Riverside Health Services

Based on record review and interview, the facility failed to report an allegation of abuse to the state agency for 1 (#1) of 3 sampled residents reviewed for abuse.The DON identified 38 residents resided in the facility.Findings:An undated Abuse, Neglect and Exploitation policy, read in part, The facility will have written procedures that include: 1. Reporting of alleged violations to the administrator, state agency, adult protective services and to all other required agencies.An admission assessment, dated 01/22/26, showed Res #1 had a Brief Interview for Mental Status (a test for cognition) score of 3, which indicated severely impaired cognition.A physician progress note, dated 04/29/26 at 7:57 a.m., read in part, Follow-up evaluation conducted today regarding prior concerns of potential inappropriate physical contact involving the patient and spouse. There have been allegations of possible sexual behavior; however, no such activity has been witnessed by staff.On 05/06/26 at 11:00 a.m., the DON stated on 04/28/26, the administrator was notified by a certified nurse aide 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.

Based on record review and interview, the facility failed to update the facility assessment as the acuity level of resident care increased. The DON identified 36 residents resided in the facility. Findings: A facility assessment, dated 10/15/25, read in part, Nursing facilities will conduct, document, and review a facility-wide assessment, which includes both their resident population and the resources that facility needs to care for their residents (42CFR SS483.71). The assessment will be reviewed annually and updated as needed.The purpose of the assessment is to evaluate the resident population and determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies. Use this assessment to make decisions about your direct care staff needs (including those who provide services under contract and volunteers), as well as your ability to provide services to the residents in your facility, at least annually and as necessary, for the above requirement. Using evidence-based, data driven methods focus 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 observation, record review, and interview, the facility failed to perform pressure ulcer care in a manner to prevent infection for 1 (#3) of 5 sampled residents reviewed for pressure ulcer care. A weekly wound flow sheet, dated 04/15/26, showed 11 residents with pressure ulcers. Findings:On 04/29/26 at 2:10 p.m., LPN #1 donned gloves and gown and entered Resident #3's room to provide pressure ulcer care. LPN #1 was observed to push personal items to one side and place two plastic trash bags on Resident #3's overbed table, next to the resident's personal items. LPN #1 did not sanitize the resident's overbed table prior to placing their dressing change supplies, bags, and gloves on the overbed table. CNA #1 and LPN #1 stepped to each side of the bed and positioned Resident #3 onto their right side. LPN #1 used their gloved hand to wipe feces from the Resident #3's upper left leg and buttock. LPN #1 then stepped back, and CNA #2 stepped to the side of the bed and provided incontinent care. CNA #1 and CNA #2 provided incontinent care, removed the soiled cloth bed pad, 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility failed to ensure CMAs had the proper certifications to pass medications for 3 (#1, 2, and #3) of 8 sampled CMAs reviewed for certifications to pass meds via a gastrostomy tube.The DON identified 24 residents received medications through their peg tubes. An undated Medication Administration policy, read in part, medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice.1.On [DATE], upon reviewing CMA #1's certifications, CMA #1's advanced gastrostomy certification showed to have expired on [DATE].Resident #1's 10/2025 MAR showed CMA #1 had administered medications to Resident #1 on [DATE] through their peg tube (feeding tube into the stomach).2.On [DATE], upon reviewing CMA #2's certification, CMAs #2s advanced gastrostomy certification had expired on [DATE].Resident #1's 10/2025 MAR showed CMA #2 had administered…

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 update behavior care plans for 3 (#1, 2, and #4) of 3 sampled residents whose care plans were reviewed for their interventions in the management of routinely displayed inappropriate behavior. The DON identified three residents routinely displayed inappropriate behavior. Findings: 1. On 07/27/25 at 3:15 p.m., Resident #1 was observed entering the dining room. Resident #2 was observed sitting at a table in the corner of the dining room, with windows located on both walls of the corner. Resident #1 stopped and stared in the direction of Resident #2 for several minutes while mumbling unintelligible words under their breath. When Resident #1 was asked what they were saying, the resident only smiled and shook their head no. Several seconds later, Resident #2 smiled and pointed out the window as an ambulance arrived with their emergency lights on. A nurse's progress note, dated 02/09/25, showed Resident #1 yelled at other residents, attempted to grab other residents, punched another resident, blocked doorways/staff…

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 and interview, the facility failed to ensure complete and accurate documentation for 1 (#2) of 5 sampled residents reviewed for complete and accurate medical records. The DON reported the facility census was 39. Findings: A facility policy titled Charting and Documentation, revised 07/2017, read in part, All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care. Resident #2 was admitted on [DATE] and had diagnoses which included chronic respiratory failure. A review of Resident #2's medical records did not show any physician progress notes for Resident #2. On 03/03/25 at 1:17 p.m., physician #1 stated they had seen Resident #2 in person a couple of times since there was a wound noted 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 interview, the facility failed to ensure a resident with a new diagnosis of a serious mental health condition had a PASARR updated for 1 (#7) of 1 sampled resident reviewed for PASARR level ll. The DON identified nine residents with serious mental health diagnoses. Findings: Resident #7 had diagnoses which included pseudobulbar affect and a mood affective disorder. A PASARR level l, dated 10/26/18, showed the resident did not have a diagnosis of serious mental illness or other psychotic disorder. The annual assessment, dated 11/09/24, showed the resident currently was not considered by the state PASARR level II process to have serious mental illness and/or intellectual disability or a related condition. On 02/04/25 at 2:57 p.m., the DON reviewed the resident's clinical record and stated the resident had a diagnosis of mood affective disorder and a psychotic disorder. The DON stated a PASARR level ll referral should have been made to the Level of Care Evaluation Unit.

Based on record review and interview, the facility failed to provide RN coverage for eight consecutive hours seven days per week during 2 (October 2024 and January 2025) of 4 months reviewed for having RN coverage for eight consecutive hours seven days per week. The administrator identified 40 residents resided in the facility. Findings: The CASPER report for fisal year Quarter 4 2024 triggered for no RN coverage on four or more days within the quarter. A review of payroll documents for October 2024 and January 2025 showed there was no RN coverage on the following days since the last period covered on the CASPER report: October 5-6, 12-13, and 26-27 and January 5, 12, 19, and 26. On 02/05/25 at 4:44 p.m., the business office manager was asked if they had submitted all of the documents to verify RN coverage for October 2024 and January 2025. They stated that was all they could account for in their punch system. They stated the DON did not punch, but completed missed visit forms. They stated they gave all that they had. On 02/06/25 at 8:24 a.m., the DON acknowledged there was no RN…

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 interview, the facility failed to ensure nurse aides demonstrated competency in skills and techniques necessary to care for resident needs. The Administrator reported 30 residents resided in the facility. Findings: A sample of employee files were reviewed. No documentation was found related to demonstration of nurse aide competency and/or skills checklists. On 07/13/22 at 9:07 a.m., CNA #1 reported it had been a long time since the facility had an annual skills fair or competency check-off. The CNA stated the facility had an orientation checklist for new CNA's and the staff responsible for training would help with completing the orientation checklist. On 07/13/22 at 9:16 a.m., CNA #2 reported there was an orientation checklist for newly hired CNA's but she could not remember having an annual skills fair with competency check-off in a long time. On 07/13/22 at 9:26 a.m., CNA #3 reported she had worked at the facility for two years. She stated she had a skills check-off in November 2020 provided by the lead CNA. CNA #3 stated there had not been an annual…

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 interview, the facility failed to provide an advanced beneficiary notice (ABN), describing charges for covered and non-covered services, for three (#31, #12, and #22) of three residents reviewed for Skilled Nursing Facility Advance Beneficiary Notice. The Administrator reported five residents were discharged from skilled services in the past six months. Findings: A review of the clinical records for residents #31, #12, and #22 contained no documentation an ABN had been provided to residents and/or their representative. 1. Resident #31 was admitted to skilled services on 01/19/22 and discharged from skilled services on 04/30/22. 2. Resident #12 was admitted to skilled services on 01/19/22 and discharged from skilled services on 04/03/22. 3. Resident #22 was admitted to skilled services on 01/10/22 and discharged from skilled services on 04/19/22. There was no documentation Resident #31, Resident #12 and Resident #22 recevied ABN when discharging from skilled services. On 07/11/22 at 4:02 p.m., the Business Office Manager reported she had been in 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 record review, observation, and interview, the facility failed to maintain a sanitary ice machine for storage of ice. The Administrator reported 30 residents resided in the facility. Findings: On 07/11/22 at 11:53 a.m., the ice machine in the main dining room was observed to be unlocked. The ice guard was observed to have a black residue build-up along the lip of the guard, extending completely across the front of the guard. A Cleaning Log, posted on the front of the ice machine, showed a date of 03/06/22 as the last date the machine was cleaned. On 07/11/22 at 12:28 p.m., dietary staff #1 reported being the last to clean the ice machine and confirmed his initials and a cleaning date of 03/06/22. He was shown the black build-up and he stated it did not always come off. He obtained a clean cloth, wiped the black residue off, and stated he would be sure to clean it in the future. On 07/11/22 at 12:35 p.m., dietary staff reported residents did not access the ice machine themselves. The staff reported if a resident needed ice, staff would get it for them. The staff stated 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.