Riverside Health And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review, and review of the facility's policies titled, Laundry Services, Infection Prevention Plan Policy, and Hand Hygiene, the facility failed to utilize effective infection control protocols in the laundry department and during perineal care for one of 40 sampled residents (R) (R2). This deficient practice had the potential to place residents at risk of infections related to cross-contamination. Findings include: Review of the facility's policy titled, Laundry Services, review date 12/27/2025, revealed under Guideline, and Routine Handling of Soiled Linen, Standard precautions will be used by clinical and laundry staff handling the linen . All staff use standard precautions in handling linen, therefore all linen is handled in the same manner. Under Transportation of Linen, Clean linen is NOT to come in contact with dirty linen. Review of the facility's policy titled, Infection Prevention Plan Policy, dated 12/27/2025, documented INTENT It is the intent of this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, record review, and review of the facility's policy titled, Use of Oxygen Therapy, the facility failed to ensure oxygen was administered at the prescribed rate for one of 18 residents (R) (R45) receiving oxygen therapy. This deficient practice had the potential to cause adverse respiratory consequences for R45. Findings include: Review of the facility's policy titled, Use of Oxygen Therapy, review date 12/27/2025, revealed the Guideline section included, Physician's order for oxygen should be obtained and include: Oxygen with liter flow as ordered, indicate if use should be continuous or PRN (as needed), method of oxygen delivery. Review of the EMR revealed diagnoses of ataxic cerebral palsy, chronic obstructive pulmonary disease (COPD), shortness of breath, and hypoxemia. Review of the care plan for R45 revealed respiratory difficulties/risk for further decline. Oxygen as ordered. Notify the physician of changes. Orders included oxygen: nasal cannula (NC) 3 liters per minute (LPM) nasally as needed. Observation on 02/14/2026 at 9:18 AM…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, staff interviews, record review and review of the facility's policies titled Medication Storage in the Care Center and Medications Supplied by the Center (Floor Stock), the facility failed to remove expired items from one of one medication room and failed to place open dates on one bottle of eye drops and three vials of glucose test strips in two of three medication carts. This deficient practice had the potential to place residents at risk of receiving medications with altered effectiveness. Findings include:Review of the facility's policy titled Medication Storage in the Care Center reviewed [DATE], documented INTENT: To facilitate safe, secure, and proper storage of medications and biologicals following manufacturer's recommendations or those of the supplier. GUIDELINE: . Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or otherwise compromised are promptly removed from stock, disposed of according to procedures for medication…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility's policy titled Pharmacy Services: Medication Storage in the Care Center, the facility failed to store medications and biologicals at proper temperatures to preserve their integrity in one of one medication storage refrigerator. This deficient practice created the potential for residents to receive medications with altered effectiveness. The facility census was 72 residents. Findings include: Review of the facility policy titled Pharmacy Services: Medication Storage in the Care Center, dated 2023, revealed the Intent section stated, To facilitate safe, secure, and proper storage of medications and biologicals following manufacturer's recommendations or those of the supplier. The Guideline section included, Medications requiring refrigeration or temperatures between 2C (Celsius) (36F [Fahrenheit]) and 8C (46F) are kept in a refrigerator with a thermometer to allow temperature monitoring. Medications requiring storage in a cool place are refrigerated unless otherwise directed on the label. The temperature of the med…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interviews and review of the facility's policy titled Abuse Prohibition, the facility failed to protect two residents (R) (R58, R73) rights to be free from sexual abuse by R632. The facility also failed to protect R632's right to be free from sexual abuse from R58. The sample size was 38. Findings include: Review of the facility's policy titled Abuse Prohibition, dated 12/29/2023, stated, It is the intent of this center to actively preserve each resident's right to be free from abuse. We believe that each resident has the right to be free from sexual abuse. Residents in our center will not be subject to abuse by anyone (including but not limited to other residents). 1. Review of R58's clinical records documented he was admitted on [DATE] with diagnoses including dementia in other diseases classified elsewhere, mild, with anxiety, adjustment disorder with mixed anxiety and depressed mood, depression, unspecified, and anxiety disorder, unspecified. Review of R58's Quarterly Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on staff interviews, record review, and review of the facility policy titled Abuse Prohibition-Reporting and Investigating, the facility failed to report an incident of inappropriate behavior to the State Survey Agency (SSA) within the required time frame for one of 38 sampled residents (R) (R26). The deficient practice had the potential for timely interventions not to be implemented for the protection of the residents. Findings include: Review of the facility policy titled Abuse Prohibition-Reporting and Investigating, review date 12/29/2023, revealed the Intent section stated, It is the intent of the center to establish standards of practice for investigation and reporting of abuse, neglect, mistreatment, exploitation, and misappropriation of property. The Guidelines section included, All allegations of abuse or allegations involving serious bodily injury must be reported immediately but no later than 2 hours. Allegations that do not involve abuse or allegations with serious bodily injury must be reported immediately but no later than 24 hours. Review of a Facility Incident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility policy titled Patients Plan of Care, the facility failed to develop a person-centered comprehensive care plan for one of three residents (R) (R68) reviewed for behaviors. This deficient practice had the potential for R68 to not receive treatment and/or care according to their needs. Findings include: Review of the facility policy titled Patients Plan of Care, revision date 12/29/2023, revealed the Intent section stated, To promote person centered patient care through a comprehensive care plan. The Guideline section stated, Each patient will have a person-centered comprehensive care plan developed and implemented to meet his or her other preferences and goals, and address the patient's medical, physical, mental, and psychosocial needs. Review of R68's Face Sheet revealed she was admitted to the facility on [DATE] with diagnoses that included but were not limited to vascular dementia, depression, visual hallucinations, and auditory…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on staff interviews, record review, and review of the facility's policy titled Discharge Recapitulation Summary, the facility failed to complete a recapitulation of stay and discharge instructions for one of 24 discharged residents (R) (R73). The deficient practice had the potential to affect the continuance of care for R73 after being discharged from the facility. Findings include: Review of the facility's policy titled Discharge Recapitulation Summary, dated 12/29/2023, documented It is the intent of this center to complete a recapitulation summary for patients discharge from the Center. A recapitulation summary should be completed when the patient is discharged home, to another nursing center or an assisted living center, respite care and patient's discharge. The recapitulation will include a service summary by each discipline. Review of the most recent Quarterly Minimum Data Set (MDS) dated [DATE] documented R73 had a Brief Interview for Mental Status (BIMS) score of 15 (indicating intact cognition).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, staff interviews, and review of the facility's policies titled Hand Hygiene and Cleaning of Shared Equipment, the facility failed to follow proper hand hygiene practices between residents' care and to sanitize shared medical equipment between residents' use during two of five medication pass observations. The deficient practices had the potential to increase the potential for cross-contamination and spread of infection. Findings include: Review of the facility policy titled Hand Hygiene, review date 12/29/2023, revealed the Purpose section stated, Hand hygiene is the single most important means of preventing the spread of infection. The use of gloves does not replace hand washing. The Guidelines section included, Associates should use alcohol-based hand rub or wash hands with soap and water for the following indications: -Immediately before touching a patient -Before performing an aseptic task -Before moving from a soiled body site to a clean body site on the same patient -After touching a patient or the patient's immediate environment. -After contact with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, record review, and facility policy review, it was determined that the facility failed to provide necessary care and services to maintain or improve a resident's ability to carry out activities of daily living (ADLs) for three (Resident #17, Resident #41, and Resident #56) of six residents reviewed. Specifically, Resident #17, Resident #41, and Resident #56 did not receive restorative care services as recommended by the therapy department to maintain mobility. Findings included: Review of a facility policy titled, Skilled Inpatient Services - Restorative, dated 12/04/2021, specified the intent of the policy was, To provide nursing interventions that promote the patient's ability to adapt and adjust to living as independently and as safely as possible. When clinically appropriate, these interventions may be captured in a formalized restorative nursing care plan overseen by Restorative Nursing Supervisor(s). The policy further indicated, The plan of care will be outlined in EMR…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure four (Residents #25, #45, #47, and #17) of six residents reviewed for activities of daily living (ADL) care, who were unable to carry out ADLs, received the necessary services to maintain good grooming. Specifically, the facility failed to provide nail care for Residents #25, #45, and #47 and failed to provide showers for Resident #17. Findings included: A review of a facility policy titled, Care of Fingernails/Toenails, revealed, It is the intent of this center to provide appropriate nail care to all patients. The policy further indicated guidelines for providing care that included, Identify resident. Gently, clean under each nail. You may have to soak hand before cleaning. Trim the fingernails/toenails. Smooth with nail file or emery board if needed. 1. A review of a Face Sheet revealed the facility admitted Resident #25 to the facility with diagnoses including Alzheimer's disease, dementia, psychotic…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet the daily needs of six (Resident #17, #41, #56, #47, #25, and #45) of six residents reviewed for activities of daily living. Specifically, the facility failed to ensure there were enough staff to provide restorative nursing care, showers, and fingernail care. Findings included: On 12/29/2022 at 7:57 AM the Staffing Coordinator (SD) was asked to provide a policy on staffing; however, the facility did not have a staffing policy. A review of the Facility Assessment Tool revealed the facility needed six certified nursing assistants (CNAs) on dayshift based on the resident population and their needs for care and support to ensure there were sufficient staff to meet the needs of residents. The facility assessment further defined this need as a CNA to patient ratio of one CNA per 12 residents. A review of the Facility Two Week Staffing Grid for the dates of the survey, 12/27/2022, 12/28/2022, and 12/29/2022,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, facility document review, and facility policy review, it was determined that the facility failed to maintain accurately documented medical records for three (Resident #17, Resident #41, and Resident #56) of six residents reviewed for activities of daily living (ADL) care. The medical record for each resident indicated the resident received restorative nursing care services for 15 minutes every day, 7 days a week; however, the facility failed to provide restorative nursing services. Findings included: A review of the facility policy titled, Clinical Documentation, dated 12/04/2021 revealed, It is the intent that progress clinical documentation should be maintained for each patient. The policy indicated, Clinical documentation reflects the patient's progress and response to his/her care plan, medications, diet, etc. Further review revealed, Clinical Documentation is recorded and signed by the individual responsible for monitoring the patient's progress (i.e.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, document review, staff and resident interviews, and facility policy review, the facility failed to maintain a safe and comfortable environment for one (300 Hall) of three halls of the facility. Observations revealed walls and equipment were not in good condition. Findings included: Review of a facility policy titled, Skilled Inpatient Services Work Orders, dated 12/04/2021, indicated, In order to establish a priority for maintenance service, work orders should be filled out in the TELS [a computerized system to communicate maintenance concerns] work orders system. The policy further indicated, It should be the responsibility of all Associates to fill out and forward such work orders to the Engineering Safety Manager. 1. A review of Resident #38's quarterly Minimum Data Set (MDS), dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 15, indicating no cognitive deficit. Resident #38's care plan noted a concern with limited mobility, dated 09/30/2021, that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.