Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
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 Riveroaks Health Campus during CMS and state inspections, most recent first.
The facility did not designate a certified Infection Preventionist (IP) for its infection prevention and control program. The ADON, who was responsible for the program, began her role as IP without specialized training and was only able to dedicate limited hours to the program. This resulted in the failure to implement Enhanced Barrier Precautions, potentially affecting all residents.
The facility failed to implement Enhanced Barrier Precautions (EBP) for six residents, as EBP signs were not posted, and staff did not consistently wear gowns during high-contact activities. Residents with conditions such as anemia, COPD, pressure ulcers, and urinary catheters were affected. Observations revealed a lack of EBP signs and protective equipment, despite physician orders and care plans indicating the need for such precautions.
A facility failed to properly document and notify a resident's transfer to the hospital. The resident, who was moderately cognitively intact and diagnosed with encephalopathy, was transferred for an appointment after oral surgery. The transfer paperwork was incomplete, missing resident information and the reason for transfer, contrary to the facility's guidelines requiring such documentation.
A facility failed to obtain immediate doctor's orders for an indwelling urinary catheter for a newly admitted resident with significant medical conditions, including facial/skull fracture and brain hemorrhages. The resident was observed with a catheter, but their clinical record lacked corresponding orders. The facility's policy requires assessment for catheter removal unless clinically necessary, but orders and care plans were delayed to allow physician assessment.
A facility failed to revise a care plan quarterly for a resident with major depressive disorder and mild cognitive impairment. The care plan indicated a risk for adverse consequences from a hypnotic medication, but the resident's record showed no order for such medication, and the MDS assessment confirmed no hypnotic use. The MDS Coordinator acknowledged the need for care plan updates when medications are discontinued, which was not done, violating the facility's policy.
A facility failed to follow professional standards for a resident's PICC line care. The resident had a PICC line for osteomyelitis, but physician orders for care were not followed, and no care plan was developed. The resident's clinical record did not reflect IV access, and there was no documentation of refusal to remove the line or education provided. Observations showed the insertion site was red with purulent drainage, and the facility lacked a policy for IV care.
A medication error rate of 5.71% was identified when a nurse administered discontinued famotidine to a resident via gastric tube and incorrectly applied eye drops. The resident, with a history of colon cancer and duodenal ulcer, was not assessed for cognitive ability. Facility policies on medication administration and disposal were not followed.
A facility failed to document neurological checks for a resident with a history of falls and cognitive impairment after three unwitnessed falls. Despite the facility's policy requiring neuro-checks for 24 hours post-fall, no documentation or order sets were initiated for these checks. The Regional Support Nurse confirmed the lack of documentation and adherence to the policy.
The facility failed to provide adequate assistance with bathing and oral hygiene for four residents, as documented in the report. Residents with various medical conditions, including cognitive impairments and mobility issues, did not receive scheduled showers or daily mouth care. The facility's grievance log showed multiple complaints about inadequate assistance, and staff interviews revealed that short-staffing often prevented scheduled care. Facility policies requiring regular bathing and documentation were not consistently followed.
The facility failed to provide adequate nursing staff, resulting in delayed responses to call lights and incomplete ADLs for residents. Observations and interviews revealed that residents experienced long wait times for assistance, with some waiting up to an hour and a half. The grievance log showed multiple complaints about call light delays, and staffing patterns indicated inconsistencies in meeting the facility's scheduling standards.
Failure to Designate Certified Infection Preventionist
Penalty
Summary
The facility failed to ensure the designation of a certified Infection Preventionist (IP) responsible for the infection prevention and control program. The Assistant Director of Nursing (ADON) was assigned the role of IP without having received specialized training in infection prevention and control at the time of her appointment. She began her role as IP on June 4, 2024, and obtained her IP certification on June 17, 2024. Subsequently, on July 17, 2024, she was promoted to ADON. The ADON indicated that she could only dedicate approximately 5-10 hours per week to the infection control program. This lack of a dedicated IP led to the failure in implementing Enhanced Barrier Precautions, potentially affecting all 56 residents in the facility.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to implement infection control practices for six residents who required Enhanced Barrier Precautions (EBP). Observations revealed that EBP signs were not posted on the doors of residents who required them, and staff did not consistently wear gowns during high-contact activities. For instance, Resident L, who had diagnoses including anemia and COPD, did not have an EBP sign on their door despite physician orders and care plans indicating the need for EBP. Similarly, Resident W, who had a neuromuscular dysfunction of the bladder and a malignant neoplasm of the colon, also lacked an EBP sign, and staff were not observed wearing gowns during care. Resident V, who had a stage four pressure ulcer, did not have an EBP sign until after the survey began, and there were no prior physician orders for EBP. Resident D, who had a urinary catheter, was observed being transferred without staff wearing protective gowns, and there was no EBP sign on their door. The clinical record for Resident D lacked an order for EBP, and there was confusion among staff regarding the reason for the precautions. Residents S and T also did not have EBP signs or carts with gowns and gloves near their rooms, despite having conditions that required such precautions. Resident S had severe cognitive impairment and an unhealed wound, while Resident T had obstructive and reflux uropathy with a urinary catheter. The facility's inconsistency in implementing EBP was acknowledged by Regional Clinical Support, and the facility's standard operating procedure indicated that EBP should be in place for residents with chronic wounds and indwelling medical devices.
Failure to Document and Notify Resident Transfer
Penalty
Summary
The facility failed to ensure proper notification and documentation for a resident's transfer to the hospital. Resident 21, who was moderately cognitively intact and diagnosed with encephalopathy, was transferred for an appointment following oral surgery. However, the transfer discharge paperwork provided by the facility was incomplete, lacking resident information and the reason for the transfer. Additionally, the facility's guidelines required documentation of the reason, effective date, and location of the transfer or discharge, which was not adhered to in this instance.
Failure to Obtain Immediate Orders for Indwelling Urinary Catheter
Penalty
Summary
The facility failed to ensure that a newly admitted resident, identified as Resident D, had immediate doctor's orders for an indwelling urinary catheter. On September 30, 2024, staff observed Resident D being transferred with a urinary catheter. However, a review of Resident D's clinical record on October 1, 2024, revealed that there were no orders for the indwelling urinary catheter or catheter care, despite the resident's diagnoses of facial/skull fracture, subdural hemorrhage, and subarachnoid hemorrhage. Further review on October 3, 2024, indicated that a nursing assessment dated October 2, 2024, noted the absence of an indwelling urinary catheter. The Regional Support RN explained that catheters are assessed during the initial admission nursing assessment, but orders and care plans are not always immediately implemented as the facility allows time for physicians to assess the medical necessity of the catheter. The facility's policy on indwelling catheter use states that residents with a catheter should be assessed for removal unless clinically necessary.
Failure to Revise Care Plan for Discontinued Medication
Penalty
Summary
The facility failed to ensure that care plans were revised quarterly for a resident reviewed for unnecessary medications. Resident 36, who had diagnoses including major depressive disorder, restlessness and agitation, and mild cognitive impairment, was found to have a care plan indicating a risk for adverse consequences related to receiving a hypnotic medication for insomnia. However, the resident's current clinical record, reviewed on 10/2/24, showed no order for a hypnotic medication, and the Annual MDS assessment indicated that the resident did not receive hypnotic medications during the assessment period. Despite this, the care plan had not been updated to reflect the discontinuation of the medication, as confirmed by the MDS Coordinator during an interview. The facility's policy requires comprehensive care plans to be reviewed at least quarterly and revised to reflect changes in the resident's condition, which was not adhered to in this case.
Failure to Implement Professional Standards for PICC Line Care
Penalty
Summary
The facility failed to ensure professional standards of practice were implemented for a resident with a PICC line. The resident, identified as Resident T, had a PICC line inserted for osteomyelitis treatment but was unsure of its purpose. The clinical record review revealed that physician orders for the PICC line care, such as changing end caps, monitoring for infiltration, flushing with normal saline, and changing the dressing, were not followed. Additionally, there was no care plan developed for the PICC line, and the resident was not marked as having IV access on the MDS assessment. The deficiency was further highlighted by the lack of documentation regarding the resident's refusal to remove the PICC line, the education provided after the refusal, and the failure to follow the physician's order for removal. Observations noted the PICC line insertion site was red and had purulent drainage, indicating potential complications. Despite requests, the facility did not provide a policy related to IV care or a PICC line care skills check-off, indicating a lack of proper procedural documentation and oversight.
Medication Error Rate Exceeds 5% Due to Administration Errors
Penalty
Summary
The facility failed to ensure a medication error rate below 5 percent, resulting in a rate of 5.71 percent. This deficiency was identified during an observation of a registered nurse administering medication to a resident. The nurse administered 2.5 milliliters of liquid famotidine via the resident's gastric tube, despite the medication having been discontinued on 9/24/24. Additionally, the nurse administered carboxymethylcellulose eye drops incorrectly by lifting the upper eyelids instead of pulling down the lower eyelids to form a pouch, as per the facility's policy. The resident involved had a history of malignant neoplasm of the colon and chronic duodenal ulcer with hemorrhage, and was not assessed for cognitive ability due to rarely or never being understood. The facility's policies on medication administration and disposal were not followed, as the discontinued famotidine was not removed from the medication cart. The Director of Nursing and Regional Support staff confirmed the discontinuation of the medication and the correct procedure for administering eye drops, highlighting the failure to adhere to established protocols.
Failure to Document Neurological Checks After Falls
Penalty
Summary
The facility failed to ensure that clinical records were accurate and complete for a resident who was reviewed for falls. The resident, who had a history of unsteadiness on feet, abnormalities of gait and mobility, and previous falls, was identified as mildly cognitively impaired and required substantial assistance with transfers and hygiene. Despite these conditions, neurological checks were not documented following three separate unwitnessed falls on 7/31/24, 8/11/24, and 8/25/24. During an interview, the Regional Support Nurse confirmed the absence of documented neurological checks after the fall on 7/31/24 and noted that no order sets for neurological checks were initiated for any of the falls. The facility's policy, revised on 12/31/23, required neuro-checks to be completed within the Fall Event Form for 24 hours, which was not adhered to in these instances.
Failure to Provide Adequate Assistance with ADLs
Penalty
Summary
The facility failed to provide adequate assistance with bathing and oral hygiene for four residents, as observed and documented in the report. Resident F, with diagnoses including heart failure and reduced mobility, did not receive any documented showers or complete bed baths, nor daily mouth care, despite being dependent on staff for these activities. Similarly, Resident G, who had severe cognitive impairment and was dependent for oral hygiene and bathing, also did not receive any documented showers or complete bed baths, nor daily mouth care during their stay. Resident H, with severe cognitive impairment and a history of falls, received only three showers over a period of several weeks, with no documentation of daily mouth care. Resident J, who required assistance for bathing, reported not receiving the scheduled showers or complete bed baths, with only one shower documented over several weeks. The facility's grievance log revealed multiple complaints from residents about not receiving timely assistance with showers and toileting, and not being offered necessary items like razors for personal grooming. Interviews with staff indicated that the inability to provide scheduled care was often due to being short-staffed. The facility's policies required bathing at least twice a week and documentation of ADL services by CNAs, but these were not consistently followed, leading to the deficiencies noted in the report.
Insufficient Nursing Staff Leads to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of residents, as evidenced by observations, interviews, and record reviews conducted during the survey. On two consecutive days, it was noted that the facility was short-staffed, leading to delays in responding to call lights and completing residents' activities of daily living (ADLs). Residents reported waiting for extended periods, sometimes up to an hour and a half, for assistance with basic needs such as standing up or using the restroom. One resident recounted an incident where she turned on her call light at 2:45 A.M. and did not receive assistance until 5:00 A.M., resulting in missed showers and meal trays left in rooms overnight. The facility's grievance log revealed multiple complaints from residents about long wait times for call lights to be answered, with some residents experiencing accidents due to the delays. The grievances spanned several weeks, indicating a persistent issue with staffing levels. Observations during the survey confirmed that call lights were frequently left unanswered, and meal trays were not cleared in a timely manner, further highlighting the staffing inadequacies. A review of the facility's staffing patterns showed inconsistencies in the number of licensed nursing staff and nurse aides scheduled for each shift. The facility's policy on scheduling standards emphasized the need for adequate staffing to meet resident needs, yet the actual staffing levels fell short of these standards. This deficiency in staffing resulted in a lack of ADL services, including bathing and oral care, for the residents.
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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 Princeton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Waters Of Princeton, The | 1.3 mi | — | 23 | 0 |
| Transcendent Healthcare Of Owensville | 8 mi | — | 2 | 0 |
| Oakview Nursing & Rehab | 10.8 mi | — | 0 | 0 |
| Good Samaritan Home & Rehabilitative Center | 13.8 mi | — | 1 | 0 |
| North River Health Campus | 15.6 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.