Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverview Nursing & Rehabilitation during CMS and state inspections, most recent first.
A facility failed to maintain the women’s secure Unit B shower room in a safe and orderly condition. Surveyors observed the shower room door not fully latched, black duct tape covering the door jamb, strike plate, and latch hole, missing buttons on the electronic lock, and an uncovered shower floor drain with debris in it. Staff stated they were unsure how long these issues had been present, and the DON and Maintenance Director were unaware of the problems until survey observation.
A facility failed to maintain an effective pest control program to keep the building free of insects and rodents. A large roach was observed in a resident’s room, and another roach ran into the surveyor’s shoe and under the resident’s bed while the resident was present. The resident, who had encephalopathy, MDD, PTSD, moderate cognitive impairment, and frequent incontinence, said there were “thousands” of roaches and that they got on his belongings. An anonymous visitor complaint and two residents also reported roaches in the facility, despite repeated pest control visits targeting American and German cockroaches.
The facility failed to update comprehensive care plans within the required timeframe for four residents, following MDS assessments. This deficiency involved residents with various medical conditions, including cognitive impairments and mobility issues. Interviews revealed that care plan conferences were missed, potentially impacting the delivery of necessary care.
The facility's kitchen operations were found deficient in food safety standards. Observations revealed open food containers, a rat trap near food storage, and staff not adhering to hygiene protocols, such as wearing hairnets and gloves. These practices contradict the facility's policies on safe food handling.
The facility failed to maintain essential equipment in safe operating condition, with non-operational dryers, washers, and HVAC in the laundry, and an improperly supported deep fryer in the kitchen. The Maintenance Director and Administrator were aware of these issues, which violated the facility's sanitation policy.
The facility failed to maintain a safe and comfortable environment in the A and B wings. In the A Wing, window blinds were broken, and in the B Wing, mold was found on the shower tile and curtain. An LVN noted the blinds issue for maintenance, while a CMA/CNA and housekeeper confirmed the mold presence, with the latter unaware of it despite recent cleaning. The facility's cleaning policy was reviewed, but the maintenance policy was not provided.
The facility failed to report a smoke incident in the women's memory care unit's pantry closet to the appropriate authorities within the required timeframe. Staff engaged the fire alarm system, alerted the fire department, and used a fire extinguisher to address the smoke. Despite these actions, the incident was not reported to the state agency as required by the facility's policy and state law, as it was deemed not to involve flames or result in serious bodily injury.
The facility failed to report a smoke incident involving an exhaust fan in the women's Memory Care Unit to the State Survey Agency. The incident, which triggered the fire alarm and involved the local fire department, was not reported due to the absence of flames. Fourteen residents were evacuated and assessed for safety, but the facility's leadership decided the incident did not meet the criteria for reporting.
A facility failed to monitor a resident for edema as ordered by the physician, despite the resident's multiple health conditions. The LVN did not document edema checks, and the order was incorrectly entered into the EMR system. The DON acknowledged the potential health risks of not monitoring edema.
The facility failed to provide food at a safe and appetizing temperature, as a test tray was found lukewarm and the food temperature log was blank. Two residents reported their food was not hot. Dietary staff admitted to not properly recording food temperatures, contrary to facility policy.
A facility failed to ensure the safe and sanitary storage of food in a resident's personal refrigerator, where 3-4 Styrofoam cups with mold were found. The resident was asleep and had just returned from the hospital. Interviews with the DON and ADM confirmed the issue, and the cups were discarded. The facility's policy requires nursing staff to discard perishable foods by their use-by date and potentially hazardous foods left unrefrigerated for over two hours, indicating a lapse in policy adherence.
Two residents in a facility did not receive proper infection control care due to staff failing to adhere to Enhanced Barrier Precautions (EBP). One CNA provided catheter care without full PPE, while another CNA provided incontinent care without a gown, both unaware of the residents' EBP status. The lack of proper signage and staff awareness led to these deficiencies, risking cross-contamination.
The facility failed to properly dispose of garbage and refuse, as the left side door of the dumpster was found open. The Maintenance Director confirmed the issue and stated that staff were regularly instructed to keep the doors closed to prevent pest attraction. The Administrator was unaware of the open door, which could lead to pest and rodent issues. Facility policy and the U.S. Public Health Service Food Code require that refuse containers be covered with tight-fitting lids or doors.
The facility failed to provide proper pharmaceutical services, resulting in incorrect medication administration for a resident and expired medications in use. A resident received the wrong medication due to a misunderstanding by a medication aide, while two residents had insulin pens that were not discarded after the recommended 28-day period. Additionally, an expired sore throat spray was found in the medication room, indicating lapses in medication management and storage.
The facility failed to store food according to professional standards, as observed in the kitchen's dry goods pantry. An open and expired salsa container was found at room temperature, despite instructions to refrigerate after opening. The Dietary Manager confirmed the error and disposed of the salsa. Facility policy mandates refrigerated foods be stored below 41°F.
The facility failed to maintain a homelike environment in A Hall, a male secured wing, due to a persistent strong urine odor observed over several days. Despite regular cleaning and acknowledgment by the administrator, the odor remained, contradicting the facility's policy to minimize institutional odors.
A resident with severe cognitive impairment and multiple health issues had their call light inaccessible on two occasions, once behind a drawer chest and once on the floor. Staff acknowledged the oversight, and the facility's policy requires call lights to be within easy reach.
A facility failed to provide a safe environment and adequate supervision for a resident, resulting in a deficiency. A used disposable razor was found in a resident's bathroom, posing a risk of infection or injury. The resident required assistance with personal hygiene due to limited mobility. Staff interviews revealed that the razor should have been discarded in a sharps container after use, as per facility policy.
A resident with severe cognitive impairment and multiple medical conditions did not receive proper incontinent care, as a CNA used multiple passes with a single wipe to clean the genital area, contrary to facility policy. This improper technique, acknowledged by the CNA and the DON, could lead to urinary tract infections.
A resident receiving hospice care for a terminal condition was not provided with appropriate respiratory care, as their oxygen tubing and nasal cannula were left uncovered when not in use. This was against the facility's policy, which required the equipment to be covered to prevent infection. The oversight was acknowledged by both the LVN and the DON, highlighting a lapse in following professional standards of practice.
A resident in a facility obtained a lighter and started a fire in his room while on oxygen, despite being readmitted as a non-smoker. The facility lacked processes to check for smoking materials upon readmission and failed to maintain a designated smoking area with proper signage and equipment. Staff supervision during smoke breaks was inadequate, and there was inconsistent enforcement of the smoking policy.
The facility required all residents in the memory care units to use plastic utensils during meals due to safety concerns, while residents in the general population used metal silverware. This practice was inconsistently documented in care plans and affected residents' dignity and quality of life.
The facility failed to maintain a safe, clean, comfortable, and homelike environment in the Men's Secure Unit. Observations revealed missing room numbers, lack of personalization, disrepair of furniture, and dirty floors. The administration acknowledged these issues but could not provide documentation of efforts to address them prior to the survey exit.
The facility failed to adhere to food safety standards, including improper use of beard restraints, wearing jewelry while preparing food, and improper storage of dented cans. These actions could potentially lead to foodborne illnesses among residents.
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for two residents receiving hospice services. The hospice binders lacked required forms and documentation, which are essential to ensure residents receive adequate end-of-life care. An interview revealed that the social worker was unaware of the required forms, and the administrator was informed of the missing documentation during the survey.
The facility failed to ensure valid OOH-DNR forms for two residents. Both forms were missing the attending physician's date signed, license number, and printed name, rendering them invalid. The Social Worker and Administrator acknowledged the issue and agreed on the need for immediate correction.
The facility failed to maintain an effective pest control program in the Men's Secure Unit. A surveyor found a dead roach in a handrail and a live roach in a resident's bathroom. The LVN was unsure if the unit was included in recent pest control measures, and the Administrator was aware of general pest issues but not specific to the unit. Pest control records showed monthly visits, with the last on April 1, 2024.
The facility failed to protect residents from verbal and physical abuse by a CNA, who pinched, pulled, and verbally abused several residents. Despite complaints from residents and staff, the administration did not take immediate action, leading to multiple incidents of abuse.
The facility failed to report allegations of abuse involving two residents within the required time frame. Both residents reported verbally abusive behavior by a CNA, but the facility did not notify the State Survey Agency as required. Staff interviews revealed known issues with the CNA's behavior, but these were not properly documented or addressed.
Shower Room Door, Lock, and Drain Deficiencies
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in the women’s secure Unit B shower room. During observation, the shower room door was not fully closed and latched, and the door jamb, strike plate, and latch hole were covered with black duct tape. The electronic door lock had missing push buttons, including 5, 6, 7, and 9. Inside the shower room were two linen carts, a toilet, sink, and shower area behind a partial tiled wall, and no razors or chemicals were observed. The shower floor drain was observed to be open and uncovered, with what appeared to be hair and debris in the drain. A shower chair was inside the room, and the chair and floor were damp. MA C stated she was unsure how long the duct tape, missing lock buttons, and missing drain cover had been in place, and said she was not aware of any accidents or residents walking in on others during showers. LVN E stated residents had pulled the buttons off the electronic lock and was unsure whether it had been reported to maintenance. The DON stated she was unaware of the duct tape on the shower room door or the missing buttons on the lock. The Maintenance Director stated he was not aware the shower room floor drain cover was missing and said nothing had been entered into the maintenance reporting system about it. In a later observation, the duct tape had been removed and the electronic lock had been replaced, but the drain cover was still missing and debris remained in the uncovered drain. The Administrator stated the shower room door should not have had duct tape on it, the lock should work and have no missing buttons, and the drain cover should be in place.
Pest Control Program Failed to Keep Facility Free of Roaches
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and rodents. During observation, a large roach was seen on the wall in Resident #43’s room near the ceiling, and later another large roach ran into the surveyor’s shoe and went under the resident’s bed while the resident was present. The resident stated there were “thousands” of roaches around the facility, that they got on his belongings, and that someone had sprayed that day but it never helped. Resident #43 was an [AGE]-year-old male admitted to the facility with diagnoses including encephalopathy, major depressive disorder, and PTSD. His quarterly MDS showed clear speech, that he understood and was understood by others, a BIMS score of 9 indicating moderate cognitive impairment, frequent urinary and bowel incontinence, and daily rejection of care. His care plan documented refusal of care and hygiene, refusal of medications and labs, preference to eat in his room in the dark at times, and verbal aggression toward staff, with an off-cycle care conference held to address refusal of showers, clean clothing, and medications. The survey also included an anonymous visitor complaint reporting roaches crawling on belongings in the facility, and two residents in a group meeting reported seeing small roaches in the facility and said the facility needed to address the issue. Pest control invoices showed repeated visits over several months targeting American and German cockroaches in different areas of the facility, and an emergency visit was made after the roach was observed in Resident #43’s room. The facility policy stated it shall maintain an ongoing pest control program to ensure the building is kept free of insects and rodents.
Failure to Update Care Plans Timely for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed, reviewed, and revised within the required timeframe for four residents. Specifically, the care plans were not updated within seven days following the completion of the Minimum Data Set (MDS) assessments. This deficiency was identified for four residents, each with various medical conditions, including cognitive impairments, mobility issues, and chronic diseases. The lack of timely care plan updates could result in residents not receiving necessary care. For Resident #28, the care plan was not reviewed or revised after the MDS assessment conducted on February 17, 2025. The resident, who has multiple diagnoses including HIV, respiratory disease, and dementia, reported not being invited to a care plan conference recently. Similarly, Resident #35's care plan was not updated following a significant change MDS assessment on February 25, 2025, despite having conditions such as cerebral infarction and chronic pain. The resident also noted the absence of regular care plan conferences. Resident #33's care plan was not reviewed or revised throughout 2023, despite having conditions like Parkinson's disease and schizoaffective disorder. Additionally, Resident #20's care plan was not updated after several MDS assessments in 2024 and early 2025, despite severe cognitive impairment and multiple health issues. Interviews with facility staff revealed awareness of the missed care plan conferences, but no immediate corrective actions were documented in the report.
Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. In the storage room, a rice container was found with its lid open and a smaller container inside, while the flour container's lid was not tightly closed. Additionally, a rat trap box was located under the shelf where the flour container was stored. These conditions were confirmed by DM R, who acknowledged the need for containers to be closed to prevent pest contamination and expressed uncertainty about the presence of the rat trap box. Further observations revealed that DM Q was not wearing a hairnet while in the kitchen to take food temperatures, which was confirmed during an interview. Additionally, Dietary aide L was observed handling chicken patties without wearing gloves, a practice that contradicts the facility's policy on food handling. The facility's policies, dated November 2022 and November 2002, respectively, emphasize the importance of safe food handling practices, including the use of hair restraints and gloves to prevent foodborne illness.
Failure to Maintain Essential Equipment in Safe Condition
Penalty
Summary
The facility failed to maintain essential equipment in safe operating condition, as observed in the laundry and kitchen areas. In the laundry department, two out of three commercial dryers and one out of two commercial washers were not operational. Additionally, the HVAC system for the laundry facility was not functioning. The laundry aide reported that the equipment had been malfunctioning for over four to five months, and the Maintenance Director confirmed the issues, citing excessive coolant gas leaks in the HVAC system. The Administrator was aware of the malfunctioning equipment but had not been able to replace it. In the kitchen, the deep fryer was missing a leg and was propped up by a piece of wood, which was not a suitable conductor and posed a fire risk. The stove and deep fryer were not properly restrained, which could lead to accidents. The Maintenance Director acknowledged placing the wood under the fryer and admitted it was a fire hazard. The Administrator was unaware of the wood under the fryer leg. The facility's sanitation policy required all equipment to be maintained in good repair, but a specific policy for maintenance and operation of essential equipment was not provided upon request.
Facility Environment Deficiencies in A and B Wings
Penalty
Summary
The facility failed to maintain a safe, functioning, and comfortable environment for residents, staff, and the public in both the A and B wings. In the A Wing common room, three windows were observed to have missing, broken, or bent window blind slats. This issue was noted during observation rounds, and a Licensed Vocational Nurse (LVN) mentioned that the concern would be logged for maintenance. The facility administrator acknowledged the frequent need to replace window blinds due to damage by residents in the male unit. In the B wing, the shower area was found to have mold on the tile floor and mold spots on the shower curtain. A Certified Medication Aide/Certified Nursing Assistant (CMA/CNA) confirmed the presence of a black substance, identified as mold, in multiple areas. The housekeeper, who was unaware of the mold, stated that the shower had been cleaned the previous day and acknowledged that mold could cause illness to residents. The facility's policy on cleaning and disinfecting environmental surfaces, dated August 2019, was reviewed, but the facility maintenance policy was not provided at the time of the survey exit.
Failure to Report Smoke Incident in Memory Care Unit
Penalty
Summary
The facility failed to report an incident involving smoke from an exhaust fan in the women's memory care unit's pantry closet to the appropriate authorities within the required timeframe. On January 21, 2025, the exhaust fan began to produce large amounts of smoke, prompting staff to engage the fire alarm system, alert the fire department, and use a fire extinguisher to address the smoke. Despite these actions, the incident was not reported to the state agency as required by the facility's policy and state law, as it was deemed not to involve flames or result in serious bodily injury. Interviews with staff members, including CNAs and an LVN, confirmed the occurrence of the smoke incident and the subsequent evacuation of residents to a safe area. The staff took appropriate immediate actions to ensure resident safety, including evacuating residents to the courtyard and later to the lobby due to cold weather. The fire department responded, cleared the building for safety, and inspected the exhaust fan. However, the facility's leadership, including the Administrator, DON, and RDO, decided not to report the incident to the state agency, citing the absence of flames as the reason. A review of the facility's policy on reporting abuse, neglect, exploitation, or misappropriation revealed that all such incidents should be reported to local, state, and federal agencies as required by regulations. The policy specifies that incidents not involving abuse or resulting in serious bodily injury should be reported within 24 hours. Despite this policy, the facility did not report the smoke incident, which could place residents at risk for not reporting allegations of abuse, neglect, or exploitation.
Failure to Report Smoke Incident to State Agency
Penalty
Summary
The facility failed to report the results of an investigation regarding an alleged fire incident to the State Survey Agency within the required 5 working days. On January 21, 2025, an exhaust fan in the women's Memory Care Unit (MCU) produced a large amount of smoke, triggering the fire alarm and prompting a response from the local fire department. Despite the activation of the fire alarm and the involvement of the fire department, the facility did not report the incident to the state agency, as the facility's leadership determined that the absence of flames did not warrant such a report. The incident involved 14 residents in the women's MCU, who were evacuated to a secured courtyard and later to the facility's lobby due to cold weather. Staff, including CNA A and LVN D, were involved in the evacuation and subsequent safety assessments of the residents. The facility conducted an ad hoc Quality Assurance Improvement Plan meeting on the same day, which included various staff members and contractors to address the incident. However, the decision not to report the incident was made by the Regional Director of Operations and the Director of Nursing, based on their assessment that the lack of flames did not constitute a reportable event. The facility's policy on reporting abuse, neglect, exploitation, or misappropriation requires immediate reporting of such incidents to the administrator and relevant authorities. However, the decision by the facility's leadership not to report the smoke incident to the state agency was based on their interpretation of the policy, which did not consider the smoke incident as meeting the criteria for reporting. This decision was made despite the facility's policy stating that all reports of resident abuse, neglect, exploitation, or injuries of unknown origin must be reported to local, state, and federal agencies as required by current regulations.
Failure to Monitor Edema as Ordered
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice. Specifically, the facility did not follow the physician's orders to monitor for edema in a resident with multiple health conditions, including Diabetes Type 2, COPD, and heart disease. The resident's care plan included monitoring for complications related to COPD, but the physician's order to check for edema every shift and report any abnormalities was not followed. Observations of the resident on multiple occasions revealed no noted edema, but the monitoring was not documented in the Medication Administration Record (MAR). Interviews with facility staff revealed that the Licensed Vocational Nurse (LVN) responsible for the resident's care had not documented edema checks in the MAR or progress notes, despite acknowledging the importance of monitoring for sudden increases in edema. The Assistant Director of Nursing (ADON) indicated that the order was incorrectly entered into the Electronic Medical Record (EMR) system and was not linked to the appropriate medication order. The Director of Nursing (DON) acknowledged that failure to monitor edema could lead to serious health consequences for the resident. The facility's policy and procedures for following physician's orders were requested but not provided.
Failure to Maintain Safe and Palatable Food Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at a safe and appetizing temperature, as evidenced by a test tray observation and resident interviews. During a lunch observation, a test tray containing a chicken patty melt was found to be lukewarm rather than hot. This issue was corroborated by interviews with two residents who reported that their food was not hot. Additionally, the food temperature log for the lunch meal was found to be blank, indicating a lack of proper documentation. Interviews with dietary staff revealed that the food temperatures were taken but not properly recorded. Dietary Aide L admitted to taking the temperatures and writing them on a piece of paper, which was subsequently misplaced. The Dietician consultant acknowledged the need for staff education on maintaining a food temperature log for every meal. The facility's policy on food preparation and service emphasizes compliance with safe food handling practices, including monitoring food temperatures throughout meal service, which was not adhered to in this instance.
Failure to Ensure Safe Storage of Resident's Food
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of foods brought to residents by family and other visitors, as evidenced by the condition of a resident's personal refrigerator. During an observation, it was noted that the refrigerator contained 3-4 Styrofoam empty cups with mold in them. The resident was asleep at the time of the observation and had recently returned from the hospital. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed the presence of the moldy cups, and the ADM stated that the cups were subsequently discarded. A review of the facility's policy on foods brought by family and visitors indicated that nursing staff are responsible for discarding perishable foods on or before their use-by date and potentially hazardous foods left unrefrigerated for more than two hours. However, the presence of moldy cups suggests a lapse in adherence to this policy.
Inadequate Infection Control Practices in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of adherence to Enhanced Barrier Precautions (EBP) for two residents. The first incident involved a CNA providing catheter care to a resident with an indwelling urinary catheter without donning the appropriate Personal Protective Equipment (PPE). The CNA only wore gloves and was unaware of the resident's EBP status, believing that gloves alone were sufficient for infection control. This oversight occurred despite the resident's care plan indicating the need for EBP due to the risk of infection related to the urinary catheter. In the second incident, another CNA provided incontinent care to a resident with a colostomy without wearing a gown, which is part of the required PPE under EBP. The CNA was confused about the resident's EBP status due to the absence of signage on the resident's door, which led to the improper use of PPE. The resident's care plan also indicated the need for EBP to reduce the risk of spreading infections due to the colostomy status. The Director of Nursing (DON) confirmed that the expectation was for staff to use gowns and gloves for residents with indwelling medical devices or colostomy bags under EBP. The facility's failure to ensure proper PPE use during high-contact resident care activities, as outlined by the Centers for Disease Control and Prevention (CDC), placed residents at risk for cross-contamination and the spread of communicable diseases.
Improper Disposal of Garbage and Refuse
Penalty
Summary
The facility failed to ensure proper disposal of garbage and refuse, as observed on March 6, 2025, when the left side door of the dumpster was found open. This deficiency was noted during an observation at 10:50 AM. The Maintenance Director confirmed the door was open and stated that he regularly instructed staff to keep the dumpster doors closed, emphasizing that open doors could attract pests. The Administrator was unaware of the open dumpster door and acknowledged the potential for pest and rodent issues. A review of the facility's policy from November 2022 indicated that garbage and refuse containers should be in good condition, without leaks, and properly contained with lids. Additionally, the U.S. Public Health Service Food Code requires that receptacles for refuse be kept covered with tight-fitting lids or doors if located outside the food establishment.
Pharmaceutical Service Deficiencies in Medication Administration and Storage
Penalty
Summary
The facility failed to provide appropriate pharmaceutical services for three residents and in one medication room. Resident #4 was administered milk of magnesia instead of the prescribed Geri-Lanta for gastro-esophageal reflux disease. The medication aide mistakenly believed the two medications were the same, leading to the incorrect administration. The Director of Nursing (DON) confirmed that the two medications serve different purposes and emphasized that the aide should have consulted a charge nurse if there was any confusion. For Resident #42, an insulin flex pen (Aspart) was found in the nursing cart beyond its 28-day usage period after being opened. The Assistant Director of Nursing (ADON) acknowledged that the insulin should have been discarded after 28 days, as per standard care practices. Similarly, Resident #38's insulin flex pen (Lantus) was also found in the nursing cart past its 28-day usage period. The DON confirmed that both insulin pens should have been discarded according to the standard care guidelines. Additionally, an expired Cherry Flavor Sore Throat Spray was found in the medication room. The Licensed Vocational Nurse (LVN) acknowledged the presence of the expired medication and stated that nurses are responsible for checking and discarding expired medications as per facility policy. The failure to remove expired medications could lead to their use, potentially resulting in ineffective treatment.
Improper Food Storage in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in the kitchen. During an observation of the kitchen's dry goods pantry, an open container of salsa was found stored at room temperature, despite being labeled with instructions to refrigerate after opening. The salsa container was also expired. This was confirmed during an interview with the Dietary Manager, who acknowledged the error and disposed of the salsa. The facility's policy on food storage requires refrigerated foods to be stored below 41 degrees Fahrenheit unless otherwise specified by law.
Persistent Urine Odor in A Hall
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment in A Hall, a male secured wing, as evidenced by a strong urine odor observed on multiple occasions. On 10/15/24, a strong urine odor was noted in the hallway, which persisted during observations on 10/17/24 and 10/18/24. The facility's administrator acknowledged the issue and mentioned that a deep clean would be conducted. Despite some improvement noted on 10/16/24, a pungent smell remained. Interviews with staff, including a housekeeper, confirmed regular cleaning practices, but the odor persisted. The facility's policy on maintaining a homelike environment emphasizes minimizing institutional odors, which was not achieved in this instance.
Call Light Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, which is a necessary accommodation for resident needs. On two separate occasions, the call light for a resident with severe cognitive impairment and multiple health issues, including cerebral infarction and heart failure, was not accessible. On the first occasion, the call light was found behind a drawer chest, and on the second occasion, it was on the floor, two feet away from the resident's bed. This oversight was observed by staff members, including a CNA and an MA, who acknowledged that the call light was not within reach and that the resident sometimes used it for help. Interviews with staff, including a CNA, an MA, an LVN, and the DON, confirmed that the call light should have been within reach at all times. The facility's policy on answering call lights, revised in 2010, also states that the call light should be within easy reach of the resident when they are in bed or confined to a chair. Despite the resident's general tendency not to use the call light, staff recognized the importance of having it accessible for when the resident might need assistance.
Failure to Ensure Safe Environment and Supervision
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident, leading to a deficiency in accident prevention. During an observation, a used disposable razor was found on the sink faucet in the bathroom of a resident who had limited mobility and required assistance with personal hygiene. The resident, who had a history of intracranial injury, hemiplegia, anxiety disorder, dementia, and muscle wasting, was cognitively intact but needed supervision for daily activities. The presence of the razor posed a risk of infection or physical injury to the resident and others. Interviews with staff revealed that the resident could not use the razor independently, and it was the staff's responsibility to dispose of used razors in a sharps container after use. The LVN acknowledged seeing the razor and stated that staff might have used it to shave the resident's beard but failed to discard it properly. The DON confirmed that staff should have discarded the razor to prevent infection and injury, aligning with the facility's policy to maintain a safe environment free from accident hazards.
Improper Incontinent Care Technique
Penalty
Summary
The facility failed to provide appropriate incontinent care to a resident, which could lead to urinary tract infections. During an observation, two CNAs were providing urinary incontinence care to a resident. One of the CNAs cleaned the resident's genital area using multiple passes with a single wipe, contrary to the facility's policy that requires using a new wipe for each stroke. This improper technique was acknowledged by the CNA during an interview, who admitted that the correct procedure should involve a single pass with one wipe to prevent possible urinary tract infections. The resident involved was an elderly male with severe cognitive impairment and multiple medical conditions, including cellulitis, cerebral infarction, dysphagia, type 2 diabetes mellitus, muscle wasting, and hyperlipidemia. The resident required substantial assistance for toilet hygiene and was frequently incontinent of bowel and bladder. The facility's care plan for the resident included checking for incontinence every 2 to 3 hours and ensuring proper cleaning to prevent urinary tract infections. However, the observed care did not adhere to these guidelines, as confirmed by the Director of Nursing, who acknowledged the potential risk of infection due to the improper cleaning technique.
Failure to Properly Store Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident who required oxygen therapy, as observed during a survey. The resident, who was cognitively intact and receiving hospice care due to a terminal condition related to cerebral infarction, had an order for medical oxygen to be administered as needed for dyspnea. However, during an observation, it was noted that the resident's oxygen tubing and nasal cannula, connected to an oxygen concentrator, were not covered in a plastic bag when not in use. This oversight was acknowledged by the LVN, who confirmed that the equipment should have been covered to prevent potential infection. Further interviews with the Director of Nursing corroborated that the facility's policy required the oxygen tubing and nasal cannula to be covered when not in use to prevent respiratory infections. The facility's policy on oxygen administration, revised in 2010, was reviewed and indicated that used supplies should be discarded into designated containers. The failure to adhere to these guidelines could lead to infections, as the equipment was not maintained according to professional standards of practice.
Failure to Prevent Smoking Hazards and Ensure Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards, particularly concerning smoking materials. A resident, who had been assessed as a safe smoker, managed to obtain a lighter and set a piece of paper on fire in his room while his oxygen concentrator was on. This incident occurred despite the resident being readmitted as a non-smoker with a nicotine patch. The staff did not have a process in place to check for smoking paraphernalia upon the resident's return from the hospital, and the resident was not asked if he had any smoking materials in his possession. The facility also failed to maintain a designated smoking area with appropriate signage and metal ashtrays. Observations revealed that residents were disposing of cigarette butts on the ground, and there were no signs indicating the smoking area. Staff supervision during smoke breaks was inadequate, as residents were left unsupervised at times, and there was a lack of proper equipment to safely dispose of smoking materials. Interviews with staff and residents highlighted a lack of consistent enforcement and understanding of the facility's smoking policy. Staff were not routinely asking residents or their families about smoking paraphernalia upon readmission or return from outings. Additionally, there was no clear process for ensuring that residents did not have access to smoking materials, which contributed to the incident involving the resident starting a fire in his room.
Use of Plastic Utensils in Memory Care Units
Penalty
Summary
The facility failed to treat each resident with respect and dignity by requiring all residents in the male and female memory care units to use plastic utensils during meals, while residents in the general population were allowed to use metal silverware. This decision was made due to safety concerns, as residents had previously used metal utensils as tools to attempt elopement. During a dining observation, residents were seen eating with plastic utensils, and staff confirmed that this practice was care planned for all residents in the memory care units. However, the care plans for some residents did not include this focus, indicating inconsistency in documentation. Resident #44, who was cognitively intact with a BIMS score of 13, had a care plan that included the use of plastic utensils due to the potential for using metal utensils as tools for elopement. Other residents, such as Resident #65 and Resident #53, had severe cognitive impairments or other significant medical conditions but did not have care plans reflecting the use of plastic utensils. The facility's actions placed residents at risk for diminished quality of life, loss of dignity, and self-worth, as they were not treated with the same respect and dignity as other residents in the general population.
Failure to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for residents in the Men's Secure Unit. Observations from 4/23/24 through 4/26/24 revealed that most of the room numbers were missing, and none of the 15 rooms were personalized with pictures or decorations. Additionally, the furniture in the resident rooms was in disrepair, with examples including drawers off track and knobs missing. The floors appeared dirty, with specific instances of sticky substances observed on the floor in some rooms. These conditions were confirmed through interviews with the facility's administration, who acknowledged the issues but could not provide documentation of efforts to secure additional furniture or decorations prior to the survey exit. During an interview, the administrator stated that the facility was in the process of replacing beds and furniture and acknowledged that many nightstands were off track. The administrator also mentioned plans to strip and wax the floors. However, the administrator admitted that attempts to decorate the rooms had been unsuccessful as residents tended to tear down the decorations. The administrator could not provide any documentation of efforts to address these issues before the survey exit, indicating a lack of proactive measures to ensure a safe and homelike environment for the residents.
Failure to Adhere to Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Observations revealed that the Dietary Manager, Cook, and Dietary Aid were not wearing beard restraints while working in the kitchen. Additionally, the Visiting Dietary Manager was observed wearing jewelry while preparing food. These actions are against the professional standards for food safety and could potentially lead to foodborne illnesses among residents. Further observations in the kitchen's dry storage area revealed a dented can of tomatoes, which had been received several months prior, stored alongside other usable canned goods. The facility did not have a written policy for handling dented cans, and staff were unsure of the proper procedures for dealing with them. This lack of policy and improper storage practices could lead to the use of compromised food products. Interviews with the kitchen staff confirmed that they were aware of the requirements for hair and beard restraints and the prohibition of jewelry while preparing food. However, these standards were not consistently enforced. The facility also lacked specific policies for the storage and disposal of dented cans, further contributing to the deficiencies observed during the survey.
Failure to Coordinate Hospice Care and Maintain Required Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. Specifically, the facility did not maintain the required hospice forms and documentation in the current hospice binders, which are essential to ensure residents receive adequate end-of-life care. This deficiency was identified for two residents, one with diagnoses including Methicillin Resistant Staphylococcus Aureus infection, acute and chronic respiratory failure, unspecified dementia, anorexia, generalized anxiety disorder, and chronic systolic heart failure, and another with diagnoses including unspecified cirrhosis of the liver, senile degeneration of the brain, myelodysplastic syndrome, and Hodgkin lymphoma. Both residents had care plans documenting death and dying issues related to their terminal conditions and were receiving hospice services. During the survey, it was found that the hospice binders for these residents lacked required forms such as the hospice election form and certification of terminal illness by the physician, as well as evidence of coordination of care plans between the hospices and the facility. An interview with the social worker revealed that she was unaware of the required forms from hospice, and the administrator was informed of the missing documentation during the interview. The required forms and documentation were provided to the surveyor before the exit of the survey, but the initial failure to maintain these documents could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.
Invalid OOH-DNR Forms for Two Residents
Penalty
Summary
The facility failed to ensure that residents had the right to formulate an advance directive, specifically an Out of Hospital Do Not Resuscitate (OOH-DNR) form, for two residents. Resident #44's OOH-DNR form, dated 02/17/22, was invalid because the attending physician's date signed, license number, and printed name were missing. Resident #44, a cognitively intact male with diagnoses including unspecified intracranial injury and dementia, had his care plan indicating a DNR status, but the form was not properly executed by the physician. Similarly, Resident #65's OOH-DNR form, dated 03/06/24, was also invalid due to the same missing physician information. Resident #65, a severely cognitively impaired male with diagnoses including cirrhosis of the liver and Hodgkin lymphoma, had his care plan indicating a DNR status. During an interview, the Social Worker (SW) acknowledged the missing documentation and agreed that the forms needed correction. The Administrator was also informed and agreed on the need for immediate correction. The SW, who had recently taken the position, stated she would audit all DNR forms to ensure their validity.
Pest Control Deficiency in Men's Secure Unit
Penalty
Summary
The facility failed to maintain an effective pest control program in the Men's Secure Unit. During an observation, a surveyor found a dead roach in the bottom of a handrail and a live roach in the bathroom of a resident's room. The Licensed Vocational Nurse (LVN) on duty mentioned that pest control had sprayed three days prior but was unsure if the Men's Unit was included. The LVN also stated that housekeeping cleans daily but had not yet been to the unit that day. The Administrator acknowledged awareness of pest control issues but had not heard of specific bug issues in the unit. A review of the pest control records showed that the pest control company visits monthly and upon request, with the last visit recorded on April 1, 2024.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents' rights to be free from verbal abuse, physical abuse, and involuntary seclusion. On 01/11/24, CNA A was reported to have pinched, pulled, and verbally abused Residents #2, #5, and #6. Additionally, CNA A was observed arguing disrespectfully with Resident #4 and being physically aggressive with Resident #7. Residents #1 and #3 also reported verbal abuse by CNA A, although the exact dates were not specified. These incidents were corroborated by witness statements from other staff members who observed or were informed about the abusive behavior. Resident #2, a female with severe cognitive impairment, was found with a slight discoloration on her left forearm. Resident #5, also with severe cognitive impairment, and Resident #6, with Alzheimer's disease, were subjected to similar abusive actions by CNA A. Resident #4, with severe cognitive impairment, was argued with in a disrespectful manner by CNA A. Resident #7, with severe impairment, was aggressively handled by CNA A, who forcefully sat her down and shoved a baby doll into her arms. Residents #1 and #3, both with moderate to intact cognition, reported verbal abuse by CNA A, which was not initially addressed by the facility's administration. Interviews with various staff members revealed that CNA A had a history of being impatient and aggressive with residents, particularly those in the women's secure unit. Despite complaints from residents and staff about CNA A's behavior, the facility's administration did not take immediate action to address these concerns. It was only after the incidents on 01/11/24 that CNA A was suspended and an investigation was initiated. The facility's failure to promptly address the abusive behavior of CNA A led to multiple residents experiencing physical and verbal abuse, as well as involuntary seclusion.
Failure to Report Allegations of Abuse Timely
Penalty
Summary
The facility failed to report allegations of abuse, neglect, exploitation, or mistreatment involving two residents within the required time frame. Resident #1 and Resident #3 both reported not wanting care from CNA A due to verbally abusive behavior. Despite these reports, the facility did not notify the State Survey Agency as required. Resident #1, who had moderate cognitive impairment, reported being yelled at multiple times by CNA A and informed a nurse and the administrator, but no action was taken. Similarly, Resident #3, who had intact cognition, reported being yelled at by CNA A and informed a CNA, the ADON, and the administrator, but again, no action was taken. Interviews with staff revealed that there were known issues with CNA A's communication and behavior, but these were not properly documented or addressed. LVN B and MA C acknowledged that CNA A's behavior could overwhelm residents due to a language barrier and inappropriate responses. The ADON admitted that she did not investigate why residents did not want CNA A to care for them and failed to document any complaints. The facility's grievance records showed no complaints related to CNA A, indicating a lack of proper documentation and follow-up on resident grievances.
What surveyors are citing around you — mapped
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What surveyors actually found near you
We read the 540 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Boerne
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cibolo Creek | 0.1 mi | ★★★★★ | 12 | 1 |
| Care Choice Of Boerne | 1.1 mi | ★★★★★ | 17 | 0 |
| Town And Country Nursing And Rehabilitation Center | 1.3 mi | ★★★★★ | 5 | 0 |
| Kendall House Wellness & Rehabilitation | 1.3 mi | ★★★★★ | 7 | 0 |
| Estates At Shavano Park | 16.9 mi | ★★★★★ | 20 | 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 July 2026) and official state health department websites.