Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Manor Nrsg & Rehab Ctr during CMS and state inspections, most recent first.
A resident with recent right hip surgery, poor standing balance, and an inability to pivot was evaluated by PT, who recommended use of a Sara Steady or sit‑to‑stand lift for all transfers. This recommendation was not converted into orders or added to the care plan, and there was no written communication process to ensure nursing staff were aware of the change. Despite the resident’s increased dependence for transfers, two CNAs later performed a manual two‑person transfer from wheelchair to recliner using an under‑arm lifting technique without a gait belt. During the transfer, the resident’s feet slid, she became "dead weight," and staff bore her weight under her arms, hearing a loud pop from the right shoulder. The resident developed pain and limited ROM, and subsequent imaging showed an acute angulated fracture of the humeral neck. The DON and therapy staff confirmed that a mechanical stand‑assist device and gait belt should have been used and that the facility had no transfer policy, leading to the unsafe transfer and resulting injury.
A resident with cognitive impairment and behavioral issues was verbally abused by an LPN, who yelled at the resident to "shut up" during a behavioral episode in the dining room. The incident was witnessed by a CNA and confirmed through staff and resident interviews. The LPN admitted to possibly making the statement and continued working after the event, contrary to facility policy. The facility was cited for not ensuring the resident was free from verbal abuse.
A resident with severe cognitive impairment and a history of falls was placed in a new wheelchair with a harness and seatbelt, but staff used these devices without proper assessment, physician orders, or adequate training. There was confusion among staff and family about when the harness should be used, and inconsistent application led to a red mark on the resident's neck. The facility did not follow its policy requiring interdisciplinary assessment before using restraints.
A resident with cognitive impairment and multiple diagnoses began screaming during lunch. A CNA attempted to calm the resident, but an LPN yelled at the resident to "shut up" and removed her from the dining area. The CNA did not immediately report the alleged verbal abuse to supervisory staff as required by policy. The administrator confirmed the delay in reporting and the failure to follow procedures for immediate notification and staff removal.
The facility failed to maintain a safe environment in the resident smoking area, with cigarette butts improperly discarded on the ground instead of in a fireproof container. Leaves were also present, increasing fire risk. The facility's smoking policy did not address proper disposal, and the staff policy requiring use of a metal ashtray was not followed.
A resident with multiple diagnoses, including dementia and Alzheimer's, reported grievances about personal care provided by a CNA, which were not addressed promptly by the facility. The resident felt the care was rough and perceived it as abusive. Despite the grievances being documented and submitted to the DON, they were not addressed in a timely manner, leading to a deficiency.
A resident with multiple medical conditions reported verbal abuse by a CNA during a shower when her face was washed against her wishes. The resident felt verbally abused when the CNA told her to report the incident. The facility's investigation found no physical injuries but noted the resident's claim of verbal abuse, highlighting a failure to respect resident preferences and ensure protection from abuse.
The facility failed to provide written summaries of baseline care plans to two residents within 48 hours of admission. One resident, with multiple diagnoses including fractures and diabetes, and another with conditions such as malignant neoplasm and heart failure, did not receive the required documentation. Both the residents and the DON confirmed the absence of these summaries.
The facility failed to revise care plans timely for two residents, leading to outdated interventions. A resident with multiple diagnoses was incorrectly noted to need a smoking apron, while another with recurrent UTIs had unchanged care plans despite ongoing infections. Interviews revealed a lack of adequate investigation and updates to address these issues.
A resident with multiple health conditions did not receive necessary assistance with oral care as per their care plan. Despite being dependent on staff for oral hygiene, there was no documented evidence of oral care on several dates. Observations confirmed dental buildup, and a CNA failed to report a refusal of care. The DON acknowledged the lack of documentation and noted the removal of oral care tasks from CNA duties.
The facility failed to comprehensively assess and treat non-pressure related skin issues for two residents. One resident with a history of ovarian cancer had an abdominal wound that was not consistently monitored, while another resident with cognitive impairment had a bruise with an open area that lacked proper documentation and treatment. Staff interviews revealed non-adherence to the facility's skin assessment policy.
A facility failed to apply splints and braces as ordered for a resident with limited range of motion due to conditions like Parkinsonism. The resident's care plan required daily application of wrist braces and finger splints, but these were inconsistently documented and applied. Staff interviews revealed confusion about the application process, with CNAs responsible but lacking clear instructions. The DON acknowledged inaccuracies in the range of motion assessment and missing therapy notes, contributing to the oversight.
A resident with severe cognitive impairment and a history of falls did not have fall prevention interventions implemented as per their care plan. Observations revealed missing dycem in the wheelchair and bed, and no signs in the room. Staff interviews confirmed these deficiencies, highlighting a lapse in the facility's fall prevention policy.
The facility did not date multi-dose insulin pens when first accessed, affecting two residents. An LPN confirmed the oversight, and the DON stated that all insulin should be dated upon first use, as per facility policy.
The facility failed to maintain complete psychiatric and medical records for two residents, affecting their care documentation. One resident's records lacked psychiatrist notes for several visits, while another resident's records were missing notes for multiple psychiatric visits and a primary provider visit. The facility contacted the respective offices to obtain the missing documentation.
A resident was prescribed antibiotics for a UTI despite not meeting the criteria for treatment. The resident, with a history of UTIs and recent surgery, was given Doxycycline for infection prevention. A urinalysis later showed no UTI, but Nitrofurantoin was still ordered. An LPN acknowledged the criteria were not met and failed to communicate this to the physician. The facility's antibiotic stewardship policy lacked guidance on prophylactic antibiotic use.
The facility did not post daily nurse staffing information, with the last update being three days old. Business Office Personnel confirmed the outdated posting and was unaware of who should update it, potentially affecting all 62 residents.
A facility failed to provide a bed hold notice to a resident who was hospitalized for a right hip fracture. The resident, with multiple medical conditions, was transferred to the emergency room for surgical repair. Although a discharge and transfer notice was signed by the resident's spouse, no documentation of a bed hold notification was found. A medical specialist stated that such notices were only given to Medicaid recipients.
Improper Manual Transfer Without Implementing PT Recommendations Leads to Humerus Fracture
Penalty
Summary
The facility failed to ensure a resident was transferred safely in accordance with physical therapy recommendations and safe transfer practices, resulting in an arm fracture. The resident had a history of significant orthopedic issues, including a surgically repaired right femur neck fracture and a prior nondisplaced fracture of the right humerus, along with diagnoses such as heart failure, kidney disease, and hyperlipidemia. Following a fall at home on Easter that caused a right hip fracture requiring surgical repair, the resident was readmitted with orders for weight bearing as tolerated to the right lower extremity and with hospital instructions that included no pivoting, no bending the hip beyond 90 degrees, and avoiding low chairs. A physical therapy evaluation on 04/10/26 documented that the resident had poor standing balance, was unable to pivot, and recommended use of a Sara Steady or sit‑to‑stand lift for transfers. However, this recommendation was not converted into physician orders or incorporated into the resident’s care plan, and there was no written communication process between therapy and nursing to ensure implementation of new transfer recommendations. At the time of the incident, the resident’s functional status had declined compared to earlier assessments. The discharge‑return anticipated MDS showed that the resident was now dependent on staff for sit‑to‑stand, bed/chair transfers, toilet transfers, and tub/shower transfers, and the walking section was skipped, indicating increased dependence. Despite this, the active transfer order in the chart had been updated only later to “transfer with two assistance and sit to stand,” and staff continued to perform manual transfers. On 04/12/26, two CNAs attempted to transfer the resident from a wheelchair to a recliner using an under‑arm lifting technique, with one CNA on each side hooking their arms under the resident’s arms. No gait belt was used during this transfer, and the CNAs reported that there was no gait belt available in the room. The resident, who was known by staff to have a history of not bending her legs or assisting with pushing up during transfers, began to slide, panicked, and became “dead weight,” causing staff to bear her full weight under her arms. During this improper manual transfer, both CNAs reported hearing a loud crack or pop from the resident’s right shoulder area, and one CNA felt the shoulder move up as if it dislocated. The resident immediately experienced pain, numbness, and limited range of motion in the right upper extremity. Initial x‑ray of the right shoulder showed no acute fracture or dislocation, but the resident continued to have pain and limited range of motion, and subsequent imaging of the right humerus and surrounding structures the next day revealed an acute mildly angulated fracture of the humeral neck. The DON and therapy staff later confirmed that the resident should have been transferred with a Sara Steady or sit‑to‑stand mechanical lift per the PT’s 04/10/26 recommendation and that a gait belt should have been used for all transfers. The DON also confirmed that the facility had no transfer policy and that she was unaware of the PT’s recommendation until after the incident, as the facility relied on verbal communication in morning meetings and had no written process to ensure therapy recommendations were implemented. These actions and omissions led to the resident being transferred manually without a gait belt and contrary to therapy recommendations, resulting in the humeral fracture. The facility’s internal investigation documented that the root cause of the injury was an unsuccessful transfer when the resident began to slide and staff had to bear all of her weight under her arms. CNA interviews corroborated that they used the under‑arm technique instead of a gait belt and were unaware of the PT’s recommendation for a mechanical lift. The DON confirmed that staff on the date of the incident should have been using a stand‑assist mechanical lift and a gait belt for transfers, and that there was no facility policy on transfers at the time. The survey findings concluded that the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents, as evidenced by the improper transfer that caused the resident’s humeral fracture.
Failure to Protect Resident from Verbal Abuse by Staff
Penalty
Summary
A deficiency occurred when a resident with cognitive impairment and multiple psychiatric diagnoses, including dementia, anxiety, bipolar disorder, and schizophrenia, was subjected to verbal abuse by a staff member. The resident, who had a history of yelling behaviors, began screaming in the dining room while other residents were present. During this episode, a Certified Nursing Assistant (CNA) called out the resident's name in an attempt to calm her, but a Licensed Practical Nurse (LPN) then loudly yelled at the resident to "shut up." The LPN subsequently removed the resident from the dining room to the common area, and then to her room, where she was fed by the CNA. The incident was witnessed by the CNA, who reported it to a Registered Nurse (RN). The facility's investigation included statements from the involved staff and other residents. The LPN admitted she may have told the resident to "shut up" and described feeling overwhelmed by the situation. Other staff and residents confirmed hearing yelling from the staff member, though not all could specify what was said. The facility's policy defined verbal abuse as the use of disparaging or derogatory language within hearing distance of a resident, regardless of their ability to comprehend. The facility's investigation found that the LPN continued to work after the incident until the end of her shift, contrary to policy, which requires staff involved in possible abuse incidents to be removed from duty pending investigation. The administrator acknowledged the LPN's behavior as unprofessional but did not initially consider it abuse, citing a lack of negative outcome for the resident. The deficiency was cited for failure to protect the resident from verbal abuse as required by regulation.
Failure to Ensure Proper Assessment and Training Before Use of Wheelchair Restraint
Penalty
Summary
The facility failed to ensure that a resident was not restrained in a wheelchair without adequate training, assessments, and physician orders. The resident, who had diagnoses including dementia, Down syndrome, severe cognitive impairment, and a history of falls, was provided with a new custom-fitted wheelchair equipped with a seatbelt and harness. The harness and seatbelt were intended to aid in positioning and prevent falls, but their use was not properly assessed or ordered prior to implementation. Staff began using the harness and seatbelt immediately after the wheelchair's arrival, despite not having received comprehensive training or clear guidance from therapy or the interdisciplinary team. There was confusion among staff regarding when and how the harness should be used, with some staff applying it routinely and others only in specific situations such as during meals or when the resident was leaning significantly. The resident's family expressed conflicting wishes about the use of the harness, at times requesting its use and at other times objecting to it, particularly after observing a red mark on the resident's neck. Documentation and interviews revealed that staff were not uniformly educated on the proper application of the harness, and therapy staff were not present for the initial fitting or evaluation of the wheelchair. Orders and assessments for the use of the harness and seatbelt were completed only after their use had already begun. The lack of a coordinated assessment and training process led to inconsistent and potentially unsafe application of the harness, resulting in physical signs of harm such as a red mark on the resident's neck. Staff statements indicated uncertainty about whether the harness constituted a restraint and how it should be used, and there was no clear documentation or communication regarding the intended protocol. The facility's own policy required an interdisciplinary assessment and consideration of less restrictive alternatives before implementing restraints, which was not followed in this case.
Failure to Immediately Report Alleged Verbal Abuse by Staff
Penalty
Summary
The facility failed to ensure that an allegation of verbal abuse by staff towards a resident was immediately reported as required. The incident involved a resident with cognitive impairment, hemiplegia, hemiparesis, dementia, anxiety, bipolar disorder, and schizophrenia, who exhibited verbal behaviors. During a lunch period, the resident began screaming in the dining room. A CNA called the resident's name in an attempt to calm her, but an LPN then yelled at the resident to "shut up" in front of others. The LPN subsequently removed the resident from the dining room to a common area and then to her room, where the CNA fed her lunch. The CNA reported the incident to a registered nurse, but not immediately, as required by facility policy. The facility's investigation included written statements from both the CNA and LPN, with the LPN acknowledging she may have told the resident to "shut up" and describing the ongoing disruptive behavior. The administrator confirmed that the allegation was not reported immediately and that facility policy requires immediate reporting of abuse allegations to the administrator or designee, with staff involved to be removed from the facility pending investigation.
Improper Disposal of Cigarette Butts in Smoking Area
Penalty
Summary
The facility failed to maintain a safe and clean environment in the resident smoking area, as observed by surveyors. Several cigarette butts were found discarded improperly on the concrete pad and in the stones by the building, rather than in the designated fireproof container. Leaves were also present in the area, posing a potential fire hazard. Housekeeper #201 confirmed that the cigarettes were not discarded properly. The facility's undated Smoking/Electronic Cigarettes policy did not address the proper disposal of cigarettes, while the Staff Smoking policy required cigarettes to be discarded in a metal self-closing ashtray, which was not adhered to in this instance.
Failure to Address Resident Grievances Timely
Penalty
Summary
The facility failed to address a resident's grievances regarding personal care in a timely manner, which led to a deficiency. Resident #5, who was admitted with multiple diagnoses including schizophrenia, dementia, and Alzheimer's, expressed concerns about the care provided by CNA #102. The resident reported that the CNA did not assist with hygiene care after bowel movements unless prompted and used a disrespectful tone. Additionally, the resident felt that the CNA was rough during care, which was perceived as abusive. These grievances were communicated to the staff, but the facility did not promptly address them. The resident's complaints were documented in an employee disciplinary conference report by RN #104 and submitted to the DON. However, the DON did not address the concerns immediately due to being on vacation and not having seen CNA #102. The facility's grievance process was not followed effectively, as the resident's concerns were not resolved promptly, leading to the initiation of a Self-Reported Incident after the resident reported the abuse to the surveyor.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to protect a resident from verbal abuse by a staff member, specifically a Certified Nursing Assistant (CNA). The incident involved a resident with multiple medical conditions, including hypertensive heart disease, depression, and anxiety disorder, who had intact cognition. During a shower, the resident became upset when a CNA washed her face with soap, which she did not want. The resident reported feeling verbally abused when the CNA told her to go ahead and report her complaint. The facility's investigation revealed conflicting accounts from staff members involved. The resident claimed that the CNA scrubbed her face too hard and ignored her requests to stop, leading to a verbal exchange where the CNA allegedly told the resident to report her if she wished. The Director of Nursing (DON) assessed the resident and found no physical injuries but noted the resident's claim of verbal abuse. Interviews with other residents and staff did not corroborate any pattern of abuse by the CNA in question. The facility's policy on abuse prevention defines abuse as the willful infliction of injury or intimidation causing mental anguish. Despite the lack of physical evidence, the resident's perception of verbal abuse and the staff's failure to respect her preferences during care led to the deficiency. The incident highlights a breakdown in communication and adherence to resident preferences, resulting in a failure to ensure the resident's right to be free from abuse.
Failure to Provide Baseline Care Plan Summaries
Penalty
Summary
The facility failed to provide a written summary of the baseline care plan to residents and/or their representatives within 48 hours of admission, affecting two residents. Resident #61, admitted with multiple diagnoses including fractures, depression, and diabetes, did not receive a summary of her baseline care plan. Her representative confirmed not recalling receiving such a document, and the Director of Nursing (DON) was unable to find evidence that the summary was provided. Similarly, Resident #165, who was admitted with complex medical conditions such as malignant neoplasm, sepsis, and heart failure, also did not receive a summary of her baseline care plan. The resident herself did not recall receiving the document, and the DON confirmed the absence of evidence that the summary was provided. These findings indicate a lapse in the facility's process of ensuring that residents and their representatives are informed of the initial care plans upon admission.
Failure to Revise Care Plans Timely for Residents
Penalty
Summary
The facility failed to ensure comprehensive care plans were revised in a timely manner, affecting two residents. Resident #10, who had multiple diagnoses including hemiplegia and major depressive disorder, was noted to have a care plan indicating the need for a smoking apron due to a previous incident where he dropped a cigarette on himself. However, observations and interviews revealed that the resident was not using a smoking apron, and the Director of Nursing (DON) confirmed that the care plan was incorrect as the resident had been reassessed and deemed safe without the apron. Resident #61, admitted with diabetes mellitus and a urinary tract infection (UTI), had an acute care plan addressing the UTI with interventions such as administering medications and monitoring for symptoms. Despite recurrent UTIs and multiple antibiotic treatments, the care plans remained unchanged with the same interventions. Interviews with the DON and a Registered Nurse (RN) revealed that the interdisciplinary team had not adequately addressed the recurrent UTIs or investigated additional preventative measures, and the interventions in place had not been effective in preventing further infections. The deficiencies in care planning for both residents highlight a lack of timely updates and revisions to care plans based on the residents' current conditions and needs. The facility's failure to revise care plans appropriately resulted in outdated interventions that did not reflect the residents' current health status or address ongoing health issues effectively.
Failure to Provide Oral Care Assistance
Penalty
Summary
The facility failed to ensure that a resident received necessary assistance with oral care, as required by their care plan. The resident, who had multiple medical conditions including diabetes, severe protein-calorie malnutrition, and heart disease, was dependent on staff for oral care. Despite the care plan indicating the need for assistance with oral hygiene twice daily, there was no documented evidence that oral care was provided on numerous dates over a month-long period. Observations confirmed the resident had buildup on her teeth, and the resident's battery-operated toothbrush appeared unused. The CNA reported that the resident had refused oral care on one occasion but did not document or report this refusal to the nurse. The Director of Nursing confirmed the lack of documentation for oral care on the specified dates and noted that the task for oral care had been removed from the CNA's charting duties due to the volume of documentation required. The facility's policy stated that residents unable to perform activities of daily living independently should receive necessary services, and staff should address any resistance to care by identifying underlying causes rather than assuming refusal.
Failure to Monitor and Treat Non-Pressure Skin Issues
Penalty
Summary
The facility failed to ensure comprehensive assessment and routine treatment for residents with non-pressure related skin issues, affecting two residents. Resident #165, with a history of ovarian cancer and a fistula, had an abdominal wound that was not consistently monitored or documented after initial assessments. Despite recommendations from a wound nurse practitioner for daily dressing changes and monitoring, there was no evidence of comprehensive assessments by nurses after a certain date, and the wound nurse was not following the case. Resident #51, who was severely cognitively impaired and at risk for injury, had a bruise with an open area on the right elbow that was not properly documented or treated. Although the area was initially cleaned and covered, there were no subsequent treatment orders or documentation of monitoring. The facility's standard procedure for skin impairments, which includes notifying the wound nurse and implementing treatment orders, was not followed. Interviews with facility staff, including the DON and LPNs, revealed a lack of adherence to the facility's policy on skin assessments and treatment initiation. The DON confirmed the absence of treatment orders for Resident #51's skin issue, and the wound nurse practitioner noted the need for ongoing monitoring of Resident #165's wound, which was not being done. These deficiencies highlight a failure in the facility's processes for managing non-pressure related skin impairments.
Failure to Apply Splints and Braces as Ordered
Penalty
Summary
The facility failed to ensure that splints and braces were applied according to the physician's orders and the resident's care plan, affecting a resident with limited range of motion due to conditions such as Parkinsonism and chronic pain. The resident's medical records indicated orders for wrist braces to be applied daily and finger splints for boutonniere deformities, but these were not consistently documented or applied. Observations and interviews revealed that the resident often did not have the splints in place, and staff were unaware of the specific requirements for their application. The wrist splint was found misplaced, and the finger splints were initially missing, indicating a lack of adherence to the care plan. Interviews with staff, including CNAs and LPNs, confirmed that there was confusion regarding the application of the splints, with the CNAs responsible for applying them but lacking clear documentation or instructions. The task tab for CNAs did not include the splints, and the TAR did not list the finger splints, leading to inconsistent application and documentation. The Director of Nursing acknowledged the inaccuracies in the range of motion assessment and the lack of access to previous therapy notes, which contributed to the oversight in the resident's care.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement fall prevention interventions for a resident at risk for falls, as outlined in the resident's care plan. The resident, who had severe cognitive impairment and required assistance with activities of daily living, had experienced multiple falls. The care plan included interventions such as keeping the call light within reach, monitoring the environment for hazards, and using dycem under the bed pad and wheelchair. However, during an observation, it was noted that the dycem was not present in the resident's wheelchair or bed, and no signs were posted in the resident's room as specified in the care plan. Interviews with facility staff, including a CNA and an RN, confirmed the absence of these interventions. The RN acknowledged that the care plan needed updating to reflect current fall interventions. The Director of Nursing described the facility's process for fall investigations, which included nurse assessments, root cause analysis, and updating care plans. Despite these procedures, the necessary interventions were not in place for the resident, indicating a lapse in the implementation of the facility's fall prevention policy.
Failure to Date Multi-Dose Insulin Pens
Penalty
Summary
The facility failed to ensure that multi-dose insulin pens were dated when first accessed, as required by their policy. During an observation of the rehabilitation hall medication cart, it was found that two insulin pens, belonging to two residents, were not dated. These pens were a Glargine Solostar 100-unit pen for one resident and a Tresiba 200-unit pen for another. An LPN confirmed that the pens were not dated, and the Director of Nursing stated that all insulin should be dated when first accessed. The facility's policy, dated 06/02/15, mandates that multi-dose pens be dated and initialed by the first user.
Incomplete Psychiatric and Medical Records for Residents
Penalty
Summary
The facility failed to maintain complete medical records for two residents, affecting their psychiatric care documentation. Resident #5, who was admitted with multiple diagnoses including schizophrenia, dementia, and Alzheimer's disease, was seen by a psychiatrist on several occasions. However, the medical records lacked psychiatrist notes for visits on 09/25/24, 10/23/24, and 11/20/24. The Director of Nursing confirmed the absence of these notes and had contacted the psychiatrist's office to obtain them. An LPN also confirmed the missing notes, stating that the psychiatrist's office had not yet typed the notes for the latter two dates. Similarly, Resident #18, with diagnoses such as Parkinsonism, bipolar disorder, and dementia, was seen by psychiatry multiple times throughout the year. However, the medical records did not contain psychiatrist notes for any of these visits. The facility contacted the psychiatry office, which then provided some of the missing notes, but the notes for 10/23/24 and 11/20/24 remained unavailable. Additionally, Resident #18 had not been seen by her primary provider since September 2024, and the facility was awaiting the faxed progress notes from a Nurse Practitioner visit in November 2024.
Inappropriate Antibiotic Use for Resident
Penalty
Summary
The facility failed to ensure antibiotics were utilized only when medically necessary, affecting one resident reviewed for antibiotic use. Resident #61, who had a history of urinary tract infection, a fracture of the left humerus, and diabetes mellitus, was admitted to the facility and later sent to the hospital for a fracture of the proximal right femur. Upon returning to the facility, the resident was prescribed Doxycycline for post-operative infection prevention. However, a subsequent urinalysis and culture revealed that the resident did not meet the criteria for a urinary tract infection, as the urine culture showed 40 to 50,000 CFU/ml of enterococcus faecium, which did not warrant antibiotic treatment according to the facility's guidelines. Despite the laboratory results indicating no UTI, the nurse practitioner ordered Nitrofurantoin for five days. LPN #106 acknowledged that the resident did not meet the criteria for antibiotic therapy and failed to document any communication with the nurse practitioner or doctor regarding the results and the infection criteria not being met. The facility's antibiotic stewardship policy did not address the use of prophylactic antibiotics, and the infection control nurse was responsible for evaluating new admissions against McGeer's criteria. The policy required communication with the physician if antibiotics were started before test results, but this protocol was not followed in this case.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted daily, as required. On January 27, 2025, at 8:59 A.M., it was observed that the only staffing information available was dated January 24, 2025. Business Office Personnel #157 confirmed that the posted information was outdated and was unaware of who was responsible for updating the staffing information. This oversight had the potential to affect all 62 residents residing in the facility.
Failure to Provide Bed Hold Notice for Hospitalized Resident
Penalty
Summary
The facility failed to provide a bed hold notice to Resident #61, who was hospitalized, which is a requirement when a resident is transferred to a hospital or goes on therapeutic leave. Resident #61, who had been admitted with conditions including vitamin D deficiency, disorders of bone density and structure, diabetes mellitus, and a displaced fracture of the surgical neck of the left humerus, was transferred to the emergency room for admission and surgical repair after an x-ray indicated a right hip fracture. Although a discharge and transfer notice was signed by the resident's spouse, there was no documentation found in the medical record indicating that a written bed hold notification was provided to the resident or her responsible party. An interview with a medical specialist revealed that bed hold notices were only provided to residents receiving Medicaid.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 165 citations issued within 25 miles in the last 12 months — including the 1 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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Illustrative
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Nursing homes near Newcomerstown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lafayette Pointe Nursing & Rehab Ctr | 8.1 mi | ★★★★★ | 1 | 0 |
| Oak Pointe Nursing & Rehabilitation | 13.2 mi | ★★★★★ | 0 | 0 |
| Altercare Coshocton Inc. | 14 mi | ★★★★★ | 20 | 0 |
| Altercare Cambridge Inc. | 14.4 mi | ★★★★★ | 14 | 0 |
| Claymont Health And Rehabilitation | 14.6 mi | ★★★★★ | 6 | 0 |
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