Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Terrace Health Campus during CMS and state inspections, most recent first.
The facility did not ensure sufficient nursing staff were available to meet residents' needs, resulting in delayed responses to call lights, unmet toileting needs, and lack of timely pain medication. Residents experienced long waits for assistance, some were left incontinent, and necessary equipment was inaccessible. Staff reported being unable to provide adequate care due to being the only person on a hallway, especially when two staff were needed for certain residents.
The facility failed to provide timely ADL and incontinence care for multiple residents, including delays in toileting, lack of access to mobility equipment, insufficient response to call lights, and inadequate provision of water and oxygen supplies. Several residents with complex medical needs experienced prolonged waits for assistance, resulting in incontinence, discomfort, and unmet care needs.
A resident with multiple medical conditions, including a recent right femur fracture, did not receive pain medication in a timely manner after requesting it, resulting in prolonged periods of unmanaged pain. Documentation and staff interviews confirmed delays in administering PRN hydrocodone, despite physician orders and facility policy requiring prompt pain management and monitoring.
Two residents experienced pain and injury due to improper transfer techniques at the facility. A resident with osteoarthritis suffered severe shoulder pain after being pulled by the arm instead of using a gait belt. Another resident with cognitive impairment and on blood thinners was bruised from being lifted under the arms instead of using a mechanical lift. Staff interviews revealed a lack of training and equipment, leading to non-compliance with the facility's transfer policy.
A facility failed to document non-pressure wounds on the TAR and perform wound treatments in a timely manner for a resident with a diabetic ulcer. Despite physician orders for regular dressing changes, observations showed that dressings were not changed as required, and the TAR often indicated no skin impairments. Interviews with staff revealed inconsistencies in following orders and maintaining accurate records, contributing to the deficiency in care.
A resident with a history of hemiplegia and dementia experienced inadequate pressure ulcer care in an LTC facility. The facility failed to follow physician orders for wound care, including dressing changes and preventive measures like floating heels. Observations showed the resident's heels were not floated, and a new pressure area was not measured or treated. Staff interviews revealed inconsistencies in wound care practices, contributing to the resident's deteriorating skin condition.
A resident with diabetes did not receive their prescribed Lantus insulin dose due to a failure in transferring the medication to the correct cart after a room change. The insulin was initially removed from the emergency drug kit but was not administered as required, leading to a lapse in medication administration.
Failure to Provide Adequate Staffing for Resident Care Needs
Penalty
Summary
The facility failed to provide adequate nursing staff each day to meet the needs of all residents, resulting in unmet care needs related to toileting and timely administration of as-needed pain medication. Observations revealed that at one point, no staff were present on a hallway where multiple call lights were alarming, and a resident was found lying on the floor after a fall, calling for help without staff in sight or within hearing distance. Staff were located only after a delay, and the resident reported needing assistance after her fall. Another resident, who required oxygen, was unable to access the bathroom due to insufficient oxygen tubing length and lack of a bedside commode, resulting in incontinence after waiting for assistance that did not arrive in time. Interviews with staff and residents indicated that staffing shortages led to significant delays in response to call lights, unmet toileting needs, and lack of access to necessary equipment such as walkers, wheelchairs, and commodes, which were stored in the basement and inaccessible without leaving the floor unattended. Residents reported waiting extended periods for assistance, including one who waited over an hour for water and another who had to contact a family member for help after waiting more than an hour for toileting assistance. Staff confirmed that it was difficult to provide care when only one person was assigned to a hallway, especially when residents required two staff for mobility or mechanical lifts, leaving other residents unattended. Record review showed the facility had 18 rehab to home licensed beds and 39 long-term care licensed beds. The facility administrator stated there was no policy for staffing. Cross-references to other deficiencies included failure to provide timely as-needed pain medication and failure to provide incontinence care for residents dependent on staff for activities of daily living. The findings affected all 41 residents in the facility.
Failure to Provide Timely ADL and Incontinence Care
Penalty
Summary
The facility failed to provide adequate activities of daily living (ADL) care, including incontinence care and personal assistance, for four out of five residents reviewed. One resident reported activating her call light for bathroom assistance, but the CNA on duty was unable to help due to being the only staff member present. The resident was also informed that no walker or wheelchair was available, and after waiting over an hour, she contacted her family for help. Staff interviews confirmed that necessary mobility equipment was stored in the basement and could not be accessed without leaving the floor unattended. Another resident was observed sitting in her wheelchair for several hours without being toileted, resulting in swelling of her lower legs and incontinence. The resident's call light was out of reach, and staff indicated that they were covering both sides of the hallway, delaying care. When toileting was finally provided, the resident was found to have soiled herself, and her skin showed signs of redness and deep purple areas. The resident's medical history included dementia, chronic pain, and weakness, requiring wheelchair mobility and staff assistance. Additional deficiencies included a resident who waited up to 40 minutes for call light responses and was left without water for over an hour and a half, and another resident who was unable to access the bathroom due to short oxygen tubing and lack of a bedside commode. This resident became incontinent and was later observed without oxygen while being assisted back to bed, reporting difficulty breathing. The facility's own policy required appropriate interventions for incontinence, but these were not consistently provided.
Failure to Provide Timely Pain Medication Administration
Penalty
Summary
A deficiency occurred when a resident with a history of right femur fracture, chronic kidney disease, Type 2 diabetes mellitus, and anemia did not receive timely administration of pain medication as requested. The resident reported waiting for hours to receive pain pills, particularly during the evening shift, which resulted in pain escalating to a level that was difficult to control. Documentation in the clinical record and EMAR showed that the resident consistently reported pain levels of 6 out of 10 and requested pain medication every six hours to prevent pain from becoming unmanageable. However, the administration times of hydrocodone 10/325 mg as needed for pain were not consistently aligned with the resident's requests or the physician's order, leading to delays in pain relief. Interviews with staff confirmed that medication administration was sometimes late due to workload challenges. Facility policies required timely initiation of pain management plans, evaluation of effectiveness, and proper documentation of PRN medication administration, including reasons and efficacy. Despite these policies, the resident's pain was not managed in a timely manner, as evidenced by both the resident's statements and the medication administration records.
Improper Transfer Techniques Result in Resident Injury
Penalty
Summary
The facility failed to ensure proper transfer techniques were used for two residents, leading to pain and injury. Resident 183, who had diagnoses including osteoarthritis and spinal stenosis, experienced severe right shoulder pain after being improperly transferred by a CNA who pulled him by the arm instead of using a gait belt. Despite being cognitively intact and requiring moderate assistance, the resident reported ongoing pain and requested an X-ray and increased pain medication. Interviews with staff revealed that new CNAs were still learning proper techniques, and there was a shortage of gait belts. Resident 14, with severe cognitive impairment and a history of hemiplegia, was also subjected to improper transfer techniques. The resident, who required maximal assistance and was on blood thinners, was found with bruising under both arms, attributed to being lifted under the arms instead of using a mechanical lift as required. Despite the care plan indicating the need for a mechanical lift, staff continued to use improper methods, leading to further bruising. The resident's condition necessitated a full body mechanical lift for all transfers to prevent further injury. Interviews with staff highlighted a lack of adherence to the facility's transfer policy, which required the use of gait belts and mechanical lifts as specified in the care plans. The facility's failure to provide adequate training and equipment for safe transfers resulted in physical harm to the residents, as evidenced by the pain and bruising experienced by Residents 183 and 14.
Failure to Document and Timely Perform Wound Care
Penalty
Summary
The facility failed to ensure that non-pressure wounds were documented on the Treatment Administration Record (TAR) and that wound treatments were performed in a timely manner as ordered by the physician for a resident. The resident, who had multiple diagnoses including Parkinson's disease, severe morbid obesity, type 2 diabetes mellitus with diabetic chronic kidney disease, and muscle weakness, was observed to have a diabetic ulcer on the left shin. Despite physician orders for regular dressing changes and wound assessments, the TAR often indicated no skin impairments, and observations showed that dressings were not changed as frequently as required. The resident's wound was initially identified during a weekly skin assessment, and new orders were received to culture the drainage and administer antibiotics. However, subsequent TAR entries failed to consistently document the presence of skin impairments, and observations revealed that dressings were not changed according to the prescribed schedule. For instance, during an observation, the dressing was found to be dated several days prior, with curled corners and discoloration, indicating it had not been changed as ordered. Interviews with nursing staff revealed inconsistencies in following physician orders and maintaining accurate records of wound care. The nurse responsible for the resident's care acknowledged that the dressing had not been changed as required and that the wound had not been properly assessed. This lack of adherence to treatment protocols and documentation requirements contributed to the deficiency in providing appropriate care for the resident's non-pressure wound.
Inadequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for a resident, leading to deficiencies in the management of existing wounds and the development of new pressure areas. The resident, who had a history of hemiplegia, dementia, and severe protein-calorie malnutrition, was at high risk for skin breakdown. Despite this, the facility did not consistently follow physician orders for wound care, including the necessary dressing changes and interventions to prevent further skin damage. Observations and record reviews revealed that the resident's pressure ulcers were not being measured, tracked, or treated as required. The resident's care plan included interventions such as floating the heels, turning and repositioning, and using pressure-reducing devices, but these were not consistently implemented. For instance, during multiple observations, the resident's heels were not floated as ordered, and the resident was found lying directly on the bed, which could exacerbate pressure ulcer development. Additionally, the facility's documentation and communication regarding the resident's wounds were inadequate. A new pressure area on the resident's left outer buttock was not measured, tracked, or treated, and there was a lack of documentation for this area. Interviews with staff indicated a lack of clarity and consistency in wound care practices, with some staff expressing doubts about the classification of the resident's wounds and the effectiveness of preventive measures. The facility's failure to adhere to its own policies and physician orders contributed to the deterioration of the resident's skin condition.
Failure to Administer Lantus Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident, identified as Resident B, received Lantus insulin as ordered by the physician. Resident B, who had a diagnosis of diabetes, was supposed to receive 20 units of Lantus insulin subcutaneously at bedtime according to the admission order. However, the Medication Administration Record lacked documentation of the administration of Lantus insulin on one occasion, specifically on 11/15/24, due to the medication being unavailable. This lapse in medication administration was discovered during a review of the resident's clinical record and interviews with facility staff. Interviews with the nursing staff revealed that the Lantus insulin was initially removed from the emergency drug kit and placed in a medication cart, but it was not administered as required. The Assistant Director of Nursing (ADON) indicated that the Lantus was not available in the emergency drug kit and was ordered from the pharmacy, but it was delivered after her shift ended. The Director of Nursing (DON) noted that the resident had moved rooms, and the insulin was not transferred to the new medication cart. This oversight resulted in the resident not receiving the prescribed insulin dose on the specified date, despite the medication being available for administration.
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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 Madison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Hickory Creek At Madison | 2 mi | — | 3 | 0 |
| Waters Of Clifty Falls, The | 2.3 mi | — | 7 | 0 |
| Thornton Terrace Health Campus | 5.2 mi | — | 8 | 0 |
| Aperion Care Hanover | 5.7 mi | — | 11 | 0 |
| Bedford Springs Health And Rehabilitation | 11.2 mi | — | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.