River Place Nursing Center

Based on observation, interview, record review and facility policy review the facility failed to ensure that a call light was within reach for one (1) of forty-nine residents observed. Resident #30. Findings Include: Review of the facility policy, Call Light Policy with revision date of 01/12/15, revealed Procedure .8.When providing care to residents be sure to position the call light conveniently for the resident to use An observation on 12/16/25 at 11:00 AM and on 12/17/25 at 8:30 AM, revealed Resident #30 lying in her bed and the call light was not within reach. The call light cord was draped over her nightstand to the right of her bed with the red call button approximately two (2) feet from the head of her bed. During an observation and interview on 12/16/25 at 8:35 AM with Certified Nursing Assistant (CNA) #1, she confirmed that Resident #30's call light was draped over the nightstand to the right of her bed and it was not within her reach. CNA #1 revealed that Resident #30 was cognitive and could use the call light to voice her needs. She also revealed that the call light 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right for self-determination related to end-of-life care was respected as evidenced by resident not receiving the opportunity to sign her own code status directive for one (1) of 24 residents sampled. Resident #7Findings include: Record review of facility policy titled, Resident Rights, dated [DATE] revealed, The resident has the right to be informed of, and participate in, his or her treatment, including: . the right to request, refuse, and/or discontinue treatment . The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. Record review of facility policy titled, Cardiopulmonary Resuscitation (CPR), dated [DATE], revealed, It is the policy of the facility to adhere to residents' rights to formulate advance directives. Record review of Resident #7's Resident/Legal Representative Consent for Cardiopulmonary…

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 record review, staff interview, and facility policy review, the facility failed to initiate and implement a physician's order obtained during a Gradual Dose Reduction (GDR) attempt for 1 (one) of five (5) residents reviewed for unnecessary medications. Resident #39.Findings Include: Review of the facility policy Gradual Dose Reduction of Psychotropic Drugs with revision date of 05/03/18 revealed Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Record review of Resident #39's Consultation Report revealed a pharmacy recommendation to change Trazodone to 50 milligrams (mg) at bedtime as needed (PRN) for insomnia for 90 days. Physician's Response: I accept the recommendation(s) above, please implement as written The Consultation Report was signed by the physician on 09/10/25. Record review of Resident #39's Order Summary Report revealed an order dated 10/11/25 for Trazodone HCL (Hydrochloride) 50mg by mouth in the evening related to insomnia,…

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, staff and resident interviews, record review and facility policy review the facility failed to provide services to maintain or prevent worsening of contractures for one of three residents reviewed with contractures. Resident #38.Findings Include: Review of the facility policy Range of Motion revealed Policy: To safely move the resident's joints as full a range of motion as possible; To improve or maintain joint mobility and muscle strength; To prevent contractures; To increase strength and activity tolerance; To reduce pain; To prevent complications of mobility. An observation on 12/15/25 at 3:05 PM revealed Resident #38 sitting up in her wheelchair in her room. She had contractures to her left wrist and four fingers on the left hand. Her left wrist was bent downward and her second, third, fourth and fifth fingers were bent at the second joints, and she was unable to straighten them. An observation and interview on 12/16/25 at 12:04 PM with Resident #38 revealed her sitting in her wheelchair in her room. She had contractures to her left wrist and four fingers.…

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, resident and staff interviews, record review, and facility policy review, the facility failed to store medications in a secure manner for one (1) of forty-nine (49) residents observed during the initial tour. Resident #47 Findings Include:Review of the facility policy titled Medication Storage undated, revealed under, Policy: Medication supply must be accessible only to licensed nursing personnel, or staff members lawfully authorized to administer medications. All drugs, treatments, and biologics must be stored securely and following the manufacturer's Labeled recommendations, or per facility policy. Also revealed under, 6. Medications will be stored on the medication cart, or in other designated area for extra supply of medications.During an observation on 12/15/25 at 11:04 AM, Resident #47 was observed lying in bed and he was verbal but confused. A bottle of Antacids 750-milligram, approximately one-quarter full, was observed on the resident's bedside dresser. The resident stated the medication belonged to him and that he took it when needed.An observation of…

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, record review, and facility policy review the facility failed to document a summary of the resident's repeated grievances regarding showers and any corrective actions and follow-up for the grievances for one (1) of 14 sampled residents. Resident #39. Findings include: Review of the facility policy titled, Resident and Family Grievances, with a review date of 2/3/2023 revealed, Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance. D .The Grievance official will take steps to resolve the grievance, and record information about the grievance, and those actions, on the grievance form. An interview on 5/28/24 at 10:35 AM, Resident #39 revealed he is supposed to get his showers on Tuesday, Thursday, and Saturday but is lucky if he gets a shower two times a week. He revealed, I didn't get one this past Saturday and usually don't get them if Certified Nurse Aide (CNA) #3 is not here.…

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 interview, staff interviews, and facility policy review, the facility failed to promptly deliver postal mail to residents on Saturdays for 54 of 54 residents in the nursing facility that would possibly receive postal mail. Resident #25 Findings include: Review of a document on facility letterhead from the Administrator dated 4/20/23, revealed, The Policy of (Proper Name of the facility) is to pass mail daily. Activities passes on the weekdays and the Registered Nurse (RN) supervisor or charge nurse is responsible for mail collection on the weekends. Review of the Resident's Rights with a copyright date of 2018, revealed, .7. Information and communication . i. The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through means other than a postal service. An interview on 4/18/23 at 3:45 PM with Resident #25, the Resident Council President, revealed there is no mail delivered to the residents on…

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 interview, staff interviews, and facility policy review the facility failed to protect a resident's right to privacy in her room for one (1) of 54 residents reviewed for resident rights. Resident #39 Findings include: Review of the facility policy titled, Resident Rights, with a copyright date of 2018, revealed 1. Resident rights. The resident has the right to a dignified existence . 9. Safe environment. The resident has a right to a safe, clean, comfortable and Homelike environment, including but not limited to receiving treatment and support for daily living safely. An interview on 4/18/23 at 4:00 PM, with Resident #39, during the Resident Council Meeting, revealed Resident #36 had wandered into her room and she did not want uninvited men in her room. She revealed it makes her very uncomfortable for him to be in her room, she feels he was intruding in her private space. She revealed the staff would hear her tell him to get out and would come to convince him to leave. She shared that she would…

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 resident interview, staff interviews, record review, and facility policy review, the facility failed to record, initiate, and resolve a grievance for a resident, for one (1) of five (5) residents reviewed for grievances in Resident Council. Resident #39 Findings include: Review of the facility policy titled, Resident and Family Grievances, with the date implemented of March 1, 2019, revealed . Prompt efforts to resolve include facility acknowledgment of a complaint/grievance and actively working toward resolution of that complaint/grievance . 8. Grievances may be voiced in the following forums: a. Verbal complaint to a staff member or Grievance Official. d. Verbal complaint during resident or family council meetings. 10. Procedure: . b. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance from or assist the resident or family member to complete the form; . 11. Take any immediate actions needed to prevent further potential violations of any resident right . d. The Grievance Official will take steps to…

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, resident interview, staff interview, record review and facility policy review the facility failed to ensure a resident was free of the use of a restraint as evidenced by use of a body alarm that restricted the movements of a resident who could turn and position themselves and they could not easily remove the device for one (1) of 54 residents reviewed. Resident #43 Findings include: A review of the facility's policy titled SUBJECT: RESTRAINT POLICY, revealed, POLICY: As per OBRA (Omnibus Budget Reconciliation Act) requirements all residents have the right to be unrestrained. Restraints should be used only as a last alternative and only when other less restrictive measures have been tried and rejected. DEFINITION: Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body .PROCEDURE: 2.) All residents using a restraint are to be evaluated and re-evaluated…

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 facility policy review the facility failed to develop a care plan for a resident who wanders, failed to develop a care plan for a resident with the use of a body alarm, and failed to implement a positioning care plan for a resident for three (3) of 24 residents reviewed for care plans. Resident #2, Resident #36, and Resident #43. Findings Include: A record review of the facility's policy titled, Care Plans updated 2/03/23, revealed Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Definitions: Care plan- contains resident problems/needs/strengths, Resident goals and interdisciplinary approaches .Resident Care Summary- part of the Comprehensive Care plan and used as the tool to make staff aware of the resident's care needs as ADL (Activity of Daily Living) care plan . Record review of the facility care plan, titled, TURNING AND POSITIONING…

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, staff interview, and facility policy review, the facility failed to apply heel booties and float heels while in bed for one (1) of 24 residents reviewed. Resident #2 Findings include: Record review of the facility policy, TURNING AND POSITIONING POLICY, with no date, revealed All residents will be .positioned as per the plan of care .Procedure: .2. Charge Nurse is responsible for visually observing .positioning as needed . An observation on 4/17/23 at 2:46 PM, revealed Resident # 2 lying in bed, propped on her left side. Her heels were not elevated and there were no heel booties in place. In an observation and interview with Certified Nursing Assistant (CNA) # 2 on 4/17/23 at 5:26 PM, she verified that Resident #2 did not have her heels floating or have heel booties in place. CNA #2 verified that Resident # 2 should have had heels floating and have heel booties in place. She stated that Resident #2's right heel bothered her and if Resident #2 did not have the heel booties in place she could…

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.