Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Health And Rehabilitation Center Llc during CMS and state inspections, most recent first.
Food Storage and Sanitation Deficiencies: Surveyors observed multiple food safety and sanitation issues, including unlabeled and undated food items, expired milk, food stored on the floor, uncovered or improperly stored items, debris and unknown substances in storage areas and the ice machine, and a resident refrigerator without a thermometer and with an incomplete temperature log. Staff interviews confirmed several items were not being stored, labeled, or monitored as required, and the FSD, DON, and LNHA acknowledged multiple concerns during the observations.
Failure to maintain resident rooms and common areas in a clean, sanitary, and homelike condition. Surveyors observed stained furniture, foul odors, stained bedding, peeling paint and veneer, exposed drywall, hair in a shower room sink, and damaged wall and floor molding with temporary tape repairs. Staff interviews confirmed routine room cleaning and maintenance expectations, and the LNH Administrator stated some issues required quicker attendance.
Controlled medication records were not accurately maintained for three residents after surveyors found mismatches between narcotic box contents and declining inventory records on two medication carts. An LPN stated doses had been given but the sheets were not signed, and an RN confirmed a tramadol count could not be correct because the resident’s dose required two tablets while the remaining count reflected an odd number; the DON and ADON confirmed staff did not follow the facility’s controlled substance documentation policy.
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 resident admitted with Medicare A as the primary payer source did not receive the required SNF ABN, Form CMS-10055, for the Part A skilled services episode. The facility’s Beneficiary Notification Review showed the form was not provided and no explanation was documented, and the Business Manager stated the SW did not know the ABN had to be issued.
A resident with a gastrostomy tube and dysphagia was care planned for EBP, but the EMR had no EBP order and staff initially observed no EBP signage or doorway identifier marking outside the room. The UM stated she was unaware of the policy for a resident care planned for EBP without an order, while the IP stated residents with gastrostomy tubes should be on EBP and that an order should be entered once care planned.
A resident receiving routine pain meds had multiple scheduled doses of acetaminophen and tramadol administered outside the allowed time window, including several doses given more than an hour late. The resident had diagnoses including muscle weakness and lack of coordination, and the DON, ADON, and Unit Manager acknowledged the late administration; the facility policy required pain management consistent with professional standards of practice.
An open, undated multi-use vial of PPD house stock was found in the medication refrigerator during an inspection of the first-floor nursing office. The DON, ADON, and IP confirmed the vial should have been dated when opened, and the IP stated it was only good for 30 days after opening. The facility policy required multi-use vials to be dated when opened and discarded within 28 days unless the manufacturer specifies otherwise.
A resident on contact isolation for E. coli/UTI and MRSA was observed with staff entering the room without gowns or gloves despite a posted sign directing hand hygiene and PPE use before entry. CNAs and an LPN/Unit Manager stated PPE was only needed for hands-on care, while the IP confirmed PPE had to be worn before entering the room.
A live brown insect was observed crawling on a wall near the nurses station on the 2nd floor, and an LPN/UM disposed of it with a glove. The LNHA stated pest control services are scheduled biweekly and that the company had provided more in-depth treatment, while invoices showed treatment for cockroaches. The facility policy required an effective pest control program to eradicate and contain common household pests and rodents.
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.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner. During kitchen observations, surveyors found a partially empty jar of applesauce in the stand-up/cold prep refrigerator with no opened date or use-by date, debris on the floor beside the ice machine, boxes of single-serve cereal bowls stored directly on the floor in the dry storage room, additional cereal boxes without a received-by date, and an opened box of enriched macaroni product with no opened date or use-by date. In the walk-in refrigerator, an uncovered cardboard box of green and red bell peppers contained four green peppers that were discolored and mottled. In the walk-in freezer doorway, a used disposable glove was on the floor, and inside the freezer a box of burger patties was open to air with no opened date or use-by date, with a meat patty also observed on the floor against the wall. Surveyors also observed meat slicer components, including the blade cover and the tray used to hold meat during slicing, left open to air on top of oven mitts. The Food Service Director stated she was unsure whether they needed to be covered with the slicer and then placed them under the cover with the meat slicer. In a fourth-floor pantry refrigerator, two cartons of milk were frozen to the back of the refrigerator and were found to be expired, with expiration dates of April 1 and April 7. In a third-floor pantry freezer, an unknown brown substance was observed on the bottom and door of the freezer, a white bin had light brown particles at the bottom, and an unlabeled and undated take-out container was present. An LPN stated the take-out container belonged to another staff member and should have been labeled and in the refrigerator. The surveyor also observed a resident's personal refrigerator with no thermometer inside and a temperature log attached to the side that had November written on it, but the log was not being completed. The resident stated the thermometer had been removed and placed in a drawer. The UM confirmed that nursing staff were responsible for maintaining and recording the refrigerator temperature log. Additional observations included a dark brown substance inside the ice machine and on top of it. The DON stated housekeeping should clean the pantry monthly and all staff should monitor daily for old or expired food items, and the LNHA stated staff should not store personal food items in the pantry. Facility policies reviewed required food items to be labeled and dated, dry goods to be stored at least 6 inches above the floor, cold foods to be wrapped or in covered containers and labeled and dated, and resident refrigerator temperatures to be recorded weekly with a thermometer remaining in the refrigerator.
Failure to Maintain Clean, Sanitary, and Homelike Resident Areas
Penalty
Summary
The facility failed to maintain residents’ living areas in a clean, sanitary, and homelike manner on the Second and Fourth Floors. During the initial tour, surveyors observed a chair in a bathroom with a brown stain on the seat, a bathroom wall with large scuff marks that penetrated through the drywall, a foul odor in a room with an unmade bed and stained sheets and pillowcases, and a 3rd Floor shower room with a tiled wall patch that had not been retiled and floor molding that was peeling and held in place with tattered blue tape. On follow-up rounds, the foul odor remained in the room, the bed was made with visible stains on the top blanket, and the same stained chair remained in the bathroom with an open, half-used roll of toilet paper sitting on it. Surveyor interviews documented that a CNA stated residents’ bedding is changed every other day unless it needs to be changed more often. A housekeeper stated rooms are entered several times a day to clean, including sterilizing the room, cleaning the bathroom, and emptying trash, and said it would be her responsibility to clean the chair if she saw it. The DES stated resident rooms are cleaned daily, including wiping high-touch areas, cleaning bathrooms, and sweeping and mopping floors, and that dirty furniture or surfaces should be cleaned. The MAD stated resident rooms and common areas are rounded on at least monthly, concerns are typically fixed immediately, and holes should be patched with sheetrock and repainted; the MAD also confirmed the shower room patch should have been retiled and the floor molding repaired rather than taped. On the low side of the Second Floor, surveyors also observed a dresser with peeling wood veneer exposing particle board, peeling paint under a window exposing drywall, and a sink in the shower room with multiple black and gray strands of hair in it. The LNH Administrator later stated the dresser and paint issues had been resolved the day before and that the issues required quicker attendance.
Controlled Medication Counts and Documentation Were Inaccurate
Penalty
Summary
The facility failed to accurately account for the administration, disposition, and reconciliation of controlled medications for three residents after surveyors found discrepancies in two medication carts. On the second-floor high-end cart, Resident 58’s methadone 100 mg oral solution chain-of-custody record did not match the contents of the secured narcotic box, which contained seven bottles with six containing medication and one empty, while no doses had been documented as administered. In the same narcotic box, Resident 69’s buprenorphine/naloxone 8/2 mg film count did not match the Individual Patient’s Controlled Drug Record, as the box contained two films even though the declining inventory sheet showed three films remaining. The LPN stated the medications had been administered earlier and that she had forgotten to sign the declining inventory sheets. On the second-floor low-end cart, Resident 47’s tramadol 50 mg tablets were also not accurately accounted for. The resident’s order required two tablets to make a 100 mg dose, yet the blister pack contained nine tablets and the declining inventory sheet also showed nine tablets remaining, which the RN acknowledged could not be correct if two tablets were administered per dose. The reverse side of the declining inventory showed two tablets had been wasted, and the RN confirmed she had not administered tramadol to Resident 47 that day. The LPN/UM, DON, and ADON stated nurses should sign out controlled medications when removed from packaging and then sign in the EMR after administration, and they confirmed the nurses had not followed facility policy.
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 SNF ABN for Medicare Part A Resident
Penalty
Summary
The facility failed to provide the Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN), Form CMS-10055, to 1 of 3 residents reviewed under Beneficiaries Task. Resident #56 was admitted with Medicare A as the primary payer source, and the Beneficiary Notification Review showed a Medicare Part A skilled services episode start date of 09/04/2025 with the last covered day of Part A service on 12/1/2025. The review also showed that the SNF ABN, Form CMS-10055, was not provided to the resident, and no explanation was documented on the Beneficiary Notification Review form. During interview, the Business Manager stated that the Social Worker at the time did not know the SNF ABN form had to be issued, and that the form had originally been marked yes before being changed to no when it was discovered the form had never been sent.
Failure to Obtain and Implement EBP Order for Resident With Feeding Tube
Penalty
Summary
The facility failed to implement care consistent with Resident #3’s care plan by not obtaining and implementing an order for Enhanced Barrier Precautions (EBP). Resident #3 was observed in bed connected to an enteral feeding pump, and the resident’s record showed diagnoses including gastrostomy status and dysphagia. The care plan included a focus for EBP initiated on 02/17/2026 with a goal of infection control intervention designed to reduce transmission of multidrug-resistant organisms using targeted gown and glove use during high-contact care activities related to the PEG tube. During multiple observations, no EBP signage was seen outside Resident #3’s room and no colored mark was seen next to the resident’s name on the doorway identification sign until 04/17/2026, when both were observed. The EMR contained no order for EBP. Staff interviews showed the Unit Manager was unaware of the policy for a resident care planned for EBP without an order, the Infection Preventionist stated residents with gastrostomy tubes should be on EBP and that an order should be entered once care planned, and the ADON stated the DON and IP review resident orders and care plans for accuracy. The facility policy stated that an order for EBP will be obtained for residents with indwelling medical devices, including feeding tubes.
Late Administration of Scheduled Pain Medication
Penalty
Summary
The facility failed to provide pain management that met professional standards of practice for one resident who was receiving routine pain medication. Resident #106 had diagnoses including muscle weakness and lack of coordination, and the admission MDS dated 03/20/26 reflected that the resident received routine pain medication. The physician’s orders in the EMR included Acetaminophen Extra Strength 500 mg, 2 tablets by mouth twice daily for arthritis pain, and tramadol 50 mg, 2 tablets by mouth four times daily. A review of the Medication Administration Audit for March and April 2026 showed multiple doses of the resident’s pain medications were administered outside the scheduled time, including acetaminophen doses given more than an hour late and tramadol doses given late on several occasions. During interview, the Unit Manager stated medications can be administered one hour before and one hour after the scheduled time, and the nurse should document the medication at the time of administration. The DON and ADON later acknowledged that Resident #106 received pain medication late. The facility policy titled Pain Management stated that pain management must be provided consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident’s goals and preferences.
Undated Open Multi-Use PPD Vial Found in Medication Refrigerator
Penalty
Summary
The facility failed to ensure that medications used in the facility were labeled and stored in accordance with accepted professional standards of practice to preserve their integrity. During inspection of the first-floor medication storage area, the surveyor and DON found that there was no medication refrigerator in the room, and the DON stated that medications were stored in a refrigerator located in the first-floor nursing office. When the refrigerator in the nursing office was inspected with the DON, ADON, and IP present, an open, undated multi-use vial of Tuberculin Purified Protein Derivative (PPD) 5 TU/0.1 ml, labeled as house stock, was observed. The IP stated the vial should have been dated when opened and that it was only good for 30 days after opening before being discarded. The DON and ADON confirmed that the vial should have been dated when opened. The facility policy stated that multi-use vials must include the date initially opened or accessed and be discarded within 28 days unless the manufacturer specifies אחרת.
Failure to Follow Contact Isolation PPE Requirements
Penalty
Summary
The facility failed to ensure infection control practices were followed for a resident on contact isolation. Resident #65 had an EMR order for E. coli/UTI with contact precautions starting 4/16/2026, and the care plan identified the resident as being on isolation contact precautions. The care plan also noted MRSA and included interventions such as wearing gowns and masks when changing contaminated linens, placing soiled linens in biohazard bags, giving antibiotic therapy as ordered, and instructing visitors to wear disposable gloves and gowns and wash hands before leaving the room. On 04/17/2026 at 10:53 AM, a surveyor observed a contact precaution sign outside the room instructing staff to perform hand hygiene and put on a gown and gloves before entering. The surveyor observed CNA #1 enter the room and speak to the resident without applying a gown or gloves, and upon exiting she stated she did not have to wear a gown unless she was doing care. Another CNA entered the room without a gown and placed supplies on the bedside table, then stated staff must wear a gown when they are hands on with the resident. At 10:58 AM, the LPN/Unit Manager stated staff only wears PPE when doing hands-on care. At 12:29 PM, the Infection Preventionist confirmed the resident was on contact isolation and stated staff had to wear the PPE before going into the room.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an environment free of pests when a live brown insect was observed crawling on the wall near the hand rail in the hallway by the nurses station on the 2nd floor. The LPN/UM also observed the insect and disposed of it with a disposable glove, and stated he would document the occurrence in the Pest Control Log. During interview, the LNHA stated that pest control services are scheduled biweekly and that the company had been brought in for a more in-depth treatment. He also stated that when the facility becomes aware of rooms with insects, pest control treats those specific rooms. Review of March 2026 pest control invoices showed the facility had been treated for cockroaches, and the facility policy stated it is the guideline of the facility to maintain an effective pest control program that eradicates and contains common household pests and rodents.
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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What surveyors actually found near you
We read the 922 citations issued within 25 miles in the last 12 months — including the 17 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
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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 | ★★★★★ | 0 | 0 |
| Hamilton Grove Healthcare And Rehabilitation, Llc | 3.1 mi | ★★★★★ | 17 | 0 |
| Complete Care At Mercerville Llc | 3.8 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.