Above 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 during CMS and state inspections, most recent first.
Failure to Assess Self-Administration of Medications: A cognitively intact resident was observed with a medication cup left at the bedside for independent use, including senna that staff reportedly left for her to take based on how she felt. Although the resident had been assessed for self-administration during a prior stay, she did not have a current self-administration assessment, physician order, or care plan documentation after returning to the facility, and the DON confirmed she lacked current authorization for self-administration.
A resident with colitis, anemia, CKD, DM2, and moderate cognitive impairment developed dark tarry stools, a positive hemoccult, and abnormal CBC/BMP results including low Hgb/Hct and low sodium. Nursing documented the findings and emailed the PA, but the record did not show timely provider consultation regarding the abnormal labs until the PA later reviewed them and ordered ED transfer for increased weakness with known GI bleed, anemia, low Na+, and low Mg. The DON stated the labs should have been reported immediately by phone.
A resident with multiple chronic conditions and severe cognitive impairment experienced severe unintentional weight loss while having frequent poor meal intake. Although weights repeatedly fell below the care plan and MD parameters and the electronic record flagged the losses, staff did not recheck the weights, notify the MD or RD, or update the care plan. Interviews showed CNA, LPN, charge nurse, RD, and DON awareness of the weight-loss process, but the resident’s decline was not escalated and no new nutrition interventions were documented.
Undated eye drop bottles were found on two medication carts during a medication storage observation. One resident had latanoprost for glaucoma, and another had brimonidine for glaucoma and macular degeneration; both bottles were opened but lacked open dates, despite the facility policy requiring multi-dose containers to be dated when opened. The DON confirmed opened eye drops should have an open date and should not remain in circulation without one.
A resident with severe cognitive impairment, bilateral lower extremity amputations, and metastatic cholangiocarcinoma was enrolled in hospice, but the hospice binder at the nurse's station was empty and no hospice notes or care plan were found in the chart. Staff interviews showed confusion about where hospice records were kept and who was responsible for obtaining them, and the hospice RN said visit notes and the care plan should have been part of the resident's medical record.
A resident with severe cognitive impairment was left vulnerable to further abuse after a CNA witnessed another CNA strike the resident and left to report the incident. The facility failed to immediately remove the alleged abuser, leading to a finding of immediate jeopardy. The police observed physical signs of abuse, and the CNA admitted to the act, resulting in arrest.
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to the development and worsening of pressure injuries. Residents were not repositioned as required, and there was a lack of documentation regarding refusals to reposition. This resulted in new and worsening pressure injuries, despite existing care plans and interventions.
The facility did not follow food safety protocols during meal preparation and distribution. A CNA prepared and served breakfast without changing gloves after touching contaminated surfaces, and another CNA delivered uncovered meal trays to residents, exposing food to potential contamination.
During a COVID-19 outbreak, a facility failed to adhere to CDC guidelines for PPE use, particularly in a dementia unit. Staff were observed not changing N95 masks after leaving precaution rooms, not using eye protection, and neglecting hand hygiene between glove changes. Residents with COVID-19 were seen wandering without masks, and staff entered rooms with contact precautions without proper PPE. The infection preventionist admitted the facility had modified CDC guidance without a supply issue justification.
Failure to Assess Self-Administration of Medications
Penalty
Summary
The facility did not ensure that all residents were clinically appropriate to self-administer medications for one sampled resident. R49 was observed in her room with a medication cup containing a red pill left on her bedside table for her to take independently, along with another cup containing a spoon and what appeared to be yogurt or pudding. When asked about the pill, R49 identified it as senna and stated that staff leave it for her because she takes it depending on how she feels, since she has intermittent constipation and diarrhea. R49 was cognitively intact with a BIMS score of 15 and had previously been assessed during an earlier stay to self-administer certain medications. However, after returning to the facility, she did not have a current self-administration assessment, physician order, or care plan documentation indicating that she could self-administer medications. An LPN stated that R49 had previously had an order to self-administer certain medications but no longer did after her return, and the DON stated that R49 did not currently have a self-administration assessment or order and should have been reassessed and care planned again with the new admission.
Failure to Immediately Notify Provider of Abnormal Labs and Change in Condition
Penalty
Summary
The facility failed to immediately notify and consult the resident’s physician when the resident had a change in condition and abnormal lab results. The resident was admitted with diagnoses including colitis, hypomagnesemia, anemia, DM type 2, CKD stage 3b, and debility, and had a BIMS score of 11/15. During the stay, nursing documented multiple dark tarry stools and a positive hemoccult test, along with ongoing loose stools and later abdominal firmness and distention. The facility policy required provider notification for abnormal lab values and significant changes in condition. On 10/19/25, nursing documented dark tarry stools and a positive hemoccult, and the charge RN documented that the physician was notified and ordered a CBC and BMP. The resident’s labs were drawn and later faxed from the hospital on 10/20/25, showing abnormal values including hemoglobin 8.5, hematocrit 26.9, erythrocytes 3.07, elevated RDW, elevated leukocytes and neutrophils, sodium 130, and chloride 130/96 as documented in the record. A charge RN emailed PA E asking for review of the results and any new orders, but the record did not show that the provider was consulted regarding the abnormal lab results at that time. The resident continued to have multiple loose, dark, and black tarry stools, with notes documenting hemoccult-positive stool, minimal cough, and later a firm and distended abdomen. On 10/21/25, PA E reviewed the labs in person and ordered the resident sent to the ED for increased weakness with known GI bleed and anemia, decreased sodium, and decreased magnesium. Surveyor review and interview with the DON indicated staff should have reported the labs to the provider immediately and by phone, and the DON stated the delay in notifying the provider was unacceptable.
Failure to Address Severe Unintentional Weight Loss
Penalty
Summary
The facility failed to recognize, evaluate, and address a resident’s nutritional and hydration needs when the resident experienced severe unintentional weight loss. The resident had diagnoses including hemiplegia and hemiparesis following cerebral infarction with right-sided weakness, congestive heart failure, chronic kidney disease stage 3, type 2 diabetes mellitus, aphasia following stroke, vascular cognitive impairment, and reduced mobility. The resident’s MDS showed severe cognitive impairment with a BIMS score of 3, required set up and/or clean up assistance with eating, and did not have a swallowing disorder. The resident’s care plan included a goal to maintain weight within 145-155 pounds, with interventions such as a low calorie sweetener diet, snacks, ordered vitamins and probiotic, notification to dietary if weight dropped below 145 pounds, and use of a deep divided plate. Physician orders directed weights twice weekly and notification to the MD if weight loss exceeded 3 pounds in a week or if the resident was out of the 150-165 pound goal range. Despite these parameters, the resident’s documented weights declined from 145.6 pounds to 137.2 pounds over about one month, including a nearly 5-pound loss in one week and repeated weights below the goal range. The electronic health system flagged several of these weights, but there was no indication that the weight was rechecked for accuracy, the physician or RD was notified, or the care plan was updated with new interventions. Meal intake documentation from the same period showed frequent poor intake, including multiple refusals or no intake, many meals at 1-25%, and additional meals at 26-50%. The resident was observed eating breakfast in the room and had only a few bites of the meal. Staff interviews showed CNA staff were responsible for recording weights and notifying nurses of changes, but the CNA had not notified the nurse of the resident’s weight loss. An LPN stated she had not notified the physician or charge nurse about the recent weight loss. The charge nurse stated she would normally notify the PA and discuss possible nutritional supplements, but said the resident’s POA did not want supplements and that staff were encouraging snacks, although no snacks had been charted. The RD stated the severe weight loss was news to her and that she had not been notified, even though she expected to be informed so she could monitor the resident and make recommendations. The DON also stated the weight loss was severe and that the RD should have been notified.
Undated Eye Drop Bottles Found on Medication Carts
Penalty
Summary
The facility did not ensure that drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. During medication storage observation, surveyors found two medication carts with opened eye drop bottles that did not have open dates documented: R2’s latanoprost eye drops and R47’s brimonidine eye drops. The report states that the facility policy required the date opened to be recorded on multi-dose containers and that the expiration or beyond-use date must be checked before administration. R2 was admitted with primary open-angle glaucoma and was cognitively intact per the Quarterly MDS assessment. R2 had a physician order for latanoprost eye drops, 1 drop in both eyes at bedtime, and the EMAR showed the medication was being administered during the month reviewed. On observation, the latanoprost bottle was opened and undated on the medication cart. The CMA stated the bottle should be dated when opened, but the open date was unknown, and the bottle would be removed from the cart and reordered. R47 was admitted with nonexudative age-related macular degeneration of the right eye, exudative age-related macular degeneration of the left eye, and primary open-angle glaucoma. The Quarterly MDS showed severe cognitive impairment. R47 had an order for brimonidine eye drops, 1 drop in the right eye twice daily, and the EMAR showed the medication was being administered during the month reviewed. On observation, the brimonidine bottle was opened and undated on the medication cart. The CMA stated the bottle should have an open date, could not determine when it was opened, and said it was expired without knowing the open date. The DON later stated opened eye drop bottles should have an open date and that undated bottles should not be on the medication cart in circulation for use.
Missing hospice documentation for a resident enrolled in hospice
Penalty
Summary
The facility did not ensure that a resident receiving hospice services had hospice documentation available in the medical record. R6 was admitted to the facility with diagnoses including acute kidney failure, type 2 diabetes mellitus, and COPD, and the most recent MDS indicated severe cognitive impairment with a BIMS score of 4 out of 15. R6 was also dependent on staff for toileting and transfers, required substantial to maximal assistance for lower body dressing, and had bilateral lower extremity amputations. R6 was admitted to hospice with a primary diagnosis of metastatic cholangiocarcinoma, and the hospice admission note stated that a hospice binder was provided to the facility. Surveyor review found that R6's hospice binder at the nurse's station was empty. The resident's comprehensive care plan identified that the resident was enrolled in hospice and stated that hospice and facility staff would provide collaborative care, but the surveyor could not locate hospice notes or the hospice care plan in the electronic medical record. The HUC stated that hospice notes and the care plan were typically scanned into the chart, but when the chart was accessed, no hospice documentation was present. The HUC also stated that the binder was empty and that hospice records could be requested if needed. Interviews with facility staff showed uncertainty about where hospice documentation was maintained and who was responsible for obtaining it. The charge nurse stated she did not know whether hospice would provide documentation unless changes were made, and the DON stated that charge nurses were responsible for communicating with hospice and obtaining documentation. The hospice RN stated that he had seen R6 several times and usually faxed notes to the facility after visits, but he had been notified that the facility was not receiving the hospice documentation and said the care plan, visit notes, and IDT meetings should be part of the resident's medical record.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by a staff member, which resulted in a finding of immediate jeopardy. On the night of January 6, 2025, a Certified Nursing Assistant (CNA) witnessed another CNA strike a resident across the face. The witnessing CNA left the resident alone with the alleged abuser to report the incident to the nursing staff, leaving the resident at risk for further abuse. The resident, who had severe cognitive impairment and a history of physical and verbal agitation, was left vulnerable during this time. The incident was reported to a Registered Nurse (RN) who attempted to contact the Nursing Home Administrator and Director of Nursing but was unable to reach them. The RN then called the police to report the incident. Upon entering the unit, the RN found the alleged abuser still with the resident, indicating a delay in removing the staff member from the situation. The police arrived and observed physical signs of abuse on the resident, including redness and cuts on the lips. The CNA admitted to hitting the resident and was subsequently arrested. The facility's policy required immediate protection of residents from alleged offenders, which was not followed in this case. The delay in removing the alleged abuser and ensuring the resident's safety contributed to the finding of immediate jeopardy. The facility's failure to act promptly and protect the resident from further harm was a significant factor in the deficiency identified by the surveyors.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for four residents, leading to the development and worsening of pressure injuries. Resident 58, who was admitted with multiple pressure injuries and at risk for further development, was not repositioned for several hours, resulting in an unstageable pressure injury. Despite having a care plan that included regular repositioning and the use of pressure-relieving devices, the facility did not adhere to these protocols consistently. Observations showed that Resident 58 was left in a wheelchair for extended periods without repositioning, and there was a lack of documentation regarding any refusals to reposition. Resident 89, also at risk for pressure injuries, was not repositioned for four hours, and the facility failed to evaluate the effectiveness of the interventions in place. The resident was observed lying in bed with heels directly on the bed, and staff did not offer or perform repositioning during multiple observations. The facility missed a weekly skin assessment, and there was a lack of further assessment for a suspected deep tissue injury on the resident's heel, attributed to staffing issues. Residents 9 and 28, both with existing pressure injuries, were not repositioned as required to promote healing and prevent further injuries. Resident 9 was observed sitting in a chair for extended periods without repositioning, leading to an increase in the size of an existing pressure injury. Resident 28, with a deep tissue injury, was not offloaded during observations, and there were documented refusals of repositioning. The facility's failure to adhere to repositioning protocols and adequately document refusals contributed to the deficiencies observed.
Food Safety Protocols Not Followed During Meal Preparation and Distribution
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey. A Certified Nursing Assistant (CNA) was seen preparing and serving breakfast without following proper hygiene protocols. The CNA did not wash hands or use hand sanitizer before putting on gloves and proceeded to touch various surfaces in the kitchenette with the same gloves. These gloves were then used to handle ready-to-eat food, such as toast, which was served to two residents. The Culinary Services Manager confirmed that the CNA did not follow safe food handling practices, as gloves should be changed after touching potentially contaminated surfaces. Additionally, another CNA was observed delivering hot lunch meal trays to residents in their rooms without maintaining proper food safety standards. The CNA removed covers from the main course plates and cold drinks, then carried the uncovered trays down the hallway, exposing the food to potential contamination. This practice was observed for several residents, indicating a lapse in maintaining food safety protocols during meal distribution.
Inadequate Infection Control Practices During COVID-19 Outbreak
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program during a COVID-19 outbreak, as observed by surveyors over a four-day period. Staff were repeatedly seen not adhering to CDC guidelines for PPE use, particularly in the dementia unit where 18 residents were at risk. Staff were observed wearing surgical masks over N95 respirators and not changing the N95 masks after leaving rooms designated for droplet and contact precautions. Additionally, staff did not consistently use eye protection or sanitize goggles after use, and there was a lack of hand hygiene between glove changes during resident care. Specific incidents included a resident with Alzheimer's disease and COVID-19 who was seen wandering and touching surfaces without wearing a mask, and staff not performing hand hygiene after glove changes while providing care. Another resident with vascular dementia and COVID-19 was observed moving around the facility without a mask, and staff were seen assisting residents without proper PPE. The facility's infection preventionist acknowledged that the staff's practices did not align with CDC guidance and that the facility had modified the guidance for their outbreak unit without a supply issue justification. Further observations revealed that staff, including CNAs and food service aides, were not following proper PPE protocols, such as not using hand sanitizer between mask changes and not wearing appropriate PPE when entering rooms with contact precautions. The facility's policy required gowns and gloves for contact precautions, but staff were seen entering and exiting rooms without the necessary PPE. Interviews with staff indicated a lack of recent training on infection control practices, contributing to the observed deficiencies.
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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 La Crosse
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Manor Of Lacrosse | 0.8 mi | ★★★★★ | 1 | 0 |
| Bethany St Joseph Care Ctr | 1.8 mi | ★★★★★ | 0 | 0 |
| Hillview Health Care Ctr | 2.1 mi | ★★★★★ | 15 | 0 |
| La Crescent Health Services | 4.4 mi | ★★★★★ | 25 | 1 |
| Onalaska Care Center | 7 mi | ★★★★★ | 1 | 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.