Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverview Estates Rehab And Senior Living Center during CMS and state inspections, most recent first.
Menus were not posted on the LTC units, were not consistently followed, and were changed without RD review. The FSD said corporate menus were emailed on a 3-week cycle, but she did not print or save signed copies, served meals based on meal tickets, and changed items based on available supplies and resident preferences. Survey review found discrepancies between the FSD and RD versions of the Week 3 menu for 9 of 21 meals, and signed menus for the other weeks in the cycle could not be produced.
A resident with diabetes, muscle wasting, impaired mobility, and a Stage 3 pressure ulcer was observed multiple times lying on an air mattress whose pump was set to 600 lbs despite the resident weighing 175 lbs. The care plan addressed skin breakdown and pressure reduction, but no air mattress order was noted. An LPN was unsure of the correct setting and changed it to 300 lbs, while the DON stated nursing was responsible for checking mattress function and setting it according to resident weight.
Failure to document and implement a resident’s meal preferences. A cognitively intact resident with moderate protein-calorie malnutrition reported requesting grilled cheese and salads for lunch and dinner, but was not consistently served those items and was given a cheese quesadilla instead of grilled cheese at one meal. Meal tickets listed allergies and “SEND SALAD,” but did not include grilled cheese, and the FSD acknowledged a prior conversation about the request was not documented or shared with the RD.
QAPI identified a food preference and meal ticket accuracy issue, but the facility did not use its PIP to measure or track whether residents’ meal choices were being honored. The LNHA said the PIP had started and then “fell to the wayside,” and although the new FSD began offering alert residents choices, the AIT only audited 3 trays for accuracy and verbally reported the results. The facility could not show audits, tracking, or follow-up related to residents’ preferences.
The facility failed to have an RN on duty for at least 8 hours a day, 7 days a week, as required. On two weekends, there were no RNs on duty for any shift. Despite claims from the administration that RNs were always present, staffing reports and schedules showed otherwise, violating the facility's staffing policy.
The facility failed to timely respond to a consultant pharmacist's recommendations for two residents. One resident's medication administration time was not updated for several months, and another resident did not receive recommended lab tests while on Depakote. The Director of Nursing acknowledged the delay, which contradicted the facility's policy for timely implementation of pharmacist recommendations.
Surveyors identified deficiencies in food handling and storage practices, including a dented can of pizza sauce, improperly stored frozen puree moldings, and wilted coriander in the kitchen. Additionally, an unlabeled and undated food item was found in a resident pantry refrigerator. The facility's policies on food receiving, storage, and monitoring were not followed, as confirmed by the FSD and an LPN.
A facility failed to document wound care for a resident with dementia, depression, and diabetes, as required by professional standards. The resident's TAR had blank spaces for treatments on two days, indicating they were not documented as administered. The DON confirmed that treatments were completed but not signed off by the nurse, violating the facility's documentation policy.
The facility failed to follow physician orders for PRN oxygen use and did not implement proper infection control measures for respiratory equipment. A resident's nebulizer mask was left uncovered, and records showed oxygen use without documentation of need. Staff interviews revealed inconsistencies in equipment storage practices, contrary to facility policy.
A facility failed to properly label, store, and date medications, as observed during a survey. A medication cart contained a sticky substance, loose tablets, and improperly stored lorazepam liquid that required refrigeration. The LPN acknowledged the issues, and the LPN Unit Manager and DON confirmed the need for proper storage and cleanliness according to facility policy.
A facility failed to maintain proper infection control during wound care for a resident with open wounds. An LPN did not wear a gown, change gloves, or perform hand hygiene as required by facility policies. The resident, with dementia and diabetes, had specific wound care orders that were not followed correctly. Additionally, Enhanced Barrier Precautions were not implemented for the resident, despite having chronic wounds, due to unclear guidelines from the Infection Preventionist and DON.
Menus Not Posted, Followed, or Reviewed by RD
Penalty
Summary
The facility failed to develop, follow, and change planned menus with review by a registered dietician. During an initial tour, the surveyor was unable to locate a posted daily or weekly menu on 3 of 3 long-term care units. The Food Service Director stated the corporate office created menus on a 3-week cycle and emailed them to her, and that the registered dietician entered the menus into the food service computer program, signed them, and emailed them back. The Food Service Director acknowledged she did not print or save copies of the signed menus and that she could only view meal tickets, not the menus, after the dietician entered them into the computer program. The Food Service Director stated the kitchen served food based on meal tickets rather than menus and that she could change items on the meal tickets in the computer. She also stated she changed menu items based on available supplies and what she knew residents liked, and that the residents were served mashed potatoes instead of scalloped potatoes because there were not enough scalloped potatoes for everyone. She acknowledged she did not post menus in advance on the long-term care units and did not review meal changes with the registered dietician. On re-interview, she stated she and the Administrator reviewed weekly menus from corporate and changed them if they saw repetition by adjusting the meal tickets, but she did not know whether changing the meal ticket also changed the weekly menu. The surveyor reviewed facility documents and compared a Week at a Glance Fall/Winter 2025/26 Week 3 Regular menu provided by the Food Service Director with a signed Week 3 Regular menu provided by the registered dietician. Discrepancies were noted for 9 of 21 meals reviewed, including one breakfast, three lunches, and four dinners, with differences ranging from added items such as a banana or cookies to changes in the main dish served. The registered dietician stated she met with residents on admission or with significant weight change and tried to check in at mealtimes, but she could not speak to specific meals or menu changes. Signed menus for Week 1 and Week 2 of the 3-week cycle could not be produced.
Air Mattress Not Set to Resident Weight
Penalty
Summary
The facility failed to ensure that a low air loss mattress was functioning properly and set accurately according to the resident’s weight, in accordance with a physician’s order, for a resident who had already been identified as having altered skin integrity. Resident #54 had diagnoses including muscle wasting and atrophy, multiple sites; type 2 diabetes mellitus with unspecified complications; and abnormalities of gait and mobility. The resident’s most recent MDS, dated 12/8/25, indicated a BIMS score of 14 out of 15, that the resident was at risk for pressure ulcer/injury, and that one Stage 3 pressure ulcer was present. The resident’s weight was documented as 175 pounds. Surveyors observed the resident in bed on an air mattress on 1/2/26, 1/5/26, and 1/6/26, and each time the mattress pump was set to a resident weight of 600 pounds. The resident was awake, alert, and watching TV during the observations. The care plan identified the resident as at risk for alteration in skin integrity related to immobility and included interventions for pressure reduction and repositioning. Another care plan focus area documented actual skin breakdown to the sacrum and left heel, with interventions to administer treatments per physician orders and encourage repositioning. The order summary included wound-related treatments and protein supplementation, but no physician order was noted for an air mattress during the resident’s admission. When questioned, an LPN stated she was unsure what the mattress should be set to, changed it from 600 pounds to 300 pounds, and said she would contact her manager and the doctor for clarification. The DON later stated that nursing was responsible for checking the air mattress pumps for proper function and that they should be set according to a resident’s weight to prevent skin breakdown. The manufacturer’s manual stated to determine the patient’s weight and set the control knob to that weight setting.
Failure to Document and Implement Resident Meal Preferences
Penalty
Summary
The facility failed to document and implement one resident’s food preferences for meals. Resident #9, a cognitively intact long-term care resident with a diagnosis that included moderate protein-calorie malnutrition, told the surveyor they had spoken with the dietician about wanting grilled cheese and salads for lunch and dinner, but did not always receive those items. During observation, the resident was served a cheese quesadilla for lunch instead of the requested grilled cheese sandwich. The Food Service Director stated the facility did not provide menus to long-term care residents and instead served one meal choice to all residents, with alternatives available on request. She also stated that resident preferences, allergies, and restrictions were supposed to be printed at the top of the meal ticket. When the surveyor reviewed the resident’s meal tickets, the tickets repeatedly listed allergies and “SEND SALAD,” but did not include an indicator to send grilled cheese. The resident stated they did not get salad unless they asked for it, and also stated they had already spoken to the Food Service Director about their preferences. The Food Service Director acknowledged she had spoken with the resident a few weeks earlier about the request for grilled cheese, but she did not document that conversation or discuss it with the RD. The RD stated she met with residents on admission or with significant weight change and tried to check in at mealtimes, but could not speak specifically to this resident. The resident’s record showed lactose as an allergy, and the care plan initially reflected an intervention to provide preferences as available and to observe the lactose allergy; after surveyor inquiry, the care plan was revised to note the resident could have cheese, yogurt, and ice cream, but there was no prior documented revision supporting the resident’s requested grilled cheese preference.
QAPI Failed to Track Food Preference Performance Improvement
Penalty
Summary
The facility QAPI committee identified a quality concern involving food preferences and meal ticket accuracy, but it failed to use the Facility Performance Improvement Plan (PIP) to measure and use data related to residents’ food preferences. The facility’s PIP, dated 5/20/2025 and revised later, listed the problem statement as food preference and meal ticket accuracy, with the goal that alert residents would be able to choose what meal or alternate they wished to have and that meal tickets would reflect the choice printed. The tasks listed included providing weekly meal tickets and an alternate list to oriented residents and auditing whether residents’ choices were being honored. On 1/7/2026, the LNHA and DON were interviewed. The LNHA stated the PIP for food preferences had started in May 2025 but then “fell to the wayside,” and that it was restarted when the new FSD began. She stated the new FSD started giving alert residents choices, and that the AIT went into the kitchen and audited 3 trays for accuracy, verbally reporting the results to her. However, she was unable to show audits addressing residents’ preferences, how the results were tracked, or any follow-up with residents to ensure they were receiving their preferences. The facility QAPI Plan, established 6/2025, stated that the facility had a performance improvement program to systematically monitor, analyze, and improve performance to improve resident/patient outcomes.
Failure to Ensure RN Coverage 7 Days a Week
Penalty
Summary
The facility failed to ensure that a Registered Nurse (RN) was on duty for at least 8 consecutive hours a day, 7 days a week, as required by regulations. This deficiency was identified during a review of the Nurse Staffing Report sheets and interviews with facility staff. Specifically, on two weekends reviewed, there were no RNs on duty for the entire day, evening, and night shifts. On December 9, 2023, the Nurse Staffing Report showed zeros for all shifts under the RN column, and the daily nursing schedule confirmed the absence of an RN. Similarly, on August 31, 2024, the RN scheduled to work called out, resulting in no RN coverage for that day. Interviews with the Licensed Nursing Home Administrator and the Director of Human Resources/Staffing revealed a discrepancy between their statements and the staffing records. Both individuals claimed that an RN was on duty every day, yet the staffing reports and schedules indicated otherwise. The facility's policy on staffing, last reviewed in December 2023, mandates that RNs be available 8 hours a day to provide clinical oversight and care planning. However, the facility did not adhere to this policy on the specified dates, leading to the identified deficiency.
Delayed Response to Pharmacist Recommendations
Penalty
Summary
The facility failed to respond to the consultant pharmacist's (CP) medication regimen review recommendations in a timely manner for two residents. For one resident, the CP recommended updating the administration time of Pantoprazole Sodium to 9 AM, which was not implemented until several months later, despite the recommendation being made in May. This delay in updating the medication administration time was observed in the Medication Administration Records (MAR) for several months. For another resident, the CP recommended periodic monitoring of valproic acid levels and baseline liver function tests, coagulation, and complete blood count with differential while the resident was on Depakote. The recommendation was made in May, but the practitioner did not respond until late July, and no laboratory studies were ordered since June. The practitioner did not document whether they agreed or disagreed with the CP's recommendation, which was noted as a deficiency in the facility's process. The Director of Nursing (DON) acknowledged responsibility for ensuring timely completion of CP recommendations and stated that a timely manner would be within a couple of days to a week, depending on the order. However, the recommendations made in May were not completed within this timeframe. The facility's policy requires the DON to act upon CP recommendations by notifying the attending physician and ensuring timely implementation, which was not adhered to in these cases.
Deficient Food Handling and Storage Practices
Penalty
Summary
The facility failed to handle potentially hazardous food and maintain sanitation in a safe and consistent manner, as observed by surveyors. In the dry storage room, a can of Pizza Sauce with Basil was found with a dent on the upper seam, which the Food Service Director (FSD) acknowledged needed to be moved to a designated dented can area. In the walk-in freezer, a quarter pan containing frozen puree moldings was improperly stored on top of cardboard boxes, with the plastic wrap covering it torn, leaving the contents exposed to air. Additionally, in the walk-in refrigerator, a pan containing fresh coriander was found to be brown and wilted, dated from several weeks prior, and was subsequently discarded by the FSD. In the designated resident pantry, an unlabeled and undated red Wawa cloth bag containing an unidentified food item was found in the refrigerator. An LPN confirmed that nursing staff was responsible for labeling and dating foods brought in from outside the facility and removed the item, suspecting it had arrived the previous night. The facility's policies on food receiving, storage, and monitoring of cooler/freezer temperatures were not adhered to, as evidenced by the presence of dented cans, improperly covered and stored food, and unlabeled items in the resident pantry.
Failure to Document Wound Care in TAR
Penalty
Summary
The facility failed to adhere to professional standards of practice for documenting wound care on the Electronic Treatment Administration Record (TAR) for a resident. This deficiency was identified during a survey, which included interviews, medical record reviews, and examination of facility documentation. The resident involved had multiple diagnoses, including unspecified dementia, major depressive disorder, and diabetes, and was assessed to have severely impaired cognition. The survey revealed that there were blank spaces on the TAR for specific treatment orders on two separate days, indicating that the treatments were not documented as administered. These treatments included the use of a low air loss scoop mattress and wound care for the resident's right posterior shoulder and right lateral foot. The facility's Director of Nursing (DON) confirmed that the expectation was for nurses to document treatments in the Electronic Medical Record (EMR) on the TAR, and any blank spaces should have a documented reason for the omission. Further investigation showed that the treatments were later documented as administered on a different date, suggesting a lapse in timely documentation. The DON explained that the nurse responsible for the resident on the days in question had completed the treatments but forgot to sign the TAR. The facility's policy on charting and documentation requires that all treatments and services be documented accurately and completely, including the date, time, and the name and title of the individual providing care.
Failure to Follow Respiratory Care Protocols
Penalty
Summary
The facility failed to adhere to a physician's order for PRN oxygen use for a resident with chronic obstructive pulmonary disease (COPD). During an initial tour, a surveyor observed a nebulizer mask dated several days prior, left uncovered and exposed in the resident's room. The resident's electronic medical record indicated a physician's order for oxygen to be administered as needed for shortness of breath or when oxygen saturation levels fell below 93%. However, the medication administration records for several months showed no documentation that the resident required oxygen, despite records indicating oxygen use on multiple occasions when the resident's oxygen saturation was above 93%. Additionally, the facility failed to implement proper infection control measures for the handling and storage of respiratory equipment for two residents. One resident's nebulizer mask was observed uncovered and exposed on a bedside table after use. The facility's policy required that respiratory equipment be cleaned and stored in a plastic bag between uses to prevent contamination. Interviews with facility staff revealed inconsistencies in the understanding and implementation of these procedures, with some staff unsure of the exact protocol for storing respiratory equipment. The facility's Director of Nursing and Licensed Nursing Home Administrator confirmed the expectation that nebulizer masks should be cleaned and bagged between treatments. However, observations by surveyors indicated that this practice was not consistently followed, as evidenced by the uncovered nebulizer masks found in residents' rooms. The facility's policy on nebulizer administration outlined the steps for cleaning and storing equipment, but these procedures were not adhered to, leading to potential contamination risks for the residents involved.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to properly label, store, and date medications in accordance with manufacturer recommendations, as observed during a survey of medication carts. In one of the medication carts inspected, a brown sticky substance was found at the bottom of a drawer, and seven and a half loose tablets were discovered. Additionally, a lorazepam liquid, which required refrigeration, was improperly stored on the medication cart instead of in a refrigerator. The LPN present during the inspection acknowledged awareness of the sticky substance but had been unsuccessful in removing it. The LPN also admitted to not noticing the loose tablets during her shift check and confirmed that the lorazepam should have been refrigerated. The LPN Unit Manager confirmed that the lorazepam should have been stored in a locked refrigerator in the medication room and acknowledged the presence of loose tablets and the need for immediate cleaning of the spillage. The Director of Nursing reiterated that spills should be cleaned immediately and that maintenance should be contacted if further cleaning is needed. The facility's policy on medication storage emphasized maintaining medication areas in a clean, safe, and sanitary manner, with medications requiring refrigeration to be stored in a secured refrigerator.
Infection Control Deficiency in Wound Care
Penalty
Summary
The facility failed to maintain appropriate infection control practices during wound care for a resident with open wounds. During an observation, a Licensed Practical Nurse (LPN) did not wear a gown while performing wound care on the resident. The LPN also failed to change gloves after removing dirty dressings and before cleaning the wounds, and did not perform hand hygiene before or after applying skin prep to the resident's ankles. These actions were contrary to the facility's infection control policies, which require changing gloves and performing hand hygiene between handling contaminated and clean items. The resident involved was admitted with diagnoses including unspecified dementia and diabetes, and was at risk for pressure ulcers. The resident's medical orders included specific wound care instructions for the right posterior shoulder and right lateral foot, as well as preventative skin care for the ankles. Despite these orders, the LPN did not follow proper infection control procedures, which were observed by the surveyor during the wound care process. Additionally, the facility did not implement Enhanced Barrier Precautions (EBP) for the resident, who had open wounds. The Infection Preventionist (IP) and Director of Nursing (DON) were unclear about when EBP should be applied, despite the facility's policy stating that EBP should be used for residents with chronic wounds, regardless of their MDRO status. The lack of signage and proper use of personal protective equipment (PPE) further demonstrated the facility's failure to adhere to its own infection control policies.
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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.
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Nursing homes near Riverton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wynwood Rehabilitation And Healthcare Center | 1.9 mi | ★★★★★ | 13 | 0 |
| Immaculatemarycenter For Rehabilitation&healthcare | 3 mi | ★★★★★ | 26 | 1 |
| Sterling Manor | 3.1 mi | — | 0 | 0 |
| River's Edge Rehabilitation & Healthcare Center | 3.1 mi | ★★★★★ | 18 | 0 |
| Transitional Care Unit At Nazareth Hospital | 3.3 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.