Average — CMS composite of the measures below.
A standard survey is most likely before around August 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 during CMS and state inspections, most recent first.
Medications and biologicals were not securely stored when a nurse left an unlocked medication cart unattended and out of sight. Additionally, three medication cups with illegible labels and unidentified pills were found in the cart, having been prepared for residents who were not present. The nurse could not identify the medications or the intended recipients, and facility policy was not followed regarding medication preparation, administration, and cart security.
The facility did not ensure that food and beverages were served at palatable, attractive, and safe temperatures. A resident with multiple medical conditions received a cold, unappetizing meal, and confirmed that meals were often not timely or satisfactory. Observations showed that meal trays took nearly an hour to be distributed, and test tray temperatures were outside of safe ranges, contrary to facility policy. These issues had the potential to affect all residents on the involved units.
Surveyors found unsanitary conditions in the kitchen, including dirty equipment, utensils with food residue, and improper staff hygiene practices such as lack of appropriate hair restraints. An outside food sales representative also entered the kitchen and clean dish area without a hair cover, in violation of facility policy.
A resident with significant medical and cognitive impairments was found with a large, painful hematoma of unknown origin on the right forearm and was sent to the ED for evaluation. Despite facility policy requiring immediate reporting of such injuries to the SSA, no Self-Reported Incident was submitted, as confirmed by the DON and review of the EIDC system.
A resident with multiple medical conditions and impaired cognition was found with a large, painful hematoma on the forearm. The facility did not conduct or document a thorough investigation into the injury's cause, failing to interview staff or witnesses, including the roommate who had relevant information. This was not in accordance with the facility's abuse investigation policy.
A resident with multiple complex medical conditions did not receive pressure ulcer care as ordered due to an LPN's failure to timely and accurately transcribe a new wound care order, specifically omitting the application of calcium alginate. The error was not corrected for several days, resulting in care that was not consistent with physician instructions.
The facility did not ensure timely responses to monthly medication regimen review recommendations for two residents receiving psychotropic medications. In both cases, the pharmacist recommended trial dose reductions, but the CNP's responses were delayed by over a month, contrary to facility policy requiring prompt review and action by the next mandatory physician visit.
A resident with complex medical needs did not have their physician orders accurately updated after returning from the hospital, resulting in midodrine not being consistently administered before scheduled dialysis sessions as required. Facility staff confirmed the hospital's updated order was overlooked and not transcribed, leading to missed doses in accordance with the discharge instructions.
A nurse failed to perform hand hygiene and used improper sanitary practices while preparing and administering oral medications and a nasal spray to a resident with multiple diagnoses. The nurse touched potentially contaminated surfaces and dispensed pills directly into her unwashed hands, contrary to facility policy, before giving the medications to the resident.
A resident with diabetes and dementia had their dignity violated during medication administration. A nurse checked the resident's blood sugar and administered insulin without consent during lunch, lifting the resident's shirt in the dining room. This action was against the facility's policy and violated the resident's rights, as confirmed by the nurse and the DON.
A facility failed to follow its water management plan, resulting in Legionella exposure. Two residents tested positive for Legionella pneumonia, with one resident hospitalized and subsequently passing away. The facility did not promptly implement public health recommendations to restrict water usage or install filters, leaving residents at risk. Maintenance lapses and communication issues contributed to the deficiency.
The facility failed to maintain milk at a safe temperature during meal service, affecting multiple residents. Observations revealed milk temperatures above the safe limit, and staff interviews confirmed non-compliance with the facility's policy to keep milk cold using ice. Temperature checks showed milk was served at 57.6 to 62 degrees Fahrenheit, exceeding the required maximum of 41 degrees Fahrenheit.
A resident with multiple diagnoses, including a fractured ankle and morbid obesity, required a two-person assist for transfers and toileting. Despite this, an STNA transferred the resident without the required second staff member on multiple occasions, as confirmed by staff interviews and a self-reported incident.
Failure to Secure Medication Storage and Properly Label Prepared Medications
Penalty
Summary
Surveyors observed that medications and biologicals were not stored securely in the facility, as required by professional standards and facility policy. During continuous observation, a registered nurse left a medication cart unattended and unlocked, with the cart out of her line of sight. This allowed for the possibility of unauthorized access to medications. The nurse confirmed that she had left the cart unlocked while attending to a resident in another room. Additionally, during medication administration, three medication cups containing various pills with illegible labels were found in the top drawer of the medication cart. The nurse admitted to preparing these medications for residents who were not present in their rooms and placed the cups in the drawer to administer later, as she was behind schedule. She was unable to identify the medications or the intended residents for each cup. Facility policy requires medications to be prepared and administered one resident at a time, with immediate documentation, and for medication carts to be locked when not in direct view. Interviews with the DON and Regional Clinical Manager confirmed that these practices were not in accordance with facility policy.
Failure to Serve Palatable and Safe-Temperature Meals
Penalty
Summary
The facility failed to provide food and drink that was palatable, attractive, and at a safe and appetizing temperature for residents on two units. One resident, who had diagnoses including hemiplegia, type 2 diabetes, and generalized anxiety disorder, was observed receiving a breakfast meal that was not warm, with a dry egg on the sandwich and no detectable warmth from the plate. This resident confirmed in interviews that meals were not served in a timely manner and were not palatable or attractive. The resident's care plan included honoring food preferences and providing meals as ordered, with a goal to maintain adequate nutritional status. Further observations revealed that meal trays delivered to another unit took 55 minutes to be distributed after arrival, exceeding the facility's policy of a 20-minute delivery window. A test tray checked by the Dietary Manager showed that the barbecued chicken was at 21°F, and the carrots and potatoes were at 100°F, which did not meet the facility's guidelines for safe food temperatures. Facility policies required hot foods to be held at 135°F or above and cold foods at 41°F or below. These failures had the potential to affect all residents on the affected units, except for two who did not consume food from the kitchen.
Failure to Maintain Sanitary Food Service and Staff Hygiene
Penalty
Summary
Surveyors observed multiple sanitation and hygiene deficiencies in the facility's kitchen during a tour with dietary management staff. The plate warmer unit in the service line area was found to have orange and black particles, dust, and rust that could not be removed. A dome cover dispenser next to the plate warmer contained multiple food crumbs, dried food, and dried liquid marks both inside and outside, as well as on the domes themselves. Several hard plastic cups in the dishwasher crate were covered in a hard white dried powder, identified as lime stains. In the clean area where utensils and silverware were stored, metal bin dividers had visible crumbs and dust, and a pair of serving tongs hanging above the utensils had a dried white food substance. Additionally, the Dietary Manager was observed not wearing proper hair restraints, using only a baseball cap and lacking a beard cover, contrary to facility policy. An outside food sales representative was also seen entering the kitchen and clean dish area without a hair cover. These observations were confirmed by dietary management staff. The facility's policy requires food service employees to practice good personal hygiene and wear hair restraints that cover all hair, including beards longer than a quarter inch.
Failure to Report Injury of Unknown Origin to State Survey Agency
Penalty
Summary
The facility failed to report an injury of unknown origin to the State Survey Agency (SSA) as required by both regulation and facility policy. A resident with multiple complex medical conditions, including hemiplegia, chronic kidney disease, epilepsy, atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism, was found to have a large, painful hematoma with bruising on the right forearm during a medication pass. The resident, who was dependent on staff for most activities of daily living and had impaired cognition, was assessed and sent to the emergency department for evaluation at the physician's direction. Physician orders were subsequently written to monitor the injury and observe for signs of bleeding due to anticoagulant use. Despite the facility's policy requiring immediate reporting of injuries of unknown source to the SSA, review of the Electronic Information Dissemination and Collection (EIDC) system showed no evidence that a Self-Reported Incident (SRI) was submitted for this event. The Director of Nursing confirmed in an interview that the incident was not reported as required. The failure to report was identified during a review of medical records, staff interviews, and policy review, and affected one of two residents reviewed for abuse in a facility with a census of 120.
Failure to Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to thoroughly investigate an injury of unknown origin for a resident with significant medical conditions, including hemiplegia, chronic kidney disease, epilepsy, atrial fibrillation, mild cognitive impairment, and chronic pulmonary embolism. The resident, who was dependent on staff for most activities of daily living and had impaired cognition, was found with a large, painful hematoma on the right forearm during a medication pass. The resident was sent to the emergency department for evaluation, where the injury was attributed to a fall, but conflicting accounts were provided, including a statement from the resident's roommate suggesting the injury may have occurred while the resident was interacting with her overbed table. Despite facility policy requiring a timely and thorough investigation of all injuries of unknown source, including interviews with all involved persons and witnesses, the facility did not conduct or document such an investigation. The DON confirmed that no staff or resident interviews were performed, no witness statements were collected, and no staff education was completed regarding the incident. Additionally, the resident's roommate reported that staff did not ask her any questions about the injury, even though she had information about the resident's activities at the time. The facility's failure to follow its own abuse investigation policy resulted in a lack of documentation and assessment regarding the cause of the injury.
Failure to Timely Transcribe and Implement Pressure Ulcer Dressing Order
Penalty
Summary
Staff failed to provide care consistent with professional standards of practice by not timely and accurately transcribing a new physician order for a pressure ulcer dressing change for a resident. The resident, who had multiple significant diagnoses including sepsis, type one diabetes mellitus, encephalopathy, and chronic respiratory failure, was identified as having a pressure ulcer. During a wound assessment and care plan review, a new order was written by the wound physician specifying the use of collagen powder and calcium alginate for the left ischial tuberosity wound, to be applied daily and as needed. However, the order was not correctly transcribed by the LPN on the day it was written, specifically omitting the application of calcium alginate to the wound. This error was not identified or corrected until seven days later. The facility's policy requires licensed nurses to accurately transcribe and initiate physician orders, but this process was not followed in this instance. The resident's wound area did not increase during this period, but the care provided was not in accordance with the physician's instructions.
Delayed Response to Monthly Medication Regimen Reviews
Penalty
Summary
The facility failed to ensure timely responses to monthly medication regimen reviews (MRR) for two residents out of five reviewed for unnecessary medications. For one resident with severe cognitive impairment and multiple diagnoses, the pharmacist recommended a trial dose reduction of Trazadone and requested documentation in the progress notes regarding the necessity of continued therapy. However, the response from the certified nurse practitioner (CNP) addressing this recommendation was not documented until over a month later, well after the pharmacist's initial recommendation. Similarly, another resident with multiple chronic conditions and a history of psychiatric disorders was receiving scheduled antidepressant, antipsychotic, and antianxiety medications. The pharmacist recommended a trial dose reduction of Duloxetine, but the nurse practitioner's response to this recommendation was also delayed by more than a month. The Director of Nursing (DON) confirmed that pharmacy recommendations are provided to the prescribing physician, but acknowledged that the CNP did not respond to the November recommendations in a timely manner, contrary to facility policy requiring review and action by the physician by their next mandatory visit.
Failure to Accurately Reconcile and Transcribe Physician Orders After Hospital Admission
Penalty
Summary
The facility failed to ensure accurate reconciliation and transcription of physician orders following a hospital admission for a resident with multiple complex medical conditions, including end-stage renal disease, diabetes, and heart failure. After returning from the hospital, the resident's discharge summary included a change to the midodrine order, specifying that it should be administered twice daily as needed for low mean arterial pressure and specifically before each scheduled hemodialysis session on Mondays, Wednesdays, and Fridays. However, the facility did not update the resident's physician orders to reflect this change, and the medication was only listed as an as-needed order without the specific instruction for pre-dialysis administration. Review of medication administration records and dialysis communication forms showed that midodrine was not consistently administered prior to dialysis sessions as directed in the hospital discharge summary. Facility staff, including the DON and Regional Clinical Manager, confirmed that the updated order from the hospital was overlooked and not transcribed into the facility's orders. The facility's policy required licensed nurses to accurately transcribe and initiate physician orders, but this process was not followed, resulting in the resident not receiving midodrine as intended after hospital discharge.
Failure to Perform Hand Hygiene and Follow Sanitary Practices During Medication Administration
Penalty
Summary
A deficiency was identified when a registered nurse failed to perform hand hygiene prior to administering medications and did not follow proper sanitary practices during medication preparation. The nurse was observed touching multiple potentially contaminated surfaces, such as medication drawer handles, medication cards, and a computer mouse, before dispensing several oral medications directly into her unwashed hands. The medications were then placed into a medication cup and administered to a resident without the nurse performing hand hygiene before or after the process. The nurse also handled a nasal spray and provided it to the resident without conducting hand hygiene. The resident involved had a medical history including dysphagia, squamous cell carcinoma, and malignant neoplasm of the head, face, and neck, and was prescribed multiple oral medications and a nasal spray. Facility policy required hand hygiene before medication administration and prohibited touching medications or the inside of medication cups during preparation or administration. Both the nurse and facility leadership confirmed that the observed practices did not comply with facility policy.
Violation of Resident Dignity During Medication Administration
Penalty
Summary
The facility failed to maintain resident dignity during medication administration, specifically affecting a resident with type two diabetes mellitus, dementia without behavioral disturbance, and anxiety. The resident was observed during a lunch meal in the main dining room, where a registered nurse checked the resident's blood sugar and administered an insulin injection without obtaining consent. The nurse lifted the resident's shirt and injected insulin into the abdomen while the resident was eating, which was against the facility's policy and violated the resident's rights. Interviews with the registered nurse and the Director of Nursing confirmed that the actions taken were inappropriate and against the facility's medication administration policy. The nurse admitted to not seeking consent due to the resident's cognitive impairment, acknowledging the violation of the resident's rights. The facility's policy requires medication administration to adhere to professional standards and resident needs, which was not followed in this instance.
Failure to Implement Water Management Plan Leads to Legionella Exposure
Penalty
Summary
The facility failed to adhere to its water management plan, which led to an elevated risk of Legionella bacteria in the water system. The plan required semi-annual descaling of shower heads and weekly flushing of dead-end pipes, but these measures were not consistently implemented. This oversight resulted in the exposure of residents to Legionella bacteria, as evidenced by the cases of two residents who tested positive for Legionella pneumonia. One of these residents, who was admitted with conditions including chronic kidney disease and heart failure, experienced a change in condition characterized by labored breathing and fatigue, leading to hospitalization and subsequent death. The facility's failure to implement immediate protective actions following public health recommendations further exacerbated the situation. Despite guidance from the Local County Health Department to restrict water usage or install point-of-use filters, the facility did not take these steps promptly. This inaction left residents vulnerable to potential Legionella exposure, as the facility continued to operate without the necessary precautions in place. The lack of routine maintenance and monitoring of the water system, as outlined in the facility's Legionella prevention plan, contributed to the growth and spread of the bacteria. Interviews with facility staff and health department officials revealed a lack of compliance with established protocols. The Maintenance Supervisor admitted to not conducting the required weekly flushes of dead-end pipes and only performing descaling once, with no records of previous maintenance activities. The facility's Administrator expressed concerns about the impact of installing filters on water testing results, delaying the implementation of critical safety measures. These lapses in protocol and communication ultimately led to the deficiency, placing residents at risk of serious health outcomes.
Removal Plan
- Resident #100 was transferred to the hospital.
- Facility staff followed LCHD guidance in reviewing all resident's medical records who were diagnosed with pneumonia for the past three months.
- The DON was made aware an additional resident (Resident #118) tested positive for the Legionella urine antigen.
- Water filters on ice machines and water fountains were serviced and cleaned by Service Company #500 according to manufacturer guidelines and preventative maintenance agreement.
- Maintenance Supervisor #221 and Maintenance Staff #166 descaled faucets and shower heads and completed dead leg flushes.
- The LCHD collected data points for water temperatures, PH levels and chlorine levels.
- The DON/designee reviewed all current residents with a respiratory assessment with no new respiratory concerns identified.
- An additional seven water samples were obtained for Legionella testing by a third party (Water Treatment Company #600) initiated by the Administrator.
- Maintenance Supervisor #221, Maintenance Staff #166 and Maintenance Staff #311 were provided education by the Administrator regarding descaling and flushing dead legs per the facilities water management policy.
- Maintenance Supervisor #221/designee will audit water temperatures, chlorine levels and flush all dead legs two times a week for two months.
- The Water Management Committee (WMC) met to review the proposed issues and concerns from the Ohio Department of Health Survey.
- The DON/designee provided in-services to all staff, residents, and residents responsible parties regarding the water management program, Legionella screening symptoms, facility remediation measures, and the plan for continued water management.
- The DON/designee will complete daily respiratory monitoring assessments until the results of the water testing are received.
- The facility began utilizing bottled water.
- The facility engaged with Legionella Consultant #650 who reviewed the facility water management plan with the team and will provide 90-day point of use filters that will be installed facility wide.
- The DON/designee will complete audits three times a week regarding employee call-offs for four weeks for signs and any symptoms related to Legionella illness.
- 20 additional water samples were obtained by Legionella Consultant #650.
- Maintenance staff installed point of use filters on all water outlets (showers, sinks) in the facility.
Failure to Maintain Safe Milk Temperature During Meal Service
Penalty
Summary
The facility failed to ensure that milk served during meal service was maintained at a safe and palatable temperature, potentially affecting 56 residents who regularly consume milk. During an observation of breakfast meal service, it was noted that milk on residents' trays, including low-fat, 2%, and whole milk, was at 60 degrees Fahrenheit, which is above the safe serving temperature. A Certified Nursing Assistant confirmed the temperature but was unsure of the safe serving temperature for milk. Interviews with the Regional Culinary Director and Food Services Director revealed that the kitchen staff did not place milk on trays as per facility policy, which requires milk cartons to be placed in a bucket of ice on top of serving carts to keep them cold. Further observations during lunch service confirmed that the dietary staff did not follow the facility's policy, as milk was again placed on residents' trays without being kept cold. Temperature checks conducted by the Food Services Director and the surveyor showed milk temperatures ranging from 57.6 to 62 degrees Fahrenheit, confirming non-compliance with the facility's policy that requires cold foods to be served at no greater than 41 degrees Fahrenheit. The deficiency was investigated under Complaint Number OH00161708.
Failure to Provide Proper Assistance with Transfers and Toileting
Penalty
Summary
The facility failed to ensure that Resident #1 received proper assistance with transfers and toileting as per the care plan. Resident #1, who had multiple diagnoses including a fractured right ankle, foot drop, unsteadiness on feet, and morbid obesity, required a two-person assist for transfers and toileting. Despite this requirement, a State tested Nurse Aide (STNA) #202 transferred the resident to the bedside commode without the assistance of another staff member on multiple occasions. This was confirmed through medical record review, staff interviews, and a self-reported incident dated 04/01/24. The resident's care plan, dated 03/09/24, clearly indicated the need for a two-person assist for transfers and toileting. However, interviews with the Regional Director of Nursing and the Director of Nursing confirmed that STNA #202 did not follow this care plan. Additionally, a telephone interview with Resident #1 revealed that STNA #202 consistently transferred her without the required second staff member. This failure to adhere to the care plan put the resident at risk for falls and other accidents.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 838 citations issued within 25 miles in the last 12 months — including the 5 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
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Columbus Alzheimer's Care Ctr | 1.5 mi | ★★★★★ | 0 | 0 |
| Sapphire Rehabilitation And Care Center | 2.1 mi | ★★★★★ | 69 | 2 |
| Wesley Glen Health Services Corp | 2.4 mi | ★★★★★ | 1 | 0 |
| Crown Pointe Care Center | 2.9 mi | ★★★★★ | 1 | 0 |
| First Community Village Healthcare Ctr | 3.5 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.