Riverview Village

Based on interview and record review, the facility failed to ensure residents' (Resident C and Resident F) medication administration accurately reflected the administration of narcotic pain medication for 2 of 3 residents reviewed for medical records. Findings include:1.The clinical record for Resident C was reviewed on 11/20/25 at 11:40 a.m. The resident's diagnoses included, but were not limited to, restless leg syndrome, depression and osteoarthritis. The physician's order, dated 5/19/25, indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg (milligrams) every 6 hours for pain at 8:00 a.m., 2:00 p.m., 8:00 p.m. and 2:00 a.m. Review of the October 2025 and November 2025 controlled substance record indicated the resident received the medication on the following dates and times: 10/03/25 at 8:00 p.m., 10/30/25 at 2:00 a.m., 11/01/25 at 2:00 a.m., 11/05/25 at 8:00 p.m., 11/07/25 at 8:00 p.m., and 11/11/25 at 8:00 a.m. The October 2025 and November 2025 medication administration record lacked documentation that the pain medication was administered. During an…

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 observation, record review, and interview, the facility failed to ensure a safe and sanitary environment for 2 of 66 resident rooms reviewed for the environment. (Residents 11 and 17). Findings include: 1. During an observation on 6/19/25 at 1:00 p.m., the following was observed: - Resident 17 was sitting on the side of his bed. He was observed to be disheveled and had a strong foul odor. - The bedside nightstand had approximately 15 Styrofoam cups stacked up. - There were 3 garlic bread sticks laying in the bed. The review of the meal menu indicated the last time the facility had served breadsticks was on 6/16/25. - There were 3 bowls of food like substances in each bowl. - The resident's linens and clothes were observed with stains, food debris, and had a foul odor. - There were 3 Styrofoam containers underneath the resident's bed with food stored in them. The resident became upset when the staff tried to open the containers. - The floor had unknown substances that had dried and stained the floor. - The bedside table had a Styrofoam container that contained breakfast…

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 observation, interview and record review, the facility failed to ensure a resident's (Resident F) record accurately reflected the discontinuation of a wanderguard for 1 of 3 residents reviewed for documentation. Findings include: The clinical record for Resident F was reviewed on 3/4/25 at 10:30 a.m. The diagnoses included, but were not limited to, severe dementia with agitation and bipolar. The physician order, dated 12/27/24, indicated the resident had a security bracelet (wanderguard) to the left ankle and to check the placement and function every day shift and night shift. On 3/4/25 at 10:18 a.m., the resident was observed slightly reclined in a broda chair in the dining room. The resident did not have a wanderguard in place. The elopement risk assessment, dated 2/13/25 at 1:45 p.m., indicated the resident resided had a significant change, resided on a secure unit and was not assigned a security bracelet. The progress note, dated 2/14/25 at 10:45 a.m., indicated the interdisciplinary team determined the resident no longer required the use of a wanderguard due to the…

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 interview and record review, the facility failed to prevent a significant medication error related to insulin administration for 1 of 3 residents reviewed for medication administration. (Resident B) Findings include: The clinical record for Resident B was reviewed on 8/27/24 at 10:08 a.m. The resident's diagnosis included, but was not limited to, diabetes with hyperglycemia. The care plan, dated 7/24/24, indicated the resident was at risk for hyperglycemia and to administer medication as ordered. The physician's order, dated 7/23/24, indicated the resident was to receive insulin degludec (ultralong-acting insulin) 50 units, subcutaneously every morning at 6:30 a.m. The physician was to be notified of a blood sugar less than 60 or greater than 400. The July 2024 medication administration record indicated on 7/24/24 at 6:30 a.m., Resident B's blood sugar was 390. The July 2024 medication administration lacked documentation that the insulin was administered as ordered by the physician. A notation was documented by RN (Registered Nurse) 4 that the drug item was not available,…

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 observation, record review, and interview, the facility failed to ensure the nursing staff followed procedure during 2 of 3 observations of the administration of insulin related to Quality of Care. (Residents 6 and 18) Findings include: 1. During an observation on 6/12/24 at 10:45 a.m., LPN (Licensed Practical Nurse) 3 prepared the lispro flexpen for administration to Resident 6 by applying the needle. The LPN failed to prime the needle prior to dialing the prescribed dosage of lispro. The LPN dialed the flexpen to 10 units and entered the resident's room and administered the insulin into the resident's abdomen. The LPN indicated the resident's blood sugar was 155 mg/dL (milligrams per deciliter). The record for Resident 6 was reviewed on 6/13/24 at 8:40 a.m. The diagnosis included, but was not limited to, type 2 diabetes mellitus. The physician's order, dated 5/17/23, indicated the staff were to administer 10 units of the lispro flexpen to the resident subcutaneously, three times a day. The Annual MDS (Minimum Data Set) assessment, dated 4/9/24, indicated the resident was…

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 observation, record review, and interview, the facility failed to ensure oxygen concentrator filters were placed and maintained for 3 of 9 residents reviewed for respiratory care. (Residents 41,14, and 31) Findings include: 1. During an observation on 6/10/24 at 9:37 a.m., Resident 41's oxygen concentrator filter was 100% lightly covered with a white powdery substance and multiple small chunks of a white substance. During an observation on 6/11/24 at 10:52 a.m., Resident 41's oxygen concentrator filter was 100% lightly covered with a white powdery substance and multiple small chunks of a white substance. The record for Resident 41 was reviewed on 6/12/24 at 11:16 a.m. The diagnoses included, but were not limited to, COPD (chronic obstructive pulmonary disease) and hospice care. The care plan, dated 1/14/21, indicated the resident was at risk for impaired gas exchange related to COPD with shortness of breath while lying flat and at times with physical exertion. The interventions, dated 1/14/21, indicated staff were to administer oxygen as ordered, assess vital signs, and…

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 observation, record review, and interview, the facility failed to ensure appropriate notification to the physician for elevated blood sugar values, administration of insulin and performance of blood glucose monitoring for 2 of 3 residents reviewed for notification of change. (Residents 4 and 70) Findings include: 1. The clinical record for Resident 4 was reviewed on 4/14/23 at 9:31 a.m. The diagnosis included, but was not limited to type 2 diabetes mellitus. The care plan, dated 1/29/16 and last revised on 3/26/23, indicated the resident was at risk for adverse effects of hyperglycemia or hypoglycemia related to the use of glucose lowering medication and the diagnosis of diabetes mellitus. The interventions, dated 1/29/16, indicated to document abnormal findings and notify the MD (medical doctor), and monitor blood sugars as ordered. The physician's order, dated 2/26/21, indicated to conduct an accu (accurate) check (blood glucose monitoring test) as needed for signs or symptoms of hyperglycemia or hypoglycemia. Notify the MD if the blood sugar was less than 70 mg/dL…

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 observation, record review, and interview, the facility failed to ensure accurate skin assessments for residents with pressure injuries were conducted for 2 of 3 resident's reviewed for pressure ulcers. (Residents 74 and 37) 1. The clinical record for Resident 74 was reviewed on 4/12/23 at 10:00 a.m. The diagnoses included, but were not limited to, acute osteomyelitis right ankle, foot, and heel, peripheral autonomic neuropathy, muscle weakness, abnormalities of gait and mobility, folate deficiency anemia, vitamin B12 deficiency anemia, and vitamin D deficiency. The admission Observation, dated 11/6/22 at 5:21 p.m., indicated the resident had no alterations in skin. The nurse's note, dated 11/6/22 at 6:00 p.m., indicated the resident admitted to the facility at 1:50 p.m. The only skin impairments documented were a surgical incision to the right hip, multiple healed scratches, bruises to all four extremities, and redness to the right heel. The Braden Scale for Predicting Pressure Sore Risk, dated 11/6/22, indicated the resident had no sensory impairment, was rarely moist,…

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 observation and interview, the facility failed to ensure employees provided meal service in a safe and sanitary manner for handling of food while serving meals in the Cottage Unit Dining Room for 1 of 4 staff observed. (CNA 4) Findings include: During the lunch meal service in the Cottage Unit Dining Room on 4/10/23 at 11:20 a.m., CNA (Certified Nurse Aide) 4 was delivering a meal to Resident 36. She picked up the top bun for the fish sandwich with her bare hands and added tartar sauce. She placed the bun on top of the fish with her bare hand, mashing down on the bun with her palm. During the lunch meal service in the Cottage Unit Dining Room on 4/10/23 at 11:30 a.m., CNA 4 delivered a meal to Resident 53. She picked up the top bun of the fish sandwich with her bare hand, laying it in the plate. She applied the tartar sauce to the fish and placed the bun on top of the fish, using her bare hand. During an interview on 4/13/23 at 1:26 p.m., CNA 4 indicated she would perform hand washing prior to the provision of meal trays. She would also apply hand sanitizer between…

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.