Below average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Staff failed to follow infection control policy requiring hand hygiene between meal tray distribution in the 400-hall dining room. During breakfast service, a CNA passed multiple food trays to residents without sanitizing hands between each tray, despite facility policies mandating hand sanitizing before and after touching each tray and staff interviews confirming this expectation. The CNA acknowledged knowing the requirement and having recent in-service training on infection control, as did other CNAs, an LVN, the DON, and the Administrator, who all stated that unclean hands during tray service is an infection control issue that could cause residents to become sick.
Two residents with significant cognitive and neurologic impairments were in a dining area when one resident, a male with vascular dementia, intermittent explosive disorder, and expressive aphasia, became frustrated that a female stroke survivor in a wheelchair was not moving quickly enough. Staff reported that he pushed her wheelchair and then hit her right arm while she cried out for him to stop and began crying. The female resident, who had right‑sided weakness, spasms, and moderately impaired cognition, later described being shocked and scared, stated she did not feel safe, and identified the male resident as the person who hit her. Staff assessments documented her emotional distress and existing bruising on both arms, while the facility’s abuse policy affirmed residents’ rights to be free from abuse and required oversight and monitoring to prevent such incidents.
Call Light Left Out of Reach: A resident with heart failure, COPD, polyneuropathy, chronic pain, and no cognitive impairment was observed lying in bed with oxygen in place while his call light was on the floor behind the bed and out of reach. The resident said he could not reach it and would have to wait for staff to pass by to get help. Staff confirmed the call light was not within reach, and the facility policy and in-service training stated call devices should be kept within residents' reach at all times.
Failure to Provide Nail Care During ADL Assistance: A resident with CVA, hemiplegia/hemiparesis, dysarthria, schizophrenia, and severe cognitive impairment was observed with long, jagged, dirty fingernails with debris under all nails. The resident said no one had offered to trim or clean the nails, and the nails interfered with phone use. Staff interviews and the facility policy indicated nail care was expected during ADL care, including cleaning and regular trimming.
A resident with dysphagia and moderate cognitive impairment was given non-crushed acetaminophen tablets by an RN who failed to review the resident's chart and special instructions, resulting in the resident coughing uncontrollably and experiencing fear and discomfort. The resident's care plan and physician orders required all medications to be crushed due to swallowing difficulties, but these were not followed during the medication administration.
A resident with hemiplegia, hemiparesis, and moderate cognitive impairment was unable to access the call light, which was left dangling near the floor and not placed on her usable side, despite staff entering and exiting the room and care plan instructions to ensure accessibility. Staff interviews confirmed the expectation for call lights to be within reach, but this was not followed, leaving the resident without a means to call for assistance.
A resident with significant cognitive and physical impairments exited the facility unsupervised by following a contract worker out the front door, which was held open by another resident. The resident self-propelled down the driveway, crossed the street, and fell from her wheelchair at the median before staff could intervene. The receptionist responsible for monitoring the exit was not attentive, and the resident was not previously identified as high elopement risk in the facility's records.
The facility failed to maintain food safety and sanitation standards in the kitchen. Food items in the refrigerator and freezer were not labeled or dated, and some were not properly sealed. The kitchen was found to be unclean, with grease, food splatters, and residues on various appliances, and the floors were dirty. Additionally, there were no paper towels at the handwashing station, compromising hand hygiene. The Dietary Manager and Assistant Dietary Manager acknowledged these issues, emphasizing the importance of labeling, sealing, and maintaining a clean environment.
The facility failed to maintain proper infection control in the laundry area. A staff member handled soiled linen without proper hand hygiene, using hand sanitizer on wet hands due to an empty paper towel dispenser. Additionally, lint traps in dryers were not cleaned or logged, contrary to facility policy. Interviews with staff confirmed these practices did not meet facility expectations.
Two residents experienced issues with missing clothing and belongings due to the facility's failure to provide a safe, clean, and homelike environment. A resident with severe cognitive impairment and another with intact cognition both reported missing items, with no inventory lists in their medical records. Staff interviews revealed systemic issues with labeling and returning clothing, leading to numerous grievances. The facility's administration acknowledged the problem, but the lack of a consistent inventory system resulted in diminished quality of life for the residents.
A resident with schizoaffective disorder and mild cognitive impairment reported missing personal items due to the facility's inconsistent inventory management. Staff interviews revealed a lack of clear responsibility for inventorying and labeling residents' clothing. Additionally, the facility failed to maintain cleanliness in the smoking area, with numerous cigarette butts observed on the ground, indicating inadequate supervision and maintenance.
The facility failed to develop and implement comprehensive person-centered care plans for three residents, leading to a lack of engagement in activities and potential diminished quality of life. The care plans did not include specific interests or preferences, and there was a lack of documentation and understanding among staff on personalizing care plans.
The facility failed to provide a resident-centered activity program, as evidenced by three residents who were not engaged in activities according to their preferences and care plans. A resident with dementia and sensory impairments was left without music or television, another with severe cognitive impairment had no documented activities, and a third with intact cognition was not invited to participate in activities. The Activity Director was unaware of specific resident needs, and there was no documentation of activities being provided.
A resident with essential tremor and intact cognition did not receive meals according to her preferences and needs, as her meal ticket instructions to cut all meats and avoid certain disliked foods were not followed by the facility staff. This oversight occurred over multiple meals, leading to dissatisfaction and potential risk to the resident's quality of life.
The facility failed to maintain effective infection control practices, as staff did not consistently follow hand hygiene and equipment sanitation protocols. CNAs did not wash or sanitize hands during peri care, and a CNA and MA failed to sanitize hands and equipment between resident interactions. These lapses occurred despite the facility's policies and training, potentially increasing the risk of infection transmission among residents with various medical conditions.
The facility's pest control program was ineffective, leading to the presence of flies and cockroaches. A resident reported discomfort with bugs, while another noted persistent fly issues despite complaints. A CNA observed flies but did not report them. The facility's pest control policy required reporting pest sightings, but the administration was unaware of the ongoing issues.
The facility failed to maintain privacy and dignity for two residents during personal care. An LVN provided wound care without closing the door or curtain, exposing a resident to the hallway. A CNA provided peri care without closing the privacy curtain, leaving another resident visible to anyone entering the room. Both staff members acknowledged the oversight, and the facility's policy emphasizes the importance of maintaining resident privacy.
A resident's bottom dentures broke, and the facility failed to assist in obtaining timely dental services. Despite the dentures being sent for repair, they were lost upon return, and staff were unable to locate them. The resident, who had multiple health conditions and was dependent on staff for daily activities, experienced discomfort and difficulty chewing. Interviews with staff revealed a lack of effective communication and follow-up, contributing to the deficiency.
A resident's right to receive visitors was violated when the facility banned a family member without documented evidence or proper communication. The administration alleged the family member brought substances into the facility, but staff interviews revealed inconsistencies and lack of awareness about the ban. The deficiency also impacted another resident related to the banned family member.
The facility failed to ensure call lights were within reach and air mattresses were functioning for several residents. Observations revealed inaccessible call lights and deflated air mattresses due to being unplugged. Staff interviews indicated inconsistent checks on these essential items, despite expectations from the DON and ADM.
A resident with moderate cognitive impairment and multiple health issues was identified as a high fall risk, but the facility failed to include fall prevention interventions in the care plan. The resident subsequently fell from bed, highlighting the deficiency in care planning. The DON acknowledged the oversight, which contradicted the facility's policy requiring comprehensive care plans.
The facility failed to provide a private place for telephone communications for three residents, forcing them to use a phone at the nurses' station where conversations could be overheard. This issue was acknowledged by staff and administration, but no immediate action was taken to resolve it.
Failure to Perform Hand Hygiene Between Meal Tray Distribution
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to hand hygiene during meal service in the 400-hall dining room. On the morning of 04/12/2025, observation showed that a CNA passing breakfast trays to three residents did not sanitize her hands between handing out each tray, contrary to facility policy requiring hand sanitizing before and after touching each tray. This occurred despite the facility’s written Infection Prevention and Control Program policy stating that personnel will wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. In subsequent interviews, the CNA who failed to sanitize her hands acknowledged she had been employed for nine months, had received infection control training, and understood she was supposed to sanitize her hands between each tray and that failure to do so could contaminate residents’ food. Other CNAs, an LVN, the DON, and the Administrator all stated that staff are expected to sanitize their hands between each tray when passing food and that they had received recent in-service training on hand hygiene and infection control. They also stated that unclean hands during tray service constitute an infection control issue and could cause residents to become sick. Despite these stated expectations and training, the observed failure to perform hand hygiene during tray distribution in the 400-hall dining room constituted noncompliance with the facility’s infection control policies for three residents.
Failure to Prevent Resident‑to‑Resident Physical Abuse in Dining Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse during a resident‑to‑resident altercation. On the date of the incident, a female resident with a history of CVA with hemiparesis, vascular dementia, bipolar disorder, major depressive disorder, chronic kidney disease, and other comorbidities was in the dining room waiting in line to see a speech therapist. Her MDS showed moderately impaired cognition (BIMS 9) and dependence on staff for toileting and lower body dressing. Staff reported that she had pre‑existing bruises on both arms from a prior hospitalization, and her care plan included an ADL self‑care performance deficit related to CVA with hemiparesis and an intervention for staff to observe her skin for bruising. At the time of the incident, a male resident with severe cognitive impairment (BIMS 0), vascular dementia with mood disturbance, intermittent explosive disorder, expressive aphasia, and a history of striking another resident was also in the dining room. His care plan, last revised shortly after the incident, documented that he had previously struck another resident on an earlier date and again on the date of this event, with identified interventions such as analyzing triggers, increasing monitoring, psych medication review, and redirection when stressed. On the day of the altercation, staff observed that he became frustrated because the female resident, who had right‑sided weakness and moved slowly, was in his way and could not move quickly enough. According to staff interviews, the male resident pushed the female resident’s wheelchair and then raised his hand and hit her on the right arm while she yelled “stop” and cried. A CNA reported hearing the female resident cry out “he hit me,” and a nurse stated that by the time she got up from the nurses’ station, the male resident was already hitting the female resident on her right arm, which was known to be painful due to spasms. Staff separated the residents. Subsequent assessments documented that the female resident was crying and tearful after the incident, described being shocked and scared, and reported fear of the male resident, stating she did not feel safe and would avoid him or seek staff if she saw him. Physical assessment documented intact skin with no new skin issues at that time, though bruising was present on both arms, with some bruising attributed to a prior hospitalization. The facility’s abuse prevention policy stated that each resident has the right to be free from abuse, including willful infliction of injury causing physical harm, pain, or mental anguish, and that the facility would provide oversight and monitoring to ensure residents are free from abuse, neglect, and mistreatment.
Call Light Left Out of Reach
Penalty
Summary
The facility failed to ensure Resident #66's call light was within reach. Resident #66 was an older male admitted to the facility with diagnoses including heart failure, atherosclerotic heart disease, COPD, polyneuropathy, and chronic pain. His quarterly MDS reflected that he had almost constant pain, received oxygen therapy, used a wheelchair, and required partial or moderate assistance with toileting, lower body dressing, oral and personal hygiene, bathing, and transfers. His BIMS score was 14, indicating no cognitive impairment. His care plan identified him as high risk for falls related to gait and balance problems and included the intervention to keep the call light within reach. During an observation and interview, Resident #66 was lying in bed with oxygen in place and stated he was in pain. The surveyor observed the resident's call light lying on the floor directly behind the bed and out of reach. The resident stated he did not know where his call light was, could not reach it, and would have to wait until staff passed by his room to get help. Staff interviews confirmed that the call light was out of reach and that all residents' call lights should always be within reach. The facility policy stated that the call device should be placed within the resident's reach before leaving the room, and in-service training reflected that call lights should be placed in reach of all residents at all times.
Failure to Provide Nail Care During ADL Assistance
Penalty
Summary
The facility failed to ensure appropriate treatment and services were provided to support ADLs for Resident #69, whose fingernails were observed to be long, jagged, and dirty with built-up dirt and grime underneath all fingernails. During the observation on 01/13/26, the resident stated he was doing okay, had been getting showers correctly, and had not used his call light. He also stated he would like his nails trimmed and that no one had offered to cut them or clean under them. He demonstrated that his fingernails interfered with his ability to use the screen on his phone. Resident #69's record showed diagnoses including cerebral infarction, hemiplegia/hemiparesis, dysarthria, and schizophrenia. The MDS reflected a BIMS score of 05, indicating severe cognitive impairment, and showed the resident required set-up or clean-up assistance with eating and substantial to maximal assistance with toileting, showering, upper and lower body dressing, and personal hygiene. The care plan identified ADL self-care performance deficit related to CVA and included assistance with bathing and personal hygiene/oral care, with the resident preferring weekly showers on Mondays. Staff interviews reflected that CNAs were expected to offer nail care during showers and other ADL care, including trimming, filing, and cleaning nails for residents who were not diabetic, while nurses handled nail care for diabetic residents. Multiple staff members stated that long, dirty, jagged fingernails could cause skin tears, nail injuries, ingrown nails, infection, or skin issues, and the facility policy stated nail care includes daily cleaning and regular trimming during ADL care. The DON and Administrator both stated it was their expectation that staff offer to trim, file, and clean residents' nails when nails were long, dirty, and jagged.
Failure to Administer Crushed Medication as Ordered for Resident with Dysphagia
Penalty
Summary
A deficiency occurred when a resident with a history of hemiplegia, hemiparesis, and dysphagia following a stroke was not administered her prescribed medication in accordance with physician orders and care plan instructions. The resident was assessed as having moderate cognitive impairment and was dependent on staff for all activities of daily living. Her care plan and physician orders clearly indicated that all medications were to be crushed due to her swallowing difficulties, as confirmed by a swallow study and special instructions in her medical record. On the date of the incident, an RN who was not regularly assigned to the building administered two non-crushed acetaminophen tablets to the resident, despite the clear instructions to crush all medications. The RN did not review the resident's chart or special instructions prior to administration and was unaware of the requirement to crush medications. Upon administration, the resident began coughing uncontrollably, refused additional water, and expressed fear and discomfort as a result of the incident. The RN later acknowledged that the medication should have been crushed and that failure to do so could result in choking. Interviews with facility staff, including the DON, speech therapist, and social worker, confirmed that the expectation was for staff to review special instructions and physician orders before administering medications. The DON and other staff reiterated that the special instructions are prominently displayed in the electronic medical record. The resident herself reported feeling scared and terrible after the incident, and staff noted that her cognitive status made it unlikely she could reliably communicate her medication needs, emphasizing the importance of staff following documented instructions.
Failure to Ensure Accessible Call Light for Dependent Resident
Penalty
Summary
The facility failed to accommodate the needs and preferences of a resident with significant physical and cognitive impairments by not providing a working communication system within easy reach. The resident, who had hemiplegia and hemiparesis following a stroke, as well as moderate cognitive impairment, was observed lying in bed unable to access the call light, which was wrapped around the right bed rail and dangling near the floor. Despite care plan interventions specifying that the call light should be within reach and on the resident's usable side, both a CNA and an RN entered and exited the room without ensuring the call light was accessible to the resident, who could only use her left side due to right-sided weakness and a sling. Interviews with staff, including the RN, CNA, DON, and ADM, confirmed the expectation that call lights should be placed within reach and on the resident's functional side. The facility's policy also required providing residents with a means of communicating with nursing staff. However, these expectations were not met, as evidenced by direct observations and staff admissions, resulting in the resident being unable to call for assistance when needed.
Resident Elopement and Fall Due to Inadequate Supervision at Exit
Penalty
Summary
A deficiency occurred when a resident with profound intellectual disabilities, dementia, muscle wasting, and cognitive communication deficit was able to elope from the facility without staff knowledge. The resident, who utilized a wheelchair for mobility and was assessed as low risk for elopement on a recent evaluation, exited the facility by following a contract worker out the front door. The front door was held open by another resident, allowing the resident in question to leave the building unsupervised. Once outside, the resident self-propelled her wheelchair down the driveway, across the street, and into a median, where she bumped into the curb and fell out of her wheelchair. Staff members observed the incident and attempted to intervene, but were unable to reach her before she fell. The resident was assessed for injuries and sent to the hospital for further evaluation, where no significant injuries were found. She returned to the facility later that night at her baseline condition. Interviews and record reviews revealed that the receptionist, who was responsible for monitoring the front door and ensuring residents did not exit inappropriately, was not attentive to the residents exiting at the time of the incident. The facility's elopement binder did not previously include the resident, and staff were not consistently verifying the intentions of residents leaving the building. The deficiency was identified as Immediate Jeopardy due to the failure to provide adequate supervision and maintain a safe environment, resulting in the resident's unsupervised exit and subsequent fall.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. The survey revealed that food items in the walk-in refrigerator and freezer were not labeled or dated, which is a violation of food safety regulations. Specifically, containers of vegetable soup, chicken and pasta, tuna salad, breaded chicken filets, raw chicken, raw beef burger patties, ground meat, pie crust, and taquitos were found without labels or dates. Additionally, some items were not properly sealed, exposing them to potential contamination. The kitchen's cleanliness was also found to be substandard. The fryer was coated with dark grease, the microwave was soiled with dried food splatters, and the blender had a yellow-green residue. The toaster oven was covered in oil residue and crumbs, and the ice machine had a slimy residue and unknown substances inside. The kitchen floors were dirty, with puddles of juice and other fluids, and food debris scattered in various areas. Furthermore, the facility failed to maintain proper hand hygiene supplies, as there were no paper towels available at the handwashing station. This was observed when a dietary staff member offered a used rag to dry hands, which was declined. The Dietary Manager and Assistant Dietary Manager acknowledged these issues, stating that they expected food items to be labeled, dated, and sealed, and for the kitchen environment to be clean to prevent cross-contamination and foodborne illnesses.
Inadequate Infection Control in Laundry Area
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program in the laundry area, which was observed during a survey. Specifically, a staff member, LS A, was seen handling soiled linen without proper hand hygiene. After working with soiled linen, LS A rinsed her hands without using soap and moved to the clean linen area with wet hands, using hand sanitizer instead of drying them properly. The paper towel dispenser was empty, preventing proper hand drying. Additionally, the lint traps in the commercial-sized dryers were found with thick layers of lint, and there was no documentation of them being cleaned in January 2025. Interviews with the HS and ADM revealed that the facility's expectations were not being met. The HS stated that lint traps should be cleaned after each dryer use and logged accordingly, which LS A was unaware of. The ADM confirmed that handwashing with soap and water was expected before handling clean linen and that the handwash station should be stocked with necessary supplies. The facility's policies on laundry services and infection prevention emphasized the importance of these practices to prevent infection control issues.
Failure to Protect Residents' Personal Belongings
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by not adequately protecting the personal belongings of two residents from loss or theft. Resident #1, a male with severe cognitive impairment due to Alzheimer's disease, and Resident #2, a female with intact cognition, both experienced issues with missing clothing and belongings. Resident #1's family reported missing polo shirts and personal blankets, while Resident #2 expressed frustration over missing clothes and receiving items that did not belong to her. Both residents' medical records lacked an inventory list of their belongings. Interviews with the residents and staff revealed systemic issues in the facility's handling of residents' clothing. Resident #1 was unsure if an inventory was taken upon his arrival, and Resident #2 reported frequent issues with the laundry service, including receiving incorrect items. The housekeeping staff acknowledged that clothing often arrived at the laundry room without names, and efforts to return items to their rightful owners were inconsistent and ineffective. The facility had implemented a weekly audit system to address these issues, but it had not yet resolved the problem. The facility's administration acknowledged the expectation for nursing and laundry staff to manage and label residents' clothing properly. However, the lack of a consistent inventory and labeling system led to numerous grievances from residents about missing clothing. The facility's Resident Rights policy emphasizes the right to retain personal possessions and maintain a homelike environment, which was not upheld in this case, resulting in diminished quality of life for the affected residents.
Deficiencies in Personal Belongings Management and Smoking Area Cleanliness
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for its residents, specifically in protecting personal belongings from loss or theft and maintaining cleanliness in designated smoking areas. Resident #76, a [AGE] year-old man with schizoaffective disorder, bipolar type, paranoid schizophrenia, and mild neurocognitive disorder, reported missing several personal items, including shirts and shoes. The facility lacked a consistent process for inventorying and labeling residents' clothing, leading to frequent grievances about missing items. Interviews with staff revealed inconsistencies in the responsibility and execution of inventory management, with no clear policy or in-service training on handling missing items or maintaining inventory sheets. Additionally, the facility failed to maintain cleanliness in the smoking area, where numerous cigarette butts were observed scattered on the ground despite the presence of ashtrays. The designated smoking area, located in a pavilion in the facility's parking lot, was not adequately supervised or maintained, as evidenced by the accumulation of cigarette butts. Interviews with staff, including the DSD and ADM, indicated a lack of clarity regarding who was responsible for cleaning the area and ensuring residents disposed of cigarette butts properly. These deficiencies were observed during a survey, highlighting the facility's failure to uphold residents' rights to a safe and comfortable environment. The lack of a structured process for managing residents' personal belongings and maintaining cleanliness in common areas contributed to a diminished quality of life for the residents.
Failure to Implement Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which did not include measurable objectives and timeframes to meet their medical, nursing, and psychosocial needs. Resident #100, a male with severe cognitive impairment and multiple medical conditions, had no care planning related to recreational activities despite his expressed interests in various activities. There were no activity progress notes or documented tasks for him from admission to the end of the review period, and observations showed him consistently unengaged in activities. Resident #70, a female with moderate cognitive impairment and several medical diagnoses, had a care plan that lacked completion of the Activity Preferences section. Her care plan was generic and did not reflect her specific interests or preferences. There were no activity progress notes or documented tasks for her, and observations confirmed she was not engaged in any activities. Resident #104, a female with intact cognition and multiple medical issues, had a care plan that did not describe her specific activity interests. Like the other residents, there were no activity progress notes or documented tasks for her, and she was observed not participating in any activities. Interviews with staff revealed a lack of understanding and training on personalizing care plans, contributing to the deficiency. The facility's policy required comprehensive person-centered care plans, but this was not adhered to, placing residents at risk of diminished quality of life.
Failure to Provide Resident-Centered Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the preferences and needs of residents, as evidenced by the cases of three residents. Resident #27, a woman with multiple diagnoses including dementia and sensory impairments, was observed repeatedly lying in bed without music or television, despite her care plan indicating a preference for music and television. The Activity Director (AD) was unaware of her sensory impairments and did not ensure that her preferences were met, leading to a lack of engagement in activities. Resident #100, a male with severe cognitive impairment and multiple health issues, expressed a preference for reading materials, music, and outdoor activities. However, there was no care plan related to his recreational activities, and no activity tasks were documented for him. Observations revealed that he spent his time in bed without any engagement in activities, and he reported not being invited to participate in any facility activities. Resident #104, a female with intact cognition and various health conditions, also had no documented activity tasks or progress notes. Her care plan lacked specific activity interests, and she reported not being invited to activities. Observations showed her lying in bed without engagement in activities. The AD admitted to not being familiar with the residents' specific needs and preferences, and there was no documentation of activities being provided. The Director of Nursing (DON) and the Administrator acknowledged the inadequacy of the activity program, noting that one-to-one activities once a month were insufficient.
Failure to Accommodate Resident Meal Preferences
Penalty
Summary
The facility failed to provide food that accommodated the allergies, intolerances, or preferences of a resident, specifically Resident #24, who was reviewed for meal preferences. The resident's meal ticket indicated that all meats should be cut at all meals and listed dislikes including squash. However, during lunch on 10/28/24, dinner on 10/29/24, and lunch on 10/30/24, the facility did not cut the resident's meat as required, and on one occasion, served squash, which was listed as a disliked food. Resident #24, a [AGE] year-old female with essential tremor, lack of coordination, and muscle weakness, required assistance with personal care and had intact cognition as indicated by a BIMS score of 15. Despite her capability to cut her own meat, the resident found it difficult due to her tremors and expressed feeling unimportant because her meal preferences were not being followed. The facility's staff, including aides and the ADOR, failed to adhere to the meal ticket instructions, and the dietary manager acknowledged a three-fold failure in the process of preparing and serving meals. Interviews with the dietary manager, DON, and ADM revealed a lack of clarity and responsibility among staff regarding who should ensure meal tickets are followed. The dietary manager stated that aides, cooks, and nurses were supposed to follow meal tickets, but there was a failure in the process. The DON and ADM both indicated that the staff serving the meals were responsible for following the meal ticket instructions, but there was no recent training on this topic. This deficiency placed residents at risk of weight loss and diminished quality of life.
Infection Control Deficiencies in Hand Hygiene and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of non-compliance with hand hygiene and equipment sanitation protocols. During observations, it was noted that CNAs did not wash or sanitize their hands before and after providing peri care to residents. Specifically, CNA G and CNA F handled wet wipe packets with soiled gloves and failed to discard contaminated materials properly, potentially leading to cross-contamination. These actions were observed during care for residents with various medical conditions, including cognitive impairments and chemotherapy treatment, which increased their vulnerability to infections. Additionally, the facility's staff did not adhere to proper hand hygiene practices during meal service and medication administration. CNA J was observed failing to sanitize her hands between handling dirty and clean meal trays, while MA I did not sanitize her hands or medical equipment, such as a blood pressure cuff, between resident interactions. This lack of adherence to infection control protocols was observed during medication administration to residents with conditions such as dementia, hypertension, and diabetes, further increasing the risk of disease transmission. Interviews with staff, including the DON and MA I, revealed a lack of consistent understanding and implementation of the facility's infection control policies. Despite receiving training, staff members admitted to lapses in following hand hygiene and equipment sanitation procedures, acknowledging the potential for spreading infections. The facility's policies clearly outlined the need for hand cleansing before and after resident contact and equipment decontamination, yet these were not consistently followed, leading to the identified deficiencies.
Ineffective Pest Control Program in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies and cockroaches within the environment. Observations were made of a cockroach in a resident's room and multiple flies in another resident's room, as well as in the dining area. One resident expressed discomfort with the presence of bugs, while another resident reported that flies had been a persistent issue since their admission, despite having complained to staff multiple times. A CNA acknowledged the presence of flies but did not report it, understanding the potential for disease spread. The facility's pest control program, which involved bi-monthly treatments by a pest control agency, was found to be ineffective as insect activity continued. The facility's policy on pest control emphasized the use of pesticides only after other control measures were exhausted and required immediate reporting of pest sightings. However, the administration was unaware of the ongoing pest issues, indicating a breakdown in communication and reporting within the facility.
Failure to Ensure Resident Privacy and Dignity During Care
Penalty
Summary
The facility failed to ensure the privacy and dignity of two residents during personal care. In the first instance, a Licensed Vocational Nurse (LVN) provided wound care to a resident without closing the door or drawing the privacy curtain, leaving the resident exposed to the hallway. The resident, who had multiple diagnoses including COPD, heart failure, and dementia, did not notice the lack of privacy but acknowledged that he would be visible to others. The LVN admitted that the privacy and dignity of the resident were compromised and acknowledged awareness of the resident's rights to privacy, dignity, and respect. In the second instance, a Certified Nursing Assistant (CNA) provided peri care to another resident without closing the privacy curtain, although the door was closed. This resident, who had diagnoses including sepsis, COPD, and diabetes, was in a shared room and his bed was visible to anyone entering the room. The resident expressed that exposure would be embarrassing, and the CNA admitted to forgetting to close the curtain, acknowledging the lapse in respecting the resident's privacy and dignity. The Director of Nursing (DON) and the Administrator confirmed that privacy and dignity should be maintained during care, as per the facility's policy.
Failure to Provide Timely Dental Services
Penalty
Summary
The facility failed to assist a resident, identified as Resident #15, in obtaining timely dental services after her bottom dentures broke sometime after May 2024. Despite the resident's need for dental care, the facility did not ensure the repair or replacement of the dentures, which were sent to a lab for repair but were subsequently lost. The resident's dental progress notes indicated that the dentures were delivered back to the facility, but staff were unable to locate them, leading to a delay in the resident receiving necessary dental care. Resident #15, a female with multiple diagnoses including chronic obstructive pulmonary disease, dysphagia, and major depressive disorder, was dependent on staff for various activities of daily living. Her quarterly assessments showed no cognitive impairment, and she was on a regular diet. However, the absence of her bottom dentures made it uncomfortable for her to chew food, as observed during an interview where she expressed her discomfort and lack of communication from the staff regarding the status of her dentures. Interviews with facility staff, including the Administrator (ADM), Director of Nursing (DON), and the social worker (BSW), revealed a lack of effective communication and follow-up regarding the missing dentures. The facility's policy required prompt action within three business days for dental services, but this was not adhered to, resulting in the resident's prolonged discomfort and potential risk due to the inability to chew properly. The facility's failure to follow its dental services policy and effectively manage the situation contributed to the deficiency noted in the report.
Failure to Honor Resident Visitation Rights
Penalty
Summary
The facility failed to honor a resident's right to receive visitors of his choosing, leading to a deficiency in resident rights. A male resident, who was cognitively intact with a BIMS score of 15, was not allowed to visit with a family member. The facility's administration claimed the family member was banned due to allegations of bringing drugs and alcohol into the facility and sleeping in the resident's bed. However, there was no documentation or evidence provided to support these claims, and the resident was not informed in writing about the visitation ban. Interviews with staff, including LVNs, CNAs, and the DON, revealed inconsistencies in the facility's handling of the situation. Some staff members were unaware of the ban, and others had not observed any disruptive behavior from the family member. The ADM stated that the family member was banned for safety reasons, but there was no documentation of any incidents or law enforcement involvement. The facility's policies on visitation rights were not followed, as the resident was not given written notice or an opportunity for supervised visitation. The deficiency also affected another resident related to the banned family member, as the family member was not allowed to visit them either. The facility's failure to document the ban and communicate it effectively to staff and residents led to a violation of resident rights. The lack of evidence and documentation regarding the alleged disruptive behavior and the facility's failure to follow its own policies contributed to the deficiency.
Failure to Ensure Call Light Accessibility and Air Mattress Functionality
Penalty
Summary
The facility failed to ensure that residents had the right to reside and receive services with reasonable accommodation of their needs and preferences. Specifically, the facility did not ensure that the call lights were within reach for three residents, and there was no order to check the functioning of air mattresses for two residents. On the day of observation, the call lights for three residents were not accessible, with one resident's call light found under a fall mat and another's on the floor. Additionally, the air mattress for one resident was found deflated because it was not plugged in, and there were no orders for monitoring the air mattresses for two residents. Resident #1, a woman with cerebral palsy, autism, and congenital brain malformation, was observed with her call light under a fall mat and her air mattress deflated due to being unplugged. Her care plan indicated she was at risk for pressure injuries and required a pressure-reducing device. Resident #2, with dementia and muscle weakness, had her call light cord wrapped around the bed, leaving the button on the floor and out of reach. Resident #3, with Parkinsonism and severe cognitive impairment, had his call light cord wrapped around the bed rail, making it inaccessible. Resident #4, who was cognitively intact, reported his air mattress deflated every two hours, and the settings were not appropriate for his weight. Interviews with staff revealed a lack of consistent checks on call light placement and air mattress functionality. CNAs and LVNs acknowledged the importance of ensuring call lights were within reach and air mattresses were plugged in and set correctly. However, there was no facility policy regarding air mattresses, and staff were not consistently following procedures to ensure residents' needs were met. The Director of Nursing and Administrator both stated expectations that staff ensure residents have needed items within reach and that devices are functioning, but these expectations were not met in practice.
Failure to Address High Fall Risk in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included addressing the resident's high fall risk. The resident, a male with moderate cognitive impairment and multiple diagnoses including type II diabetes and generalized muscle weakness, was admitted and readmitted to the facility. Despite being identified as a high fall risk in the Fall Risk Assessment, the resident's care plan did not include any interventions to prevent falls. The deficiency was highlighted when the resident was found on the floor after falling from his bed. The Director of Nursing (DON) acknowledged that the care plan should have included interventions such as keeping the bed in a low position and ensuring the call light was within reach. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan with measurable objectives and timeframes, which was not adhered to in this case.
Lack of Private Telephone Communication for Residents
Penalty
Summary
The facility failed to ensure all residents had a private place for telephone communications without being overheard. This deficiency was observed for three confidential residents (CR #1, CR #2, and CR #3) out of five reviewed for private communications. The facility only provided a phone at the nurses' station for residents to use, which did not allow for private conversations. CR #1 expressed frustration and distress over the lack of privacy during a phone call, and staff confirmed that the only phone available for residents was at the nurses' station. The facility's administration was made aware of the issue but did not take immediate action to address it. During interviews, CR #2 and CR #3 also reported discomfort and the inability to have confidential phone conversations due to the lack of a private phone area. Staff members, including an LVN and the MDSC, acknowledged the importance of resident rights to private communications and recognized that the current setup did not meet these rights. The facility's Resident Rights Policy did not specifically address the right to private phone conversations, and the administration admitted to being unaware of the non-functional cordless phones that could have provided a solution.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Austin
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Heritage Park Rehabilitation And Skilled Nursing C | 4.2 mi | ★★★★★ | 8 | 1 |
| Brookdale Westlake Hills | 6.1 mi | ★★★★★ | 9 | 0 |
| Barton Valley Rehabilitation And Healthcare Center | 6.4 mi | ★★★★★ | 18 | 0 |
| The Arbour At Westminster Manor | 7.3 mi | ★★★★★ | 4 | 0 |
| Southpark Meadows Nursing And Rehabilitation Cente | 7.4 mi | ★★★★★ | 5 | 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.