Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rivers Edge Rehabilitation And Care during CMS and state inspections, most recent first.
Cleanliness and maintenance deficiencies were found in resident rooms and hallways. A resident’s room had dirt, dusty blinds, a hole in the window frame, and a soiled fall mat; two other residents had dirty rooms, broken or unaddressed room features, and malfunctioning fixtures including a light and toilet. Surveyors also observed missing handrail end caps that were covered with foam and black tape, creating an uncleanable surface.
Kitchen sanitation and food handling deficiencies were identified when a cook worked without a hair restraint while preparing food, handled ready-to-eat items with bare hands, and used a taped metal table surface for clean dishes. The Dietary Director acknowledged the improper handling of ready-to-eat food, and the Regional Dietary Director stated hair restraints were required at all times and that the taped surface could not be adequately cleaned.
Pest control and window screen deficiencies were observed after an open bathroom window without a screen was found in a resident room and an open, unscreened dining room window allowed a mosquito, a large bug, and a fly into the area during dinner. Five dining room windows lacked screens, and flies were also observed in the south hall and in an LPN office. The Maintenance Director and Administrator acknowledged that several screens were missing or damaged and that screens were required on all windows per policy.
Failure to timely report an abuse allegation involving a resident with respiratory failure. The resident reported that two CNAs injured the resident's back while assisting with repositioning in bed, and a staff note documented the resident screaming in pain and stating staff caused the pain. Staff said the allegation was reported to the charge nurse and noted for the RCM, but the DON/Administrator were not immediately notified and the state was not reported within the required time frame.
A resident with OSA, chronic respiratory failure with hypoxia and hypercapnia, and COPD had an inaccurate quarterly MDS that did not reflect continuous O2 or BiPAP use. The physician order showed continuous O2 at 2 L/min via NC or bled into the BiPAP, and the resident was observed using O2 and stated it was used continuously. The MDS Coordinator and DNS both acknowledged the MDS was coded inaccurately for O2 and BiPAP use.
Failure to Administer PRN Insulin per Order: A resident with DM had physician orders for PRN Insulin Lispro when CBG was greater than 400, but the DAR showed multiple elevated CBG readings without the PRN insulin being given. The record also lacked documentation that the CBG was rechecked after the high readings, and an RN verified there was no documentation of rechecks or PRN insulin administration.
Aspiration precautions were not followed for two residents with swallowing and aspiration risk concerns. One resident with dysphagia and confusion had conflicting aspiration instructions, and fluids were left within reach at the bedside despite 1:1 supervision being documented. Another resident with pneumonia and moderate cognitive impairment was ordered for 1:1 supervision for all eating and drinking, yet cups of juice and water were observed within reach in the room, and staff gave inconsistent awareness of the supervision and bedside fluid restrictions.
Dusty oxygen concentrator vent: A resident with OSA, chronic respiratory failure with hypoxia and hypercapnia, and COPD was ordered continuous oxygen at 2 L/min via NC or bled into the BiPAP. Although the TAR showed the oxygen concentrator and filter were cleaned, surveyors observed the external vent on the back of the concentrator had a layer of dust on multiple observations. Staff gave conflicting statements about who was responsible for cleaning the exterior of the oxygen equipment, and the DNS acknowledged the dust should not have been there.
A resident with kidney disease and intact cognition missed dialysis because the facility did not arrange transportation. The Social Services Director stated the dialysis transport contract required renewal every 90 days and had expired before renewal, and the DNS stated the contract should have been renewed before expiration so the resident would not miss dialysis.
A resident with chronic constipation was given MiraLAX despite loose stools and an order to hold the medication, and another resident with kidney disease had torsemide and sertraline without follow-up sodium monitoring after a low sodium result. Staff confirmed the bowel medication was not held as ordered and that no additional sodium levels were ordered or obtained.
Medication error rate exceeded 5% after a CMA left a resident’s prepared meds at the bedside instead of administering them directly. The resident was cognitively intact and had not been assessed or ordered to self-administer at bedside. The DNS stated bedside medication placement without assessment, orders, and care plan support was a med error.
The facility failed to provide a safe and homelike environment for its residents, as evidenced by dim bathroom lighting, damaged walls, a cracked window, cold water, and a malfunctioning bed. These issues affected several residents, including one with dementia and another with heart failure, leading to unsafe and uncomfortable living conditions. The maintenance staff acknowledged the problems, but repairs were delayed or incomplete.
A facility failed to maintain sanitary food storage in a resident's room refrigerator, which contained undated and uncovered food items, as well as expired products like chocolate milk, salsa, and bologna. The Food Service Director noted that medications should not be stored in the refrigerator and that the dietary aid was responsible for monthly cleaning.
The facility failed to offer pneumonia vaccines to five eligible residents with various medical conditions, including Parkinson's disease and diabetes. Despite being eligible, these residents were not offered the vaccine, and the DNS could not provide documentation to confirm that the vaccine had been offered, placing them at risk for pneumonia.
The facility did not provide required dementia training for five CNAs within the last 12 months, as confirmed by the administrator. This deficiency was identified through interviews and record reviews, indicating a risk to residents with dementia who may not receive appropriate care.
The facility failed to uphold resident dignity and rights for two residents. One resident experienced leaking incontinence briefs, which were not addressed in their care plan despite staff awareness. Another resident was distressed after their roommate passed away and the body remained in their shared room for hours, with no offer to relocate. Both residents were cognitively intact, and the facility's inaction led to deficiencies in care.
A facility failed to ensure informed consent was obtained for psychotropic medications for a resident admitted with depression and later to hospice services. The resident was prescribed Abilify, Cymbalta, and lorazepam without evidence of consent forms in the clinical record. Facility staff indicated that consents should have been obtained prior to administration, but the hospice director noted that specific education on medication risks and benefits was not provided unless requested by the facility.
A resident with heart failure and a BIMS score of 15 repeatedly complained about long call light times, unclean room conditions, and rude staff. Despite assurances from the Social Services Director that these issues would be reported, there was no documented follow-up or resolution. Interviews revealed that the concerns were only reported to nursing, and the LPN Resident Care Manager merely reassured the resident without addressing the grievances. The facility's grievance process was not followed, and the resident confirmed that the issues remained unresolved.
The facility failed to provide bowel care and follow medication orders for three residents. A resident with dementia did not receive bowel care despite not having a bowel movement for five days, and another resident with depression experienced similar issues without PRN medications or assessments. Additionally, a resident with heart failure received Lasix despite blood pressure readings below the physician-ordered threshold. These actions were not documented, placing residents at risk.
A resident with a history of seizures and heart disease was found smoking in a nonsmoking area without supervision, keeping a lighter in their coat pocket, contrary to the facility's smoking policy. Staff interviews revealed lapses in policy enforcement, including the absence of a check-out sheet for smoking paraphernalia.
A facility failed to provide adequate dialysis care for a resident with kidney failure. The care plan lacked instructions to avoid taking blood pressure on the arm with dialysis access and did not include emergency instructions for complications. Staff only assessed the dialysis site on dialysis days, and there was no sign indicating which arm to avoid for blood pressure measurements. The DNS confirmed these deficiencies, placing the resident at risk for complications.
A resident with PTSD did not receive trauma-informed care after a triggering incident due to the lack of a care plan. Despite being diagnosed with PTSD, the resident's condition was not addressed in their care plan until months after admission, following an incident that exacerbated their symptoms. Staff interviews revealed that the care plan should have been initiated earlier, highlighting a deficiency in the facility's care approach.
The facility did not complete annual performance reviews for two CNAs, which could risk resident care quality due to potentially incompetent staff.
A facility failed to provide a rationale for PRN psychotropic medication and did not develop a care plan for a resident on lorazepam for restlessness. The care plan lacked details on psychotropic medication use, side effects, and nonpharmacological interventions. Staff acknowledged the absence of necessary documentation, placing the resident at risk for sedation.
A resident admitted with a stroke diagnosis did not receive the required therapy evaluation and services as per hospital orders. Despite the physician's note indicating the need for skilled PT, OT, and SLP, the resident's record showed no therapy services were provided. Staff interviews confirmed that the therapy services were missed, and there was no follow-up with the provider to ensure the resident received the necessary therapy.
A resident with quadriplegia signed a binding arbitration agreement without understanding its implications, as the Social Services Director did not explain the agreement. The resident later expressed they would not have signed if they had known it meant waiving the right to sue the facility.
The facility failed to offer COVID-19 vaccines to three eligible residents, including one with Parkinson's disease, another with a stroke, and a third with seizures. The DNS confirmed their eligibility but could not provide documentation that the vaccine was offered.
A resident with PTSD was physically assaulted by another resident in the dining room after a disagreement over phone volume. The facility's investigation confirmed the abuse, noting that the aggressor had no prior history of physical aggression. Staff separated the residents and assessed them for injuries, with none noted.
A facility failed to maintain respiratory equipment for a resident with congestive heart failure. The resident, who was cognitively intact, had an order for PRN oxygen but no instructions for cleaning the oxygen concentrator. The resident reported the concentrator was filthy and had not been cleaned recently. Facility policy required weekly cleaning, but there was no documentation of this being done, and staff confirmed it should have been cleaned weekly.
The facility failed to arrange mental health services for two residents with mental health diagnoses after a resident-to-resident incident. Despite the need for follow-up, neither resident was seen by a mental health provider, as the facility lacked a visiting mental health professional.
A facility failed to act on a pharmacist's recommendation for a gradual dose reduction of psychotropic medications for a resident with depression, schizoaffective disorder, and anxiety. Despite a signed order for a psychiatric consult, there was no evidence that the consult occurred. Staff acknowledged the failure to follow up timely on the recommendation.
Cleanliness and Maintenance Deficiencies in Resident Rooms and Hallways
Penalty
Summary
The facility failed to provide a clean and well-maintained homelike environment for residents 5, 27, and 28. Resident 28’s room was observed with accumulated dirt and dust on the floor, dusty window blinds with five broken slats, a hole in the bottom left corner of the window frame leading directly outside, and a fall mat with large brown stains and sticky spots. The resident’s family member stated the blinds and window frame damage were present when the resident moved into the room and had already been reported to maintenance. Housekeeping acknowledged the room and fall mat were dirty, and maintenance stated the broken blinds and window damage required immediate repair, while the administrator stated repairs were to be made as soon as damage occurred and staff were responsible for reporting repair needs. Resident 5’s room was observed with dirty floors, dust and debris, a dirty sock, cream tube, plastic packaging, and nail clippers on the floor, a dirty and dusty area between the bed and wall, sticky red spots and visible dirt under the wheelchair, and a light next to the door that did not work. The resident stated a request to move pictures and fix the light had not been addressed, although a work order had been generated and later closed. Resident 27 stated the toilet did not flush, would run continuously at times, and required manual adjustment; a CNA stated the toilet was frequently clogged and had been reported to prior maintenance staff twice. A work order had been generated for the toilet and later closed. Surveyors also observed missing handrail end caps in resident areas, and the facility used an improvised repair of foam and black tape that created crevices, protruding tape edges, and an exposed foam area; housekeeping was observed wiping the handrails but not the taped areas, and later stated the peeling tape created an uncleanable surface.
Kitchen sanitation and food handling deficiencies
Penalty
Summary
The facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation, maintain a sanitary kitchen environment, and follow proper hand hygiene practices for food handling. The facility’s Food Preparation and Service policy stated that food preparation staff are to follow proper hygiene and sanitary practices, that bare hand contact with food is prohibited, and that food and nutrition services staff are to wear hair restraints so hair does not contact food. During observation, Staff 9, a cook, was seen working in the kitchen without a hair restraint after returning from lunch break, with her hair in a braid that swung onto the front of her shoulder while she actively prepared food items. Staff 9 also handled ready-to-eat foods with bare hands, including opening a bag of salad and dishing it out, picking up a biscuit and cutting it into pieces, and picking up pre-made sandwiches and placing them on plates. In addition, black tape was observed wrapped around the edge of the metal table used to hold clean dishes from the dishwasher, and the Regional Dietary Director acknowledged the taped surface could not be adequately cleaned.
Pest Control and Window Screen Deficiencies
Penalty
Summary
The facility failed to ensure it was free from pests, as required by its pest control policy stating that the building is maintained free of insects and rodents and that windows are screened at all times. On 6/1/26, an open bathroom window without a screen was observed in a resident room, and later that day during dinner in the main resident dining room, a window without a screen was open while a mosquito, an unidentified large bug, and a fly were observed. Five windows in the dining room did not have screens. Additional observations included a fly on the surveyor’s computer in the south hall on 6/2/26 and a fly in the LPN Resident Care Manager’s office on 6/3/26. The Maintenance Director stated he was aware several screens needed to be replaced or repaired and was auditing all window screens the following week, and the Administrator acknowledged that screens were required on all windows and that several were missing or damaged.
Failure to Timely Report Alleged Abuse
Penalty
Summary
The facility failed to ensure an allegation of abuse involving Resident 45 was reported timely. Resident 45 was admitted with a diagnosis of respiratory failure. In a 1/1/26 progress note, Resident 45 alleged that two CNAs assisted with repositioning in bed and injured the resident's back by overdoing it. A 1/1/26 event/investigation form also included a handwritten note from Staff 17 stating that on 12/30/25 Resident 45 was heard screaming in pain and reported that staff caused the pain by assisting in bed when the resident did not need repositioning. Staff 17 stated that when a resident reported abuse, the charge nurse was notified, and that on 12/30/25 the allegation was reported to Staff 18 and also written on a note to the Resident Care Manager. The Administrator stated staff should have reported the allegation on 12/30/25 and that the facility did not report it to the state within the required time frame. Staff 18 stated she was not notified of Resident 45's allegation of abuse on 12/30/25 and said that if she had been notified, she would have reported it to management.
Inaccurate MDS Coding for Oxygen and BiPAP Use
Penalty
Summary
The facility failed to ensure the MDS was coded accurately related to oxygen and non-invasive mechanical ventilator use for one resident reviewed for respiratory care. The facility’s undated Quarterly Assessments policy stated quarterly MDS assessments were used to track resident status between comprehensive assessments and monitor critical indicators of gradual change in status. Resident 7 was admitted with diagnoses including obstructive sleep apnea, chronic respiratory failure with hypoxia and hypercapnia, and COPD. The 4/25/26 Quarterly MDS indicated the resident was not using oxygen or a BiPAP. However, the physician order last signed on 5/31/26 showed an order effective 2/5/26 for continuous oxygen at 2 liters per minute via nasal cannula or bled into the BiPAP. On 6/1/26, the resident was observed with a nasal cannula in place receiving oxygen from a portable oxygen machine, and stated continuous oxygen was required, with oxygen delivered through the BiPAP while in bed and through the portable oxygen machine and nasal cannula while in the wheelchair. On 6/4/26, the MDS Coordinator stated he collected MDS information from physician orders, progress notes, and uploaded documentation, acknowledged the resident required continuous oxygen and used a BiPAP, and stated he coded the 4/25/26 Quarterly MDS inaccurately. The DNS also acknowledged the MDS was coded inaccurately related to oxygen and BiPAP use.
Failure to Administer PRN Insulin per Order
Penalty
Summary
The facility failed to provide PRN insulin according to physician orders for one resident with diabetes. The resident was admitted in 12/2023 with a diagnosis of diabetes, and the 6/24/25 physician orders directed Insulin Lispro to be given every two hours PRN when CBG was greater than 400, with the PRN dose not to be administered within two hours of the scheduled post-meal Lispro. The resident’s DAR showed multiple instances in 5/2026 when CBG was greater than 400, including 5/1/26 at 1:00 PM, 5/7/26 at 9:00 AM, 5/12/26 at 12:00 PM and 6:26 PM, and 5/26/26 at 8:25 AM, but staff did not administer the PRN Insulin Lispro. The clinical record also lacked documentation that the CBG was rechecked after those elevated readings, and on 6/4/26 Staff 4 verified that the resident had four CBG readings greater than 400 in 5/2026 with no documentation of rechecks or PRN insulin administration.
Aspiration Precautions Not Followed for Two Residents
Penalty
Summary
The facility failed to ensure aspiration precautions were followed for 2 residents reviewed for accidents. Resident 38 was admitted with dysphagia and a speech therapy evaluation noted minimal signs of dysphagia, but due to cognitive status and confusion the resident was not able to follow swallowing strategies. The evaluation recommended close supervision for oral intake and upright positioning for meals. However, the in-room aspiration precautions sheet posted above the bed did not instruct staff to provide supervision for meals, while a later aspiration precautions sheet in the dining room and a subsequent order indicated 1:1 supervision for meals with small bites and sips. During observation, the resident was in bed with two cups of fluids within arm’s reach, and staff gave conflicting statements about whether the resident could eat and drink independently or required 1:1 supervision. Resident 44 was admitted with diagnoses including pneumonia and had a BIMS score of 9, indicating a moderate cognitive deficit. The care plan and admission orders identified the resident as a high aspiration risk requiring one-on-one supervision for all eating and drinking. Despite this, the resident was observed asleep and later awake in bed with two cups within reach on the bedside table, including juice in an uncovered cup and water in a lidded cup. Staff stated the resident required 1:1 supervision during all meals and should not be left unsupervised, but other staff were unaware of the 1:1 supervision requirement and that fluids were not to be kept at the bedside unless out of reach.
Dusty oxygen concentrator vent
Penalty
Summary
The facility failed to maintain oxygen equipment for one resident who was admitted with obstructive sleep apnea, chronic respiratory failure with hypoxia and hypercapnia, and COPD. The resident’s annual MDS showed a BIMS of 15 and indicated the resident used oxygen. The physician order, last signed on 5/31/26, directed continuous oxygen at 2 liters per minute via nasal cannula or bled into the BiPAP. The 6/2026 TAR also directed staff to clean the oxygen concentrator and filter every Tuesday night shift, and this task was documented as completed on 6/2/26 by an LPN. Despite the documented task completion, observations on 6/1/26, 6/2/26, and 6/3/26 showed the external vent on the back of the oxygen concentrator had a layer of dust when touched with a finger. The resident stated the oxygen was used continuously, with oxygen delivered through the BiPAP while in bed and through a portable oxygen machine and nasal cannula while in a wheelchair. A CNA stated only nurses cleaned the exterior of the oxygen concentrator machines, while the LPN stated the concentrator did not have a filter to clean and that she did not clean the exterior because nursing did not do that. The DNS stated she expected the charge nurse to wipe down the exterior of the oxygen concentrator, including the vent on the back, and observed that it had a layer of dust that should not be there.
Missed Dialysis Due to Lapsed Transportation Contract
Penalty
Summary
The facility failed to ensure that a resident with kidney disease had transportation arranged for dialysis. The resident was admitted in 12/2023 and the annual MDS dated [DATE] showed the resident was cognitively intact. During an interview on [DATE] at 11:09 AM, the resident stated that dialysis was missed on [DATE] because the facility did not set up transportation. Staff 14, the Social Services Director, stated on [DATE] at 4:12 PM that the transportation company providing dialysis transport had a contracted schedule that needed renewal every 90 days, and the contract was not renewed before it expired, resulting in the missed dialysis appointment. The DNS stated on [DATE] at 4:16 PM that the facility should always ensure the transportation contract was renewed before it expired so the resident would not miss dialysis.
Failure to Hold Bowel Medication and Monitor Sodium Labs
Penalty
Summary
The facility failed to ensure a resident's bowel care was held according to physician orders. One resident, admitted with a genetic disorder characterized by chronic constipation, had an order for MiraLAX every morning with instructions to hold it for loose stools. The bowel care record showed loose stools on two days, but the MAR did not reflect that MiraLAX was held on those days or on another date when it was administered. A CMA stated that bowel medications should not be given when a resident has loose stools, and the DNS verified that bowel care was not held when the resident had loose stools. The facility also failed to monitor labs for another resident receiving torsemide and sertraline. That resident was admitted with kidney disease, and a pharmacy resource identified an interaction between torsemide and sertraline that could increase the risk of low sodium levels. The resident's lab record showed a sodium level of 130, and the last documented sodium level was on 3/5/25. Staff stated the resident often had labs drawn during dialysis, but the DNS verified there were no standing orders for routine laboratory tests and no additional sodium levels were ordered or obtained after the low result.
Medication Error Rate Exceeded 5% Due to Medications Left at Bedside
Penalty
Summary
A medication error rate greater than 5% was identified, with a 32% error rate based on 8 errors in 25 opportunities. During observation, Staff 19 (CMA) prepared Resident 16’s medications, entered the resident’s room, placed the medication cup on the resident’s computer table, and then left the room, leaving amlodipine, atorvastatin, disulfiram, Biktarvy, vitamin B12, Farxiga, metformin, a multivitamin, and omeprazole at the bedside. Resident 16 was admitted with a diagnosis including diabetes, and the 4/27/26 admission MDS indicated the resident was cognitively intact. When asked, Staff 19 stated Resident 16 had not been assessed to leave medications at the bedside and returned to the room to request that the resident take the medications. The DNS later stated medications were not to be left at the bedside unless the resident had been assessed as safe, had orders to leave medications at the bedside, and this was reflected on the care plan, and acknowledged that leaving medications at the bedside was considered a medication error.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by several deficiencies observed during the survey. Resident 6's bathroom light was dim, making it difficult and unsafe for the resident to navigate the bathroom. This issue was acknowledged by both the CNA and the Maintenance Director, who confirmed the light had been dim for at least a week. Resident 13 reported damaged walls in their room due to the bed scraping against them, which had not been repaired despite multiple requests to maintenance. The Maintenance Director admitted difficulty in completing repairs due to room occupancy, and the Administrator acknowledged that walls in disrepair did not contribute to a homelike environment. Resident 22 experienced a cracked bathroom window and cold water in their sink, with the water temperature recorded at 59 degrees Fahrenheit. The Administrator confirmed that the cracked window and cold water were identified but not addressed, and the Maintenance Director noted a pump issue preventing hot water from reaching the resident's room. Resident 26 faced a malfunctioning bed that was stuck in a high position, preventing them from safely getting in and out of bed. Despite being aware of the issue, the bed remained broken for several days, causing significant discomfort and mobility issues for the resident. These deficiencies collectively contributed to an environment that was not conducive to the residents' safety and comfort.
Unsanitary Food Storage in Resident's Refrigerator
Penalty
Summary
The facility failed to store food in a sanitary manner in a resident's room refrigerator, as observed during a survey. The refrigerator contained several undated and uncovered food items, including a plate of meatballs, a bowl of pears, and a dessert. Additionally, there were expired items such as chocolate milk, salsa, hot dogs, cole slaw, and bologna, with some items dating back to January. A container of cottage cheese was dated 2/12/25, and a sandwich was dated 2/21/25, both of which were past the facility's stated policy of discarding items three days after the date provided by the kitchen. Furthermore, a green canister with an unknown powder and an undated pitcher labeled as bowel prep with a resident's name were also found in the refrigerator. Staff 12, the Food Service Director, acknowledged that medications should not be stored in the refrigerator and that the dietary aid was responsible for cleaning it monthly.
Failure to Offer Pneumonia Vaccines to Eligible Residents
Penalty
Summary
The facility failed to ensure that residents were offered pneumonia vaccines, as evidenced by the review of clinical records and interviews with staff. Five residents, each with different medical conditions such as Parkinson's disease, diabetes, kidney failure, stroke, and seizures, were identified as eligible for the pneumonia vaccine but were not offered it. This oversight was confirmed by Staff 2, the Director of Nursing Services (DNS), who was unable to provide documentation that the vaccine had been offered to these residents. The deficiency was identified during a survey conducted on February 27, 2025, when Staff 2 verified the eligibility of the residents for the pneumonia vaccine. Despite requests for documentation to confirm that the vaccine had been offered, no additional information was provided. This lack of documentation and failure to offer the vaccine placed the residents at risk for pneumonia, as they were not given the opportunity to receive the preventive measure they were eligible for.
Failure to Provide Dementia Training for CNAs
Penalty
Summary
The facility failed to provide required dementia training for five Certified Nursing Assistants (CNAs), identified as Staff 4, 9, 21, 22, and 23, within the last 12 months. This deficiency was identified through interviews and record reviews, which revealed that the in-service records did not show completion of dementia training for these staff members. The lack of training placed residents with dementia at risk of not receiving appropriate care and services necessary to attain or maintain their highest practicable level of well-being. The facility's administrator confirmed the deficiency during an interview.
Failure to Uphold Resident Dignity and Rights
Penalty
Summary
The facility failed to uphold resident rights and dignity for two residents, leading to deficiencies in care. Resident 13, who was cognitively intact with a BIMS score of 15, experienced issues with leaking incontinence briefs. Despite raising concerns during a Resident Council meeting, no changes were made to the care plan to address the issue. Observations confirmed that Resident 13 often had a wet peri area and a strong smell of urine, which discouraged participation in activities due to embarrassment. Staff members were aware of the leaking briefs but failed to communicate this to the care planning team, resulting in a lack of appropriate intervention. Resident 26, also cognitively intact with a BIMS score of 15, was distressed after their roommate, Resident 100, passed away and the body remained in their shared room for several hours. There was no documentation indicating that staff offered to move Resident 26 or the deceased resident's body to another location. The Social Services Director acknowledged the incident and expressed that Resident 26 should have been alerted and possibly moved. The LPN Resident Care Manager confirmed that no actions were taken to relocate Resident 26 or provide additional support following the death of their roommate.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that a resident or the resident's representative was provided with information regarding the risks and benefits of psychotropic medications before administration. This deficiency was identified for a resident who was admitted to the facility in June 2022 with a diagnosis of depression and later admitted to hospice services in January 2025. The resident was prescribed Abilify, Cymbalta, and lorazepam, but there was no evidence of consent forms for these medications in the resident's clinical record. Interviews with facility staff revealed that consents for psychotropic medications should have been obtained prior to administration. The hospice director stated that while general admission consent and treatment plans were reviewed upon admission to hospice services, the risks and benefits of psychotropic medications were not discussed unless the facility provided a specific form and requested the inclusion of this education in the admission process.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to adequately address grievances raised by a resident, identified as Resident 26, who was admitted with a diagnosis of heart failure and was cognitively intact with a BIMS score of 15. Over a period from May 14, 2024, to June 3, 2024, Resident 26 repeatedly complained to the Social Services Director, identified as Staff 7, about long call light response times, unclean room conditions, food issues, and rude staff. Despite assurances from Staff 7 that these concerns would be reported to the appropriate departments, there was no documented follow-up or resolution of these grievances in the resident's medical record or the facility's grievance binder. Interviews conducted on February 28, 2025, revealed that Staff 7 only reported the concerns to nursing and took no further action. The LPN Resident Care Manager, identified as Staff 3, stated that she merely had conversations with Resident 26, encouraging them that there was no staffing problem, without addressing the specific grievances. The Regional Nurse Consultant and the Director of Nursing Services, identified as Staff 29 and Staff 2 respectively, acknowledged the lack of adherence to the grievance process and were unaware of the resident's documented concerns. Resident 26 confirmed that the facility did not resolve the issues and had not communicated any follow-up actions regarding the grievances.
Failure to Provide Bowel Care and Follow Medication Orders
Penalty
Summary
The facility failed to provide appropriate bowel care and follow physician orders for medication parameters for three residents. Resident 9, diagnosed with dementia, did not have a bowel movement for five days, and there was no documented nursing assessment or rationale for not providing bowel care. Staff confirmed that bowel care should be initiated if a resident does not have a bowel movement for three days, but this protocol was not followed. Similarly, Resident 22, with a diagnosis of depression, experienced two instances of not having a bowel movement for four days without any PRN bowel care medications ordered or nursing assessments documented. Staff acknowledged that bowel care should have been administered, but it was not, and there was a lack of documentation regarding the resident's bowel movements. Resident 24, diagnosed with heart failure, had a physician order to hold Lasix if the systolic blood pressure was less than 110. Despite this, the medication was administered on multiple occasions when the resident's blood pressure was below the specified threshold. Staff confirmed that the medication should have been held on those days, but there was no evidence in the progress notes that this was done. These failures in following physician orders and documenting care placed the residents at risk for adverse health outcomes.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure that cigarette lighters were not stored in resident rooms, specifically for one resident who was reviewed for smoking. This resident, admitted in October 2022 with diagnoses of seizures and heart disease, was identified as a supervised smoker due to noncompliance with the facility's smoking policy. The policy stated that smoking was only permitted in designated areas and that all cigarettes and lighters were to be kept locked at the nurse's station. However, during an observation, the resident was found smoking in a nonsmoking area without staff supervision and admitted to keeping a lighter in a box in their coat pocket. Interviews with various staff members revealed inconsistencies in the enforcement of the smoking policy. The Activities Director and a CNA confirmed that residents were supposed to check out their smoking paraphernalia from the nurse's station. However, an LPN noted that the check-out sheet used to track cigarettes and lighters was no longer in use, making it difficult to monitor compliance. The DNS and LPN resident care manager confirmed that the resident was a supervised smoker due to noncompliance and should not have had smoking paraphernalia in their room.
Failure to Provide Adequate Dialysis Care
Penalty
Summary
The facility failed to provide adequate care and services related to dialysis for a resident diagnosed with kidney failure. The resident, who was cognitively intact, was admitted to the facility with a care plan that included scheduled dialysis sessions on Mondays, Wednesdays, and Fridays. However, the care plan lacked specific instructions for staff to avoid taking blood pressure on the arm with the dialysis access and did not include emergency instructions for complications such as bleeding. The facility's policy required documentation of the dialysis site condition every shift, but staff only assessed and documented the site on dialysis days. Observations and interviews revealed that staff were not consistently following the facility's Dialysis Access and Care Policy. A Licensed Practical Nurse (LPN) assessed the dialysis site only on dialysis days, and a Certified Nursing Assistant (CNA) noted the absence of a sign in the resident's room indicating which arm should not be used for blood pressure measurements. The Director of Nursing Services (DNS) confirmed the care plan's deficiencies, acknowledging the lack of instructions for blood pressure monitoring and emergency care for the dialysis site. This oversight placed the resident at risk for dialysis access complications.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed care to a resident diagnosed with post-traumatic stress disorder (PTSD). The resident, who was admitted in July 2022, experienced a triggering event when another male resident made an inappropriate comment, which exacerbated the resident's PTSD symptoms. Despite being cognitively intact and having a PTSD diagnosis, the resident did not have a care plan addressing PTSD until February 26, 2025, following the incident. This lack of a care plan left the resident without necessary support for managing PTSD triggers. Interviews with facility staff revealed that a PTSD care plan should have been initiated upon the resident's admission or upon receiving the PTSD diagnosis in November 2024. The Social Services Director admitted to not having completed a trauma/PTSD assessment for the resident upon admission, as she was not employed at the facility at that time. The facility's administrator stated that the resident's PTSD was not care planned because the resident did not request it, and the facility aimed to avoid prying. This oversight resulted in the resident's PTSD not being adequately addressed, leading to a deficiency in providing trauma-informed care.
Failure to Conduct Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure that each Certified Nursing Assistant (CNA) received annual performance reviews, specifically for two of the five sampled CNAs. This deficiency was identified during an interview and record review, where it was confirmed that the annual performance reviews for Staff 21 and Staff 23 had not been completed within the last 12 months. The absence of these reviews placed residents at risk for receiving care from potentially incompetent staff.
Failure to Provide Rationale and Care Plan for PRN Psychotropic Medication
Penalty
Summary
The facility failed to provide a rationale for the use of PRN psychotropic medication and did not develop a care plan addressing the side effects of antianxiety medication for a resident diagnosed with depression. The resident was admitted to hospice services with orders for lorazepam to be administered PRN for restlessness. However, the care plan did not include details on the use of psychotropic medication, potential side effects of lorazepam, or nonpharmacological interventions to be attempted prior to administering the medication. The facility's staff, including an LPN and the Director of Nursing Services (DNS), acknowledged the absence of a rationale for the continuation of lorazepam and the lack of documentation of nonpharmacological interventions. The DNS confirmed that lorazepam is not an antipsychotic medication and verified the absence of a psychotropic care plan. This oversight placed the resident at risk for sedation due to the lack of a comprehensive care plan and appropriate documentation.
Failure to Provide Required Therapy Evaluation
Penalty
Summary
The facility failed to ensure a therapy evaluation was obtained for a resident who was admitted with a diagnosis of a stroke. The resident was admitted to the facility with hospital orders indicating the need for skilled therapy services, including physical therapy (PT), occupational therapy (OT), and speech-language pathology (SLP). However, the resident's record showed no therapy services were provided. Interviews with staff revealed that the therapy services were overlooked, and there was no follow-up with the resident's provider to confirm the need for therapy services. This oversight was acknowledged by the staff, who admitted that the therapy services were missed.
Failure to Inform Resident About Binding Arbitration Agreement
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood the binding arbitration agreement, as evidenced by the case of a resident with quadriplegia who was admitted in November 2022. On September 20, 2023, the resident signed an Arbitration Agreement with the new owner of the facility. However, during an interview on February 27, 2025, the resident stated they did not know what a binding arbitration agreement was and would not have signed it if they had known it meant giving up the right to sue the facility in court. Interviews with the Social Services Director revealed that the form was left with the resident at their request, and the director was unaware of the requirement to explain the binding arbitration agreement to residents.
Failure to Offer COVID-19 Vaccines to Eligible Residents
Penalty
Summary
The facility failed to offer COVID-19 vaccines to three eligible residents, placing them at risk for respiratory illness. Resident 19, admitted in September 2022 with Parkinson's disease, was eligible but not offered the vaccine. Similarly, Resident 38, admitted in August 2024 with a stroke diagnosis, and Resident 39, admitted in September 2024 with seizures, were also eligible but not offered the vaccine. Staff 2, the Director of Nursing Services (DNS), confirmed the eligibility of these residents for the vaccine but could not provide documentation that the vaccine was offered to them.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident 39, who was admitted with a diagnosis of post-traumatic stress disorder (PTSD), reported being hit on the head several times by Resident 20, who also had a diagnosis of PTSD. The incident occurred in the dining room when Resident 20 asked Resident 39 to lower the volume on their phone. Despite Resident 39's claim of compliance, Resident 20 proceeded to physically assault Resident 39. The facility's investigation confirmed the abuse, noting that Resident 20 had no prior history of physical aggression, although they were known to react verbally to loud noises. Staff interviews corroborated the sequence of events, with staff members stating that Resident 39 reported the incident immediately, and both residents were separated and assessed for injuries, with none noted. The police were notified, and Resident 39 pressed charges against Resident 20.
Failure to Maintain Respiratory Equipment
Penalty
Summary
The facility failed to maintain respiratory equipment for a resident with a diagnosis of congestive heart failure, who was cognitively intact as per a recent MDS assessment. The resident had an order for PRN oxygen, but there were no instructions for cleaning the oxygen concentrator. The resident reported that the concentrator had not been cleaned recently and was filthy. The facility's policy required oxygen cannula and tubing to be changed every seven days and filters to be washed weekly. However, there was no documentation of the concentrator being cleaned, and staff confirmed that it should have been cleaned weekly, including for residents on PRN oxygen.
Failure to Arrange Mental Health Services for Residents
Penalty
Summary
The facility failed to provide medically-related social services by not arranging mental health services for two residents with significant mental health diagnoses. Resident 20, who was admitted with schizoaffective disorder, bipolar disorder, post-traumatic stress disorder, and borderline personality disorder, was involved in an incident where he hit another resident on the head. Despite the facility's investigation indicating a need for mental health follow-up, there was no evidence that Resident 20 was seen by a mental health provider after the incident. Similarly, Resident 39, who was admitted with bipolar disorder and post-traumatic stress disorder, was the victim in the same incident. The facility's investigation also noted the need for mental health follow-up for Resident 39, but a review of the medical records showed no evidence of such follow-up. The facility acknowledged the lack of mental health services for both residents, as they did not have a mental health provider visiting the facility at the time.
Failure to Act on Pharmacist Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to act upon pharmacist recommendations for a resident reviewed for unnecessary medications, which placed residents at risk for a decrease in their quality of life. The resident was admitted with diagnoses including depression, schizoaffective disorder, and anxiety. Physician orders included aripiprazole for schizoaffective disorder, duloxetine for depression, and depakote for schizoaffective disorder. A pharmacist recommended a gradual dose reduction (GDR) for the resident's psychotropic medications, and the recommendation was signed by the provider with an order for a psychiatric consult to discuss the GDR. However, there was no evidence in the medical record that the pharmacist's recommendation for a psychiatric consult was acted upon. Staff acknowledged that the facility did not follow up timely for the psychiatric consult, which should have been done within one week of receiving the order.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 83 citations issued within 25 miles in the last 12 months — 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Sheridan
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Village At Hillside | 11 mi | ★★★★★ | 6 | 0 |
| Dallas Retirement Village Health Center | 11.9 mi | ★★★★★ | 11 | 0 |
| Evan Terrace Post Acute | 12.5 mi | ★★★★★ | 2 | 0 |
| Life Care Center Of Mcminnville | 13.3 mi | ★★★★★ | 15 | 0 |
| Avamere Court At Keizer | 18.8 mi | ★★★★★ | 19 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.