clarifying the resident's liquid Colace order to include specific concentration and dosage details. This recommendation was initially made on May 22, 2024, and reiterated on June 24, 2024, but was not acted upon until July 6, 2024, when the original order was discontinued and a new order was written. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) revealed that the facility's process for handling CP recommendations was not followed as intended. The ADON stated that recommendations are typically sent to the doctor for review and completed within a day or two, but could not recall why this particular recommendation was delayed. The DON acknowledged that the recommendation should have been completed sooner, despite the facility's policy stating that CP recommendations should be communicated and responded to in a timely fashion.
What surveyors are citing around you — mapped
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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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Trenton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trenton Gardens Rehabilitation And Nursing Center | 0.8 mi | — | 36 | 4 |
| Belle Care Nursing And Rehabilitation Center | 2.5 mi | ★★★★★ | 18 | 0 |
| Avant Rehabilitation And Care Center | 3.1 mi | ★★★★★ | 14 | 0 |
| Hamilton Grove Healthcare And Rehabilitation, Llc | 3.1 mi | ★★★★★ | 17 | 0 |
| Complete Care At Mercerville Llc | 3.8 mi | ★★★★★ | 0 | 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.