Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Riverside Health & Rehabilitation during CMS and state inspections, most recent first.
A staff member misappropriated a cognitively intact resident’s funds by entering into a private agreement to provide travel assistance for medical appointments in exchange for $1000 plus expenses. The resident and staff member exchanged text messages discussing payment, hotel, food, airline tickets, and a rental car, and the staff member requested advance payment due to financial difficulties. The resident agreed to pay half of the fee in advance and wrote a personal check for $500 to the staff member, which was cashed, despite the staff member having prior training on professional boundaries and misappropriation of funds.
A resident with paraplegia and a history of wounds developed a new pressure wound, but the care plan was not updated to reflect this change or its management. Staff interviews and record reviews confirmed that the care plan did not include the new wound or note the resolution of a previous wound, resulting in incomplete documentation of the resident's current care needs.
A resident with a history of pressure wounds and paraplegia developed a new Stage II sacral ulcer, but staff failed to provide timely pressure-relieving interventions such as an air mattress, and did not consistently assess or document the wound as required by facility policy. Inconsistent staff awareness and incomplete documentation contributed to inadequate wound management.
The facility failed to respect residents' privacy by entering rooms without consent and going through personal items, causing distress. Additionally, two residents were unable to vote due to lack of assistance in obtaining absentee ballots, despite expressing a desire to participate in elections.
The facility did not ensure residents were informed about the grievance process and lacked an option for anonymous reporting. Several residents were unaware of how to file grievances and feared retaliation. Staff interviews and observations confirmed the absence of anonymous grievance options, and the grievance policy did not include instructions for anonymous submissions.
A resident at the facility lost her dentures and was not referred for dental services, resulting in her having to eat soft and pureed foods. Despite having dentures upon admission and sufficient funds to replace them, the facility did not schedule a dental appointment. Staff interviews confirmed the dentures were lost, and the facility's policy required them to assist with dental appointments, which they failed to do.
The facility failed to ensure call lights were within reach for three residents, as observed during a survey. One resident's call light was under the bed, another's was two feet away on a nightstand, and a third's was one and a half feet away. Staff were unaware of the call light locations and acknowledged they should be accessible. The facility's policy emphasizes the importance of communication and access to services, which was not maintained.
A facility failed to assess and accommodate the wheelchair positioning needs of a resident with one-sided weakness, who was frequently observed leaning dangerously forward in his wheelchair. Despite staff awareness of the issue, no positioning aids were assessed or provided, and the care plan lacked specific interventions for safe wheelchair use. The resident had a history of falls, and no prior therapy notes on positioning were available during the survey.
The facility failed to ensure accurate MDS assessments for two residents, one regarding hearing aid usage and the other concerning antibiotic medication. A resident's care plan indicated the use of hearing aids, but MDS assessments inaccurately showed no usage. Another resident's MDS record incorrectly listed antibiotic use, which was not supported by physician orders or the resident's statement. Staff acknowledged these errors.
A facility failed to develop a baseline care plan for a resident's foley catheter care within 48 hours of admission. The resident, who was discharged from the hospital with a foley catheter, did not have this need addressed in their care plan. A staff member indicated that the omission might have been due to a missed checkbox on the admission assessment.
A facility failed to include the use of Eliquis, an anticoagulant medication, in a resident's care plan, which is essential for monitoring potential side effects. Despite the interdisciplinary team's responsibility to keep care plans current, the resident's care plan did not reflect the prescribed medication or the need for monitoring, highlighting a deficiency in the care planning process.
A facility failed to update a resident's care plan regarding denture care. The resident was observed without dentures and stated they were missing, requiring her to eat soft foods. A staff member was unaware of the care plan's active intervention for denture care, which had not been revised since its last update.
A resident's ability to hear was compromised due to a missing hearing aid that was not replaced since July 2024. Despite the care plan indicating the need for two hearing aids, one was missing, and the grievance process was not initiated. The resident missed an ear cleaning appointment, and new appointments were scheduled for later months. The social services staff was unaware of the issue, highlighting a communication lapse.
The facility failed to properly document refrigerator temperatures and date opened medications, as observed with a vial of Tuberculin PPD in a medication refrigerator. A staff member indicated that logs were kept at the nurse's station, but a review showed significant gaps in documentation for October and November.
A resident in the facility was not provided with the necessary assistive utensils, as observed during a meal where she struggled to eat with regular silverware. Despite her tray card indicating a need for built-up utensils, staff were unaware of this requirement due to communication lapses. The resident's dietary progress note highlighted her need for adaptive utensils to manage weight loss, but this was not included in her care plan.
The facility failed to provide residents with access to their personal funds on weekends, affecting their ability to purchase items like soda from vending machines. Staff interviews revealed that weekend managers lacked access to petty cash, and the only person with access was unavailable unless it was an emergency. The facility's policy was not followed, and no residents had received personal funds on weekends in the past 12 months.
Misappropriation of Resident Funds by Staff Through Private Travel Arrangement
Penalty
Summary
A staff member engaged in misappropriation of a resident’s funds by entering into a private financial arrangement for travel assistance. The cognitively intact resident, with a BIMS score of 15 and able to make his own decisions, reported that after becoming friendly with the staff member, the staff member offered to assist with travel to another city for medical appointments in exchange for $1000 plus expenses. Text messages on the resident’s phone showed ongoing discussions between the resident and the staff member about payment for services, hotel, food, airline tickets, and a rental car, and the staff member requested advance payment due to financial difficulties. The resident agreed to pay half of the $1000 fee in advance and wrote a personal check for $500 to the staff member, which was cashed. The deficiency occurred despite the staff member having previously completed education on professional boundaries and on abuse, neglect, misappropriation of funds, and abuse reporting. The staff member’s acceptance of $500 from the resident for personal services, as evidenced by the cashed check and corroborating text messages, constituted misappropriation of resident funds. The resident later expressed regret about the payment and a desire to get his money back and involve law enforcement, indicating that the financial transaction was not resolved as the resident had expected.
Care Plan Not Updated for New Pressure Wound
Penalty
Summary
The facility failed to update the care plan for a resident with a new pressure wound. The resident, who has a history of wounds and is paraplegic, reported having a current buttock wound. Staff confirmed that care plans should be updated by the wound care nurse to reflect all current care concerns, including new wounds and interventions. Nursing progress notes documented the identification of a new pressure wound, but the care plan, last revised prior to the wound's development, did not include this new wound or its management. Additionally, the care plan was not updated to reflect the resolution of a previous sacral wound, nor was it revised to address the current wound identified in the nursing notes. This lack of care plan updates was confirmed through interviews and record review, showing a failure to ensure the care plan accurately reflected the resident's current condition and needs.
Failure to Implement and Document Pressure Ulcer Prevention and Management
Penalty
Summary
The facility failed to implement appropriate wound prevention and management measures for a resident with a history of pressure wounds and an elevated risk for developing new ulcers. Despite the resident having a new Stage II sacral wound and a history of paraplegia, there was no pressure-relieving air mattress or overlay on the resident's bed. Staff interviews revealed inconsistent awareness and follow-up regarding the new wound, with some staff unaware of its presence and others only applying barrier cream for ongoing maceration and irritation. Documentation showed that a secure message about the new wound was sent to the nursing team, DON, and wound care nurse, who recommended barrier cream and an air mattress, but these interventions were not promptly implemented. Additionally, the facility failed to accurately assess and monitor the new wound. There was a lack of comprehensive wound assessment documentation, including weekly measurements and detailed wound characteristics, as required by facility policy. The care plan and weekly summary charting did not reflect compliance with recommended interventions, and there was no evidence of regular monitoring or modification of interventions based on the resident's condition. These failures in wound management placed the resident at risk for wound progression and infection.
Violation of Resident Privacy and Voting Rights
Penalty
Summary
The facility failed to honor residents' rights to privacy and self-determination, as evidenced by staff entering residents' rooms without consent and going through their personal items. Two residents reported that a staff member entered their rooms and searched through their drawers without permission, which led to distress and a lack of respect for their privacy. One resident found a staff member holding knives that were stored in a drawer, and both residents expressed dissatisfaction with the intrusion and lack of communication regarding a scheduled deep cleaning. The facility's training module emphasized the importance of notifying residents and obtaining consent before handling personal items, which was not adhered to in this instance. Additionally, the facility failed to ensure that residents had the opportunity to engage in political voting. Two residents expressed a desire to vote but did not receive the necessary absentee ballots. One resident reported informing the activities staff about the missing ballot, but no follow-up was conducted to assist her in voting. Another resident expressed disappointment at not receiving a ballot, despite wanting to vote. The facility's policy on resident rights included participation in community activities, such as voting, but the lack of follow-up and assistance resulted in these residents being unable to exercise their voting rights.
Failure to Inform Residents of Grievance Process and Provide Anonymous Reporting
Penalty
Summary
The facility failed to ensure that residents were informed about how to file grievances and did not provide an option for anonymous reporting. During interviews, several residents expressed that they were unaware of the grievance process and feared retaliation if they complained. One resident mentioned a complaint about an incident but did not know what a grievance was. Another resident had issues with staff respecting his privacy and accessing his trust account on weekends but was unaware of how to file a grievance or do so anonymously. A third resident also faced difficulties accessing her trust account and was similarly uninformed about the grievance process. Staff interviews revealed that there was no designated location for residents to file anonymous grievances, and the facility's grievance policy lacked instructions for anonymous submissions. Observations confirmed the absence of grievance boxes for anonymous reporting, and grievance forms were only available in a limited area of the facility. Additionally, a resident's missing dentures were reported to the previous administrator, but the individual was not aware of a formal grievance process. The facility's grievance log showed no records of grievances filed by the residents mentioned, indicating a lack of awareness and accessibility to the grievance process.
Failure to Provide Dental Services After Denture Loss
Penalty
Summary
The facility failed to ensure that a resident was referred for dental services after losing dentures while residing at the facility. This deficiency affected one of the sampled residents, who was required to eat soft and pureed foods due to the absence of dentures. During an observation and interview, the resident stated that her dentures were taken, and she had to find soft foods to eat. Despite the resident having dentures upon admission, the facility did not schedule a dental appointment to replace the lost dentures, even though the resident had sufficient funds to cover the cost. Interviews with staff revealed that the lower denture was lost in October 2021, but there was no record of when the upper denture went missing. The facility's policy required them to provide or obtain dental services to meet residents' needs, including assisting with making dental appointments. However, the facility did not adhere to this policy, as evidenced by the lack of action to replace the resident's dentures. The resident's care plan indicated she had upper and lower dentures and required assistance with oral care, but the facility failed to address the issue over an extended period, despite multiple opportunities to do so.
Call Lights Not Within Reach for Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for three of the 24 sampled residents, leading to a deficiency in resident care. During observations, it was noted that one resident's call light was under her bed, making it inaccessible, while another resident's call light was placed on a nightstand two feet away from the bed, and a third resident's call light was one and a half feet away on a nightstand. These residents were unable to reach or locate their call lights, which are essential for communication and requesting assistance. Interviews with staff revealed that they were unaware of the call light locations and acknowledged that call lights should always be within reach of residents. The facility's policy on Resident Rights emphasizes the importance of communication and access to services, which was not upheld in these instances.
Failure to Assess and Accommodate Wheelchair Positioning Needs
Penalty
Summary
The facility failed to accommodate the needs of a resident with one-sided weakness who required a wheelchair for mobility. The resident was observed multiple times leaning forward in his wheelchair, often to the point where his head was almost touching his knees or the table. Despite these observations, there was no assessment conducted for positioning aids to help the resident maintain a safe and comfortable posture in his wheelchair. Staff members were aware of the resident's tendency to lean forward but did not know if any positioning equipment was required or available. The resident's care plan noted a potential for falls due to impaired mobility and balance, but it lacked specific interventions for wheelchair positioning. A nursing note indicated that the resident had previously been found on the floor next to his wheelchair, complaining of pain. Despite requests, no prior physical or occupational therapy notes regarding the resident's wheelchair positioning were provided during the survey, indicating a lack of documented assessment and intervention for the resident's needs.
Inaccurate MDS Assessments for Hearing and Medications
Penalty
Summary
The facility failed to ensure the accuracy of the Quarterly MDS assessment for two residents, specifically regarding medications and hearing. For one resident, there was a discrepancy in the documentation of hearing aid usage. During an observation, the resident was noted to have difficulty hearing, and a staff member provided a hearing aid, which did not improve the resident's hearing. The resident's care plan indicated the use of two hearing aids, but the MDS assessments inaccurately reflected that the resident did not use hearing aids and had highly impaired hearing. This inconsistency was acknowledged by a staff member who admitted the error in the assessment. For another resident, the MDS record inaccurately indicated that the resident was on an antibiotic for the last seven days. However, a review of the resident's EHR and physician orders showed no antibiotics were ordered or administered during that period. The resident confirmed not being on antibiotics, and a staff member verified the absence of any antibiotic orders in the resident's records. The staff member recognized the need to correct the MDS assessment to reflect the accurate medication status.
Failure to Implement Baseline Care Plan for Foley Catheter
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident's foley catheter care within 48 hours of admission. During an observation and interview, the resident was noted to have been discharged from the hospital with a foley catheter, which was placed there, and expressed hope for its removal soon. A staff member confirmed that the resident was admitted to the facility on the same date as the baseline care plan, but the plan did not address the foley catheter. The staff member suggested that the omission might have been due to a missed checkbox on the admission assessment, which is supposed to trigger care areas for the baseline care plan.
Deficiency in Care Plan for Anticoagulant Monitoring
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident receiving anticoagulant medication. The resident, who was diagnosed with atrial fibrillation, was prescribed Eliquis, an anticoagulant medication. During an interview, a staff member stated that the interdisciplinary team was responsible for ensuring care plans remained current and that high-risk medications, such as anticoagulants, should be included in resident care plans for monitoring side effects. However, the review of the resident's current care plan, which was last revised on 10/25/24, did not reflect the use of Eliquis or the need to monitor for potential side effects, indicating a deficiency in the care planning process.
Failure to Update Care Plan for Denture Care
Penalty
Summary
The facility failed to review and revise the comprehensive care plan for a resident after Quarterly and Annual assessments. During an observation and interview, it was noted that the resident was without her dentures and stated that someone had taken them, leading her to find soft foods to eat. A staff member confirmed that the resident had not had dentures for as long as she had been living at the facility, despite the care plan indicating that she had upper and lower dentures and required assistance with oral/denture care twice daily. The care plan had not been updated since its last revision date, which was several months prior.
Failure to Replace Missing Hearing Aid for Resident
Penalty
Summary
The facility failed to replace a missing hearing aid for a resident who required hearing aids, affecting the resident's ability to hear since July 2024. During an observation and interview, it was noted that the resident was having difficulty hearing, and a staff member attempted to assist by providing one hearing aid, which did not improve the resident's hearing. The resident's care plan indicated the use of two hearing aids, but one had been missing since August 2024. A staff member admitted to neglecting to fill out a grievance form for the missing hearing aid, which is typically the first step in the replacement process. The resident had an appointment scheduled for ear cleaning in August 2024, which was missed due to illness, and a new appointment was set for November 2024. Additionally, a replacement appointment at Costco was scheduled for December 2024. The facility's policy requires employees to refer any need for hearing services to the social worker, who is responsible for assisting residents in obtaining necessary services. However, the new social services staff member was unaware of the resident's missing hearing aid, indicating a lapse in communication and follow-up on the resident's needs.
Deficient Medication Storage Practices
Penalty
Summary
The facility failed to maintain proper documentation and labeling practices for medication storage, specifically regarding the recording of refrigerator temperatures and the dating of opened medications. During an observation, a medication refrigerator on Hall B was found to contain a vial of Tuberculin Purified Protein Derivative (PPD) that was opened but not dated. Additionally, there were no temperature logs available to confirm that the refrigerator maintained a safe temperature range. An interview with a staff member revealed that refrigerator temperature logs were supposed to be kept at the nurse's station, and a new process had been implemented to address identified compliance issues. However, a review of the facility's Refrigerator Temperature Log for October and November 2024 showed significant gaps in documentation, with 27 out of 31 days in October and four out of seven days in November lacking records.
Failure to Provide Assistive Utensils for Resident
Penalty
Summary
The facility failed to provide assistive utensils for a resident who required them, impacting her ability to eat effectively and increasing her risk of weight loss. During an observation, the resident was seen struggling to use regular silverware, which was not in accordance with her dietary needs as indicated on her tray card. The tray card specified that she should receive built-up utensils, but these were not provided at the dining table. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for assistive utensils. Staff members were unaware of the resident's requirement for special utensils, and there was a breakdown in communication about dietary changes. The dietary progress note indicated that the resident had been followed by a dietician for weight loss, who noted that the resident could handle utensils more easily with adaptive utensils. However, this information was not reflected in the resident's care plan, which lacked details about the need for assistive utensils or the risk of weight loss if they were not used.
Failure to Provide Weekend Access to Resident Funds
Penalty
Summary
The facility failed to provide residents with access to their personal funds on weekends, which is a violation of their rights to manage their financial affairs. This deficiency affected three residents who were unable to access their funds for amounts less than $100 for Medicare residents or $50 for Medicaid residents. The residents reported being unable to purchase items such as soda from vending machines during weekends, as they had to wait until business hours on Monday to access their funds. Staff interviews revealed that the weekend managers did not have access to petty cash, and the only person with access was a staff member who was not available on weekends unless it was an emergency. The facility's policy stated that residents should have routine access to petty cash and be able to arrange for access to larger funds when needed. However, the policy was not being followed, as residents were not able to access their personal accounts on weekends. Staff members indicated that there was an attempt to train a weekend receptionist to manage resident trust accounts, but the training was incomplete due to the employee's termination. The facility was in the process of hiring a new weekend receptionist to address this issue, but at the time of the report, no residents had received personal funds on weekends in the past 12 months.
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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 Missoula
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Missoula Health & Rehabilitation Center | 2 mi | — | 6 | 0 |
| Village Health & Rehabilitation | 3.5 mi | — | 1 | 0 |
| The Living Centre | 24.9 mi | — | 5 | 0 |
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