Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Ottawa Co Riverview Nursing Ho during CMS and state inspections, most recent first.
Failure to Provide Dignified Feeding and Hygiene Care: Three residents with cognitive impairment and ADL needs were observed receiving care in an undignified manner. Two residents were fed while a CNA stood over them instead of sitting, and an LPN confirmed staff should not stand during feeding assistance. Another resident had dried food/substance under the lip and down the chin that remained after dinner, and the CNA verified it was still present.
A resident with depression, anxiety, restlessness, and protein-calorie malnutrition was started on buspirone, mirtazapine, and PRN lorazepam, but no informed consents were signed before the psychoactive meds were initiated. An MDS LPN verified the missing consents during chart review.
Inconsistent DNR Code Status Documentation: A resident with Parkinsonism, dementia, DM2, HTN, depression, and anxiety had conflicting code status documentation across the chart. The care plan noted DNR, but records variously showed full code, DNRCC, and DNRCCA; the signed DNR form checked DNRCCA while the e-order listed DNRCC, and an RN verified the mismatch.
A resident with dementia, Parkinson's disease, MS, and severe cognitive impairment wore socks on her hands to prevent self-biting, but the record lacked physician orders specifying when the restraint should be used or removed. Staff said skin checks were done each shift, yet they were not documented, and behavior notes did not consistently describe the resident's biting episodes. The DON verified the restraint order did not identify a specific medical reason and that the chart did not show use of a less restrictive intervention before the hand restraint was used.
Failure to Invite Residents and Families to Care Conferences: The facility failed to ensure two residents and their resident representatives were invited to care conference meetings. One resident with Parkinsonism, dementia, DM2, HTN, depression, and anxiety stated she was not invited, and there was no documentation of an invitation or refusal. Another resident with dementia, COPD, emphysema, and CHF had care conference notes showing staff attendance only, while the family reported they had not been invited and the LSW confirmed there was no documentation of family invitations.
Failure to follow the bowel protocol occurred for a cognitively impaired resident with Alzheimer's disease and other chronic conditions who was receiving bowel aides and Tramadol. The bowel log showed no BM for six days, but MOM was not administered as required by the facility's protocol, and the DON verified the omission.
Incomplete Communication With Dialysis Center: A resident with ESRD and dependence on renal dialysis received offsite HD three times weekly, but the facility did not ensure consistent exchange of dialysis communication forms with the HD clinic. The care plan lacked coordination-of-care interventions, several Outpatient Dialysis Assessment forms were incomplete or missing, and the DON confirmed multiple forms were not fully completed. The facility policy and HD contract required pertinent information to accompany the resident for coordination of care.
LPN did not apply ordered lidocaine patches to a resident with bilateral knee pain and osteoarthritis. The resident, who had impaired cognition and needed staff help with transfers, was observed with a patch rolled up above the knee under clothing. The CNA said she applied the patches after the nurse left them at bedside, and the LPN confirmed she had not applied them because it was a very busy morning.
A resident with Parkinson's disease, dysphagia, and hypokalemia received a significant med error when an LPN routinely crushed potassium chloride ER tablets despite no order to crush meds and despite pharmacy guidance that potassium chloride ER should not be crushed. During observed med pass, the LPN placed the potassium with other meds in a crusher, then administered the crushed meds and whole potassium tablets in applesauce; the resident had difficulty swallowing the whole meds. RN verification confirmed potassium should not be crushed, and the NP had not been notified of swallowing difficulty.
A resident with dementia and dependence on staff for oral hygiene did not receive requested preventative dental care after family consent was given. The care plan identified the resident as at risk for altered oral/dental status, but no dental visits were arranged despite family request and the facility’s dental policy assigning social services to coordinate dental appointments.
A facility failed to properly assess and document the risks of bed rail entrapment for residents using alternating pressure mattresses, leading to a resident's death by asphyxia after becoming wedged between the mattress and bed rail. The facility did not measure mattress gaps under compression, did not document medical need or alternatives to bed rails, and did not attempt alternative interventions before installing side rails for multiple residents, placing several at risk for harm.
Failure to Provide Dignified Feeding and Hygiene Care
Penalty
Summary
The facility failed to ensure residents were treated in a dignified manner for three residents reviewed for dignity. Resident #31 had Alzheimer’s disease, dementia, muscle weakness, dysphagia, and severe cognitive impairment, and was dependent on staff for eating meals. During observation, a CNA was standing over the resident while feeding bites of food at the dining table, and an empty chair was nearby. The CNA confirmed she was standing while feeding the resident and stated she should have been sitting while providing feeding assistance. Resident #25 had COPD, hypertension, anxiety, and severe cognitive impairment, and required supervision or touching assistance for eating meals. During observation, a CNA was standing over the resident while feeding bites of food. An LPN stated staff should not be standing when providing feeding assistance and should be sitting on a stool. The CNA confirmed she was standing while feeding the resident and should have been sitting. Resident #67 had Parkinson’s disease, mild cognitive impairment, and required maximum assistance for personal hygiene. Observation showed dried brown substance under the resident’s lower lip and down his chin, and the same dried stain remained after dinner. The CNA verified the brown stained food remained under the resident’s lip and chin, and the resident stated he needs help with ADL care and sometimes needs help with eating.
Failure to Obtain Informed Consent Before Starting Psychoactive Medications
Penalty
Summary
The facility failed to ensure that a resident was informed about treatment options and alternatives before psychoactive medications were started. Resident #9 was admitted with diagnoses of depression, restlessness, anxiety, and protein-calorie malnutrition, and later had intact cognition on the quarterly MDS assessment. The resident received buspirone 10 mg twice daily for anxiety beginning 11/15/25, mirtazapine 15 mg daily for appetite stimulant/malnutrition beginning 12/03/25, and lorazepam 0.5 mg every 8 hours as needed for anxiety beginning 01/15/26. During a 02/25/26 interview and concurrent chart review, the MDS LPN verified that no informed consents were signed before these psychoactive medications were initiated.
Inconsistent DNR Code Status Documentation
Penalty
Summary
The facility failed to ensure one resident’s code status was consistent throughout the medical record. Resident #8 had diagnoses including Parkinsonism, dementia, type 2 diabetes mellitus, hypertension, depression, and anxiety, and the quarterly MDS indicated moderate cognitive impairment. The resident’s plan of care documented that the resident had chosen a DNR, with interventions stating the code status would be reviewed quarterly at care conferences and that the DNR form would be placed in the front of the physical chart. The record contained conflicting code status documentation. The plan of care did not specify whether the resident had chosen DNRCC or DNRCCA, while a quarterly care conference note documented full code status. The signed paper DNR form showed DNRCCA was checked, quarterly care conference progress notes documented DNRCC, and an electronic physician order also documented DNRCC. RN #377 reviewed the records and verified the paper DNR form and electronic physician order did not match. The facility policy stated the DNR code status should be obtained in writing, faxed to the physician, and monitored for completeness and correctness, with discrepancies to be identified and corrected.
Failure to Properly Order and Monitor Hand Restraint
Penalty
Summary
The facility failed to ensure proper use and monitoring of a physical restraint for one resident who had Parkinson's disease, progressive multiple sclerosis, dementia, type 2 diabetes mellitus, dysphagia, anxiety, dermatitis, and severe cognitive impairment. The resident was identified as needing arm protection such as socks, gloves, or sleeves to prevent self-harm from biting or chewing her arm, and the care plan described restraint-related interventions, consent, and monitoring expectations. However, the physician orders in the record did not specify when or how long the restraint should be applied or when and how often it should be removed. The record also showed inconsistent documentation of the resident's behavior and restraint monitoring. Behavior charting noted episodes of behavioral symptoms on several dates, but there was no further description of the behaviors, and nursing notes from a later period did not document biting behaviors. The chart also lacked documentation of daily skin checks while the resident wore the hand coverings, and there was no documentation of how often the resident exhibited biting behaviors. Staff interviews confirmed that the resident wore socks on her hands to prevent biting, that skin checks were reportedly done at least once per shift, and that these checks were not being documented unless there was a problem. Observation showed the resident wearing socks covering her hands while awake and asleep, with no attempts to bite herself during the survey observations. When asked to remove the socks for inspection, the resident's skin was clean, dry, and without breakdown. The DON verified that the physician order did not identify a specific medical reason for the restraint, that the record lacked documentation of how often the restraint should be used or removed, and that there was no documentation that a less restrictive intervention had been attempted before use of the restraint on the resident's hands.
Failure to Invite Residents and Families to Care Conferences
Penalty
Summary
The facility failed to ensure residents and resident representatives were invited to care conference meetings for two residents reviewed for care planning. Resident #8 was admitted with diagnoses including Parkinsonism, dementia, type 2 diabetes mellitus, hypertension, depression, and anxiety, and a quarterly MDS showed moderate cognitive impairment. Quarterly care conference notes dated 11/26/25 and 02/19/26 showed the resident was not present at the meetings, and there was no documentation that the resident had been invited or had refused to attend. During interview, Resident #8 stated she was not invited to attend her care conference meetings, and the SW stated she coordinated care plan meetings and had no documentation that Resident #8 had been invited. Resident #25 was admitted with diagnoses including dementia, COPD, emphysema, and CHF, and a quarterly MDS showed low cognitive function. The family stated they had not been invited to a care conference for a long period of time. The care conference note dated 12/11/25 showed nursing, dietary, social work, and activities attended, but no family was present. Social service notes from 06/01/25 through 02/24/26 did not document that family had been invited to care plan conferences, and the LSW confirmed the family of Resident #25 was not invited and that she failed to document when families were invited to care conferences.
Failure to Follow Bowel Protocol
Penalty
Summary
The facility failed to follow its bowel protocol for a resident admitted with Alzheimer's disease, carotid stenosis, anxiety, heart disease, a recent fall with nondisplaced clavicle fracture, and Meniere's disease. The resident was cognitively impaired and had physician orders for Tramadol, Miralax daily, Colace twice daily, Milk of Magnesia (MOM) as needed, and bisacodyl suppository as needed for constipation. The bisacodyl suppository order was placed on 02/24/26. Review of the bowel movement log showed no documented bowel movements for six days, from 02/18/26 through 02/23/26. Although the facility's bowel program called for MOM 30 ml after three days without a bowel movement, and the DON stated that residents already on bowel aides should receive MOM 30 ml after six days without a bowel movement, the MAR showed that MOM was not administered for the six-day absence of bowel movement. The DON verified that the resident had no bowel movement for six days and that MOM was not given per the facility bowel protocol. The facility policy stated that resident records are to be reviewed daily for adequate bowel elimination and that appropriate interventions and/or medications are to be provided as ordered.
Incomplete Communication With Dialysis Center
Penalty
Summary
The facility failed to ensure consistent communication occurred between the facility and the dialysis center for a resident who received hemodialysis. Resident #12 was admitted with diagnoses of end stage renal disease and dependence on renal dialysis, had impaired cognition on the quarterly MDS assessment, and received hemodialysis offsite three times weekly on Mondays, Wednesdays, and Fridays. The care plan identified the need for hemodialysis related to renal failure, but no interventions were in place regarding coordination of care with the hemodialysis clinic. Review of the facility’s Outpatient Dialysis Assessment forms showed multiple instances of incomplete or missing communication. The facility did not complete the top portion of the form on several dates, the dialysis clinic did not complete the bottom portion on one date, and no form was available for some dialysis trips. The DON confirmed several of the forms were incomplete. The facility’s policy stated the general medical nurse should keep a dialysis log containing pertinent information from the dialysis center, and the facility’s contract with the hemodialysis center required that appropriate medical, social, administrative, and other pertinent information accompany the resident to the HD center to facilitate coordination of care.
LPN Did Not Apply Ordered Lidocaine Patches
Penalty
Summary
The facility failed to ensure licensed nurses applied lidocaine patches for pain for one resident (#57) reviewed for pain management. The resident was admitted with diagnoses including pain in both knees, osteoarthritis, and anxiety. The MDS dated 12/07/25 showed impaired cognition and dependence on staff for chair-to-bed transfers. A physician order dated 01/27/26 directed Lidocaine External Patch 4% to be applied to both knees once daily for osteoarthritis. During observation and interview on 02/23/26, the resident was seen in a wheelchair and stated she had pain in both knees and that the pain patches on her knee were rolling up under her pants. The resident showed that the left knee patch was rolled up above the knee and removed it, revealing it had been dated 02/23/26 and initialed by an LPN. The CNA stated she applied the lidocaine patches after the nurse left them at bedside, and the LPN confirmed she did not apply the patches because it was a very busy morning. The facility policy stated only persons licensed or permitted by the state to prepare, administer, and document medications may do so.
Significant Medication Error Involving Crushing Potassium
Penalty
Summary
The facility failed to ensure a resident was free from a significant medication error. Resident #67 had diagnoses including Parkinson's disease, dysphagia, hypokalemia, cardiomegaly, hypertension, and hemiparesis and hemiplegia following cerebral infarction, and the quarterly MDS indicated mild cognitive impairment. A physician order directed potassium chloride extended release 20 MEQ, two tablets by mouth daily for hypokalemia, and there were no orders to crush medications. The MAR showed an LPN administered the resident's potassium chloride extended release tablets on multiple occasions in February, and progress notes did not document any change in condition during that period. During observation of medication administration, the LPN placed several medications, including two tablets of potassium chloride extended release 20 MEQ, into a medication crusher and stated she always crushed the resident's potassium because he had difficulty swallowing. After surveyor intervention, the potassium was not crushed, but the resident was then given the crushed medications along with two whole potassium chloride extended release tablets and omeprazole in applesauce. The resident had difficulty swallowing the whole medications and required several additional spoonfuls of applesauce. RN verification confirmed nurses should not crush potassium, and the NP stated she had not been notified that the resident had difficulty swallowing medications. The facility pharmacy document listed potassium chloride extended-release as a do not crush medication, and the facility policy stated medications should only be crushed when appropriate per medication guidelines and physician orders.
Failure to Arrange Requested Dental Care
Penalty
Summary
The facility failed to arrange routine dental care visits for one resident who was admitted with dementia, COPD, emphysema, and coronary artery disease and was dependent on staff for oral hygiene care. The resident’s care plan identified him as at risk for altered oral/dental status related to cognitive loss and stated that dental exams were to occur as warranted or desired by the resident. The resident’s outside services form showed that family consent for preventative dental services was given, but the medical record showed no dental care had been received after that consent was signed. The resident’s family stated they had requested dental care and the facility failed to arrange the services, and the LSW confirmed the facility had failed to arrange preventative dental appointments per family request. The facility policy stated social services was to coordinate dental visits and email add-on needs to the dental provider.
Failure to Assess and Mitigate Bed Rail Entrapment Risks Results in Resident Death and Immediate Jeopardy
Penalty
Summary
The facility failed to thoroughly assess residents for the risk of entrapment when utilizing bed rails, particularly when used in combination with alternating pressure mattresses (APMs). The assessment process did not include compressing the APM to measure the potential gap between the mattress and the side rail, nor did it address the medical needs to be met by bed rail use, the risks associated with bed rails and how these would be mitigated, or alternatives that were attempted or considered. Documentation was lacking regarding any attempts to use alternatives prior to installing side rails for multiple residents. The Siderail Safety Questionnaire used by the facility did not capture these critical elements, and there was no evidence in the medical records that these assessments or considerations were made for the residents reviewed. One resident, who was severely cognitively impaired, dependent on staff for activities of daily living, and required a mechanical lift for transfers, was found deceased with his head wedged between the APM and the right-side grab bar rail, and his lower body on the floor mat next to the bed. The coroner determined the cause of death to be asphyxia due to neck compression from being wedged between the safety rail and mattress. Observations of the bed after the incident revealed significant gaps between the compressed APM and the side rail, which were not accounted for in the facility's assessment process. The facility's practice was to measure gaps only when the resident was lying on the bed, not when the bed was unoccupied or when the mattress was compressed, leading to unrecognized hazards. Additional residents were also found to be at risk due to similar failures in assessment and documentation. For each of these residents, there was no evidence that alternatives to side rails were attempted or considered, and the Siderail Safety Questionnaire did not include required information about medical needs, risk mitigation, or alternative interventions. Observations and interviews confirmed that gaps between the APM and side rails exceeded safe limits when the mattress was compressed, and staff were unaware of the need to assess these conditions. These deficiencies resulted in Immediate Jeopardy and serious harm, including death for one resident, and placed others at risk for entrapment.
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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.
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Oak Harbor
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Edgewood Manor Rehabilitation & Healthcare Center | 10.8 mi | ★★★★★ | 0 | 0 |
| Elmwood Assisted Living & Skilled Nursing Of Fremo | 11.7 mi | — | 0 | 0 |
| Genoa Retirement Village | 11.8 mi | ★★★★★ | 14 | 0 |
| Parkview Care Center | 11.8 mi | ★★★★★ | 13 | 0 |
| Valley View Health Campus | 12.1 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.