Ottawa Co Riverview Nursing Ho

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated in a dignified manner. This affected three (#31, #25, #67) of three residents reviewed for dignity. The facility census was 86.Findings include:1.Review of the medical record for Resident #31 revealed an admission date of 12/01/23. Diagnoses included Alzheimer's disease, dementia, muscle weakness, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for eating meals. Review of a physician order dated 02/10/24 revealed the resident was ordered a regular diet with mechanical soft texture and thin liquids. Observation on 02/24/26 at 8:45 A.M. revealed Certified Nursing Assistant (CNA) #363 was standing over Resident #31 while feeding the resident bites of food. Further observation revealed an empty chair was near where the resident was sitting at the dining table. Interview 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.

Based on record review and staff interview, the facility failed to ensure residents were informed about treatment options and alternatives before beginning treatment with psychoactive medications. This affected one (#9) of five residents reviewed for psychoactive medications. The facility census was 86.Findings include:Review of the medical record for Resident #9 revealed an admission date of 10/15/25 with diagnoses of depression, restlessness, anxiety, and protein-calorie malnutrition. Resident #9 was admitted to hospice on 02/21/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/26, revealed Resident #9 had intact cognition and received an antianxiety medication, and an antidepressant. Review of the physician order initiated 11/15/25 and discontinued 02/23/26 revealed Resident #9 received buspirone (an antianxiety medication) hydrochloride oral tablet 10 milligrams (mg), one tablet twice daily for anxiety. Review of the physician order initiated 12/03/25 and discontinued 02/23/26 revealed Resident #9 received mirtazapine (an antidepressant) tablet 15 mg,…

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 review of the electronic and paper medical records, review of care conference meeting progress notes, review of a signed Do Not Resuscitate (DNR) order, review of physician orders, review of the plan of care, staff interview, and policy review, the facility failed to ensure a resident's code status was consistent throughout the medical record. This affected one (#8) of 29 residents reviewed for code status in the initial sample pool. The facility census was 86. Findings include:Review of the medical record revealed Resident #8 had an admission date of [DATE]. Diagnoses included Parkinsonism, dementia, type two diabetes mellitus, hypertension, depression, and anxiety.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of Resident #8's plan of care revised [DATE], revealed the resident had chosen a Do Not Resuscitate (DNR), (no Cardiopulmonary Resuscitation (CPR)) code status order. Review of the resident's care plan…

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 review of the medical record, observation, staff interview, and policy review, the facility failed to ensure proper use and monitoring of a physical restraint. This affected one (#10) of one resident reviewed for restraints. The facility identified one resident with a restraint. The facility census was 86. Findings include:Review of the medical record for Resident #10 revealed an admission date of 05/03/24. Diagnoses included Parkinson's disease, progressive multiple sclerosis, dementia, type two diabetes mellitus, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was never understood. Further review of the MDS revealed the resident required physical restraints used daily as a limb restraint in bed, in chair, and out of bed. The resident was dependent on staff for activities of daily living. Review of the plan of care initiated 05/10/24 revealed the resident had a restraint and used arm protection such as socks, gloves, or…

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 review of the medical record, review of care conference meeting documentation, resident and family interview, staff interview, and policy review, the facility failed to ensure residents and resident representatives were invited to care conference meetings. This affected two (#8, #25) of two residents reviewed for care planning. The facility census was 86. Findings include:1.Review of the medical record revealed Resident #8 had an admission date of 09/04/25. Diagnoses included Parkinsonism, dementia, type two diabetes mellitus, hypertension, depression, and anxiety. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had moderate cognitive impairment. Review of the quarterly care conference meeting notes dated 11/26/25 and 02/19/26 revealed the resident was not present at the meetings. There was no documentation the resident had been given an invitation to the meeting and no documentation the resident had refused to attend the meeting. Interview on 02/23/26 at…

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 medical record review, staff interview, and review of the facility policy, the facility failed to follow the bowel protocol. This affected one resident (#95) reviewed for bowel movements. The facility census was 86. Findings include: Review of the medical record for Resident #95 revealed an admission for date 02/12/26. Diagnoses included Alzheimer's, carotid stenosis, anxiety, heart disease, history of recent fall with nondisplaced fracture of the clavicle, and Meniere's disease. Review of the admission assessment dated [DATE] for Resident #95 revealed he was cognitively impaired. Review of the current physicians orders for 02/26 for Resident #95 revealed he was prescribed Tramadol 50 milligrams (mg) for pain, Miralax 17 grams (g) daily (used for constipation prevention), Colace 100 mg twice daily (used for constipation prevention), Milk of Magnesia (MOM) 30 milliliters (ml) as needed daily (used for constipation prevention), and Bisacodyl rectal suppository 10 mg every 24 hours as needed for…

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, policy review, and review of the facility's hemodialysis center contract, the facility failed to ensure consistent communication occurred between the facility and the dialysis center for residents who received hemodialysis (HD). This affected one (#12) of one resident in the facility who received hemodialysis. The facility census was 86.Findings include: Review of the medical record for Resident #12 revealed an admission date of 11/21/23 with diagnoses of end stage renal disease and dependence on renal dialysis. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/29/26, revealed Resident #12 had impaired cognition and received dialysis. Review of the care plan, initiated 12/18/23, revealed Resident #12 needed hemodialysis related to renal failure. No interventions were in place regarding coordination of care with the hemodialysis clinic. Review of the physician order dated 12/01/24 revealed Resident #12 went to hemodialysis offsite three times weekly on Mondays, Wednesdays, and Fridays. Interview on 02/25/26 at 10:34 A.M. 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.

Based on observation, staff interview, record review, and policy review, the facility failed to ensure licensed nurses applied lidocaine patches for pain. This affected one (#57) of one resident reviewed for pain management. The facility census was 86.Findings include:Review of the medical record for Resident #57 revealed an admission date of 12/01/25 with diagnoses of pain in left knee, pain in right knee, osteoarthritis, and anxiety, Review of the comprehensive Minimum Data Set (MDS) assessment, dated 12/07/25, revealed Resident #57 had impaired cognition and was dependent on staff for chair to bed transfers. Review of the current physician order, dated 01/27/26, Resident #57 revealed Resident #57 received Lidocaine External Patch 4% applied to bilateral knees topically one time a day for osteoarthritis. Interview and observation on 02/23/26 at approximately 11:30 A.M. revealed Resident #57 dressed and in her wheelchair. Resident #57 stated she had pain in both of her knees and complained about the pain patches on her knee rolling up under her pants. Resident #57 proceeded to pull…

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 review of the medical record, review of medication administration records, review of physician orders, review of pharmacy guidelines, observation, staff interview, and policy review, the facility failed to ensure a resident was free from a significant medication error. This affected one (#67) of three residents observed for medication administration. The facility census was 86. Findings include:Review of the medical record for Resident #67 revealed an admission date of 11/06/23. Diagnoses included Parkinson's disease, dysphagia, hypokalemia, cardiomegaly, hypertension, hemiparesis and hemiplegia following cerebral infarction.Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had mild cognitive impairment.Review of a physician order dated 10/23/25 revealed Resident #67 had orders for potassium chloride extended release 20 milliequivalents (MEQ), two tablets by mouth daily for hypokalemia. There were no physician orders to crush the resident's medications. Review…

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 record review, staff interview, family interview, and facility policy review the facility failed to arrange routine dental care visits for one (#25) of two residents reviewed for dental care. The facility census was 86.Findings include:Review of Resident #25's medical record revealed an admission date of 08/06/24. Diagnoses included dementia, chronic obstructive pulmonary disease, emphysema, and coronary artery disease. Review of Resident #25's quarterly Minimum Data Set (MDS) dated [DATE] revealed the resident was a [AGE] year old male with a low cognitive function. The resident was dependent on staff for oral hygiene care. Review of Resident #25's care plan revealed he was at risk for altered oral/dental status related to cognitive loss and required assistance with dental care. Interventions were to have dental exams as warranted or desired by the resident. Review of Resident #25's outside services form revealed on 06/25/25 his family gave consent for the resident to see dental services for…

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 record review, staff interview, review of facility Self-Reported Incidents (SRI's), and review of facility policy, the facility failed to ensure staff reported an allegation of resident to resident sexual abuse to the administrator or designee in a timely manner. This affected two Residents (#10 and #11) of three reviewed for abuse. The facility census was 67. Findings include: Review of Resident #10's medical record revealed an admission date of 03/03/21. Diagnoses included Alzheimer's disease, dementia, cognitive communication deficit, and major depressive disorder. Review of Resident #10's Minimum Data Set (MDS) dated [DATE] revealed a Brief Interview for Mental Status (BIMS) score of two indicating Resident #10 was severely cognitively impaired. Resident #10 required limited assistance with bed mobility and transfer. Resident #10 required partial/moderate assistance with lower body dressing. Resident #10 had hallucinations, and delusions during the review period. Resident #10 displayed wandering…

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, medical record review, resident and staff interview, and facility policy review, the facility failed to ensure dependent residents received timely assistance with activities of daily living. This affected two (#10 and #36) of four residents reviewed for activities of daily living. The facility census was 50. Findings include: 1. Review of Resident #36's medical record revealed and admission date of 09/11/20. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, acute kidney failure, benign prostatic hyperplasia without lower urinary tract symptoms, hyperlipidemia, dysphagia, and cognitive communication deficit. Review of the Minimum Data Set (MDS) assessment, dated 03/16/23, revealed the resident was moderately cognitively impaired. Resident #36 required extensive one person assistance with personal hygiene. Review of the care plan, revised 05/09/23, revealed Resident #36 required assistance with personal hygiene. Observation on 05/15/23 at…

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 medical record review, staff interview, and policy review, the facility failed to ensure the resident's advance directives were accurate in the medical record. This affected one (Resident #40) of two residents reviewed for advance directives. The facility census was 83. Findings include: Review of Resident #40's medical record revealed an admission date of 09/12/19. Diagnoses included unspecified fracture of left pubis, unspecified sprain of left shoulder joint, sprain of unspecified site of left knee, bradycardia, unspecified dementia without behavioral disturbance, end state renal disease, acute kidney failure, dependence on renal dialysis and cirrhosis of liver. Review of the paper medical record revealed a document that indicated Resident #40 wished to have a Do Not Resuscitate Comfort Care (DNRCC) code status (only comfort measures be administered before, during, or after the time of person's heart or breathing stops), indicating the DNRCC protocol would be activated immediately. This document was signed on 09/16/19. Review of online medical record revealed 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.