Riverview Health Services

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interview, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety for 3 of 30 residents (R1, R4, and R8). Licensed Practical Nurses (LPNs) assessed R1 after a fall, without contacting a Registered Nurse (RN), the Director of Nursing (DON), or R1's provider prior to moving R1 for 5 of 8 falls. No documentation to support that the LPN contacted an RN prior to moving R8 after a fall.LPN did not report a change of condition in R4 to an RN.Per the Wisconsin LPNs Standard of Practice (N 6.04), -LPNs must work under the general supervision of an RN or direction of a provider. -LPNs provide basic nursing care, including collecting data and recording it. -LPNs must report changes in a patient's condition to the appropriate person. -LPNs must consult with a provider if they know a delegated act may harm a patient. The facility's policy titled, Fall Prevention and Management Guidelines, read in…

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, and record review, the facility failed to ensure each resident has the right to a dignified existence, self-determination, and communication by ensuring the ability to communication interventions were in place for 1 of 4 residents (R8).Surveyor observed R8 sitting in lounge area without the jingle bell R8 uses to communicate with staff when R8 needs something.R8 was admitted to facility on 11/03/25 with diagnosis that include Parkinson's disease with dyskinesia fluctuation (difficulty in performing or controlling voluntary movements).R8's admission Minimum Data with target date of 11/09/25 and documented on 11/13/25 indicates:R8 has a BIMS of 7/15 (moderately impaired).R8 has no speech sometimes understood and sometimes understands.R8's care plan, I have difficulty communicating as evidenced by whispered/soft voice, initiated on 11/03/25.R8's ADL care plan intervention labeled and dated 11/07/25 Communication states: Uses jingle bell when not in bed.On 01/26/2026 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.

Based on interview and record review, the facility did not notify a physician and/or RN about a significant change in a resident's physical status for 1 resident (R4) of 13 residents reviewed in a sample of 13.Documentation in R4's medical record by Licensed Practical Nurse (LPN) I indicated a change in R4's physical condition during an evening shift.LPN I did not notify a physician or a Registered Nurse (RN) for further guidance, resulting in R4's prolonged discomfort resulting from a dislocated hip.R4's medical record did not include further documentation of assessment by licensed staff following LPN I's initial documentation of a physical change in R4's status, resulting in delayed intervention for a dislocated hip. This is evidenced by: The facility policy, titled Change in Condition: When to report to the MD/NP/PA, adapted from AMDA Clinical Practice Guidelines 2003, states in part: Immediate notification.any symptom, sign or apparent discomfort that is: acute or sudden in onset, and a marked change in relation to usual symptoms and signs, or unrelieved by measures already…

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 interviews, the facility did not ensure residents/representatives received written or verbal consent of Bed Hold reserved payment at time of transfer and the notice of transfer prior to discharge or transfer did not include written specific reason the specific for transfer for 2 of 3 residents (R4 and R14). R4 was sent to the hospital via ambulance on 09/19/25 for a change in condition. R4's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 09/22/25 of receiving verbal consent.R14 was sent to hospital via ambulance on 12/27/2025 for a change in condition. R14's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 12/29/25 of verbal consentThe facility policy, titled Bed Hold Notice, dated 04/23/25, states: It is the policy of this facility to provide written information to the resident and/or the resident representative regarding bed hold practices both well in advance, and at the time of a…

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 did not conduct a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed (R33) within 30 days of admission to ensure individuals with a serious mental disorder received care and services in the most integrated setting possible. This is evidenced by:The facility policy, titled Resident Assessment - Coordination with PASARR Program, with a date implemented of 11/10/25, reads in part, The Level II resident review must be completed within 40 calendar days of admission.Surveyor reviewed R33's record and noted R33 was admitted on [DATE] with a diagnosis of major depressive order.R33's original order included Quetiapine Fumarate 25MG once daily and Duloxetine HCl 30 MG twice a day. R33's Quetiapine Fumarate was discontinued and on 1/26/26 R33's Duloxetine HCl was increased to 60MG in the morning and 30MG at bedtime.Surveyor noted on 11/6/25, a Level I PASRR screening noted R33 had a major mental disorder and has taken psychotropic…

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 did not ensure pain management was provided to residents, consistent with the comprehensive person-centered care plan, and the resident's goals and preferences for 1 resident (R4) of 2 residents reviewed for pain management in a sample of 13. Facility did not develop and implement a care plan on pain management for R4 with a known diagnosis of dementia. R4 may not normally recognize and verbalize when having pain resulting in a prolonged status of discomfort while experiencing a hip dislocation. This is evidenced by:The facility policy, titled Pain Management, last revised 08/09/2022, states in part: The interventions for pain management will be incorporated into the components of the comprehensive care plan, addressing conditions or situations that may be associated with pain or may be included as a specific pain management need or goal.Non-pharmacological interventions will include but are not limited to.cold compress, warm shower/bath, massage, turning and repositioning, cognitive/behavioral interventions such as music,…

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 did not ensure menus were followed to meet the nutritional needs of each resident. This practice had the potential to affect all 38 residents residing in the facility. Meals were not provided as listed on the menu. The facility did not consult with the Registered Dietitian when changes were made to the menu to ensure nutritional adequacy. Findings: According to The Academy of Nutrition and Dietetics, The menu must meet the Recommended Dietary Allowances, but the actual amount of food served to an individual resident should meet her/ his needs, not exceed them. Food is an essential component of quality of life; an unpalatable or unacceptable diet can lead to poor food and fluid intake, resulting in malnutrition and related negative health effects. On 11/04/24 at 8:11 AM, Surveyor completed initial tour of the kitchen with Dietary Manager (DM) F. DM F reported to Surveyor she will be changing menu items this week. DM F reported the planned menu for Wednesday's lunch and Thursday's dinner will be substituted with a soup and sandwich.…

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 did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 38 residents (R). The facility did not measure the internal temperature of the dishwasher. Dietary staff did not wear appropriate hair restraints. Findings: DISHWASHER The Food and Drug Administration (FDA) Food Code requires that commercial dishwashers achieve a utensil surface temperature of 71°C (160°F) as measured by an irreversible registering temperature indicator. On 11/04/24 at 1:23 PM, Surveyor observed Dietary Aide (DA) E washing dishes using a commercial dishwasher. DA E stated the dishwasher was a high temperature dishwasher. Surveyor noted the dishwasher's temperature log was not completed on 11/02/24 and 11/03/24. DA E stated sometimes he forgets. Surveyor asked DA E how dietary staff check to ensure the dishwasher's temperature is reaching the appropriate temperature for sanitization. DA E stated they were using test strips but had not been doing this. DA E was not able to find the test…

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 did not ensure staff followed procedures for the accurate administration of insulin. Staff did not complete a safety check by priming the needle on an insulin pen to ensure the injectable pens were dispensing insulin before administration for 1 of 2 residents (R), (R3). Findings include: Manufacturer's instructions for insulin pens state in part, .Step 3. Perform a Safety test. Always perform the safety test before each injection. Performing the safety test ensures that you get an accurate dose by: ensuring that pen and needle work properly. Removing air bubbles. A. Select a dose of 2 units by turning the dosage selector. B. Take off the outer needle cap and keep it to remove the used needle after injection. Take off the inner needle cap and discard it. C. Hold the pen with the needle pointing upwards. D. Tap the insulin reservoir so that any air bubbles rise up towards the needle. E. Press the injection button all the way in. Check if insulin comes out of the needle tip. You may have to perform the safety test several times before…

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 interview and record review, the facility did not ensure one of five residents (R15) reviewed for unnecessary medications had appropriate monitoring and indication for use of an antipsychotic medication. R15 was prescribed risperidone for a diagnosis of dementia with behaviors. Behavior monitoring did not include the behaviors the medication was being used to treat. This is evidenced by: The facility policy titled, Psychotropic Medications read in part, Residents should not receive psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinic record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Psychotropic medications can affect behavior, mood, thoughts, and perceptions. Psychotropic medications include antipsychotic medications. Risperidone is an antipsychotic medication used to treat schizophrenia and bipolar disorder. R15 was admitted…

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 did not perform hand hygiene when warranted during resident cares. The facility practice affected 1 of 3 residents observed for cares (R10). Certified Nursing Assistant (CNA) C did not perform hand hygiene after performing R10's peri care and before proceeding to touch presumably clean items. Findings Include: Surveyor requested and received the facility policy titled Hand Hygiene dated 11/02/22. The policy in part read: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). Policy Explanation and Compliance Guidelines: 1. Staff will perform hand hygiene when indicated using proper technique consistent with accepted standards of practice. Additional Considerations: a. The use 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 observation, interview and record review, the facility did not prepare and store foods in a sanitary manner. The facility practices had the potential to affect all 50 residents. The facility does not have a system in place to verify the internal hot water temperature of the hot water sanitizing dishwasher. During the initial tour of the kitchen, Dietary Manager (DM) G and Dietary Aide (DA) H were observed with facial hair at sides and below surgical mask that were being worn. DM G did not perform hand hygiene after contaminating his hands with dirt and grime. DM G proceeded to tour the kitchen with Surveyor, touching presumable clean surfaces and food items with his contaminated hands. Potentially hazardous food and drinks were stored in the kitchen refrigerator and were not dated with open by and use by dates. DM G was observed spraying dirty dishes in the dish room with his shirt being sprayed with contaminated water. DM G proceeded to prepare and serve foods at counter and steam table. DM G's contaminated shirt was observed contacting clean food surfaces. 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility did not prepare foods in a manner that maintained the nutritional value and palatability of foods. The facility practice has the potential to affect 14 of 50 sampled and supplemental residents (R20, R14, R45, R22, R25, R9, R12, R26, R27, R31, R21, R35, R15 and R7). Dietary Manager (DM) G was observed preparing lunch items of altered consistency without using a recipe or instructions to ensure nutritional values were maintained. This has the potential to affect 11 residents of 50 who are served an altered consistency diet (R20, R14, R45, R22, R25, R9, R12, R26, R27, R31 and R21). R35 indicated the foods served are often bland in taste and the meats are too tough to chew. R15 expressed that the food was cold and indicated it was not good. R250 expressed that the food was cold and said it was hard to eat. R7 complained about the beef tips for lunch. R7 stated he had to chew and chew. This is evidenced by: Example 1 On 9/26/23 at 11:45 a.m., Surveyor…

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 interview and record review, the facility did not ensure that 3 of 3 sampled residents (R7, R18, R35) did not receive care and services to maintain and/or improve their highest level of range of motion (ROM). R7 did not receive assistance to ambulate twice daily per his restorative program. R18 did not wear hand brace at night as recommended by occupational therapy (OT). R35's care plan was not updated to indicate independence with walker. Findings include: R7 was admitted to the facility on [DATE]. Diagnoses include fracture of left tibia and fibula, muscle weakness, and abnormal gait and mobility. Minimum Data Set (MDS) assessment, dated 07/14/23, confirmed R7 scored 15/15 during Brief Interview for Mental Status, indicating intact cognition. On 09/25/23 at 11:41 AM, Surveyor interviewed R7. R7 reported he has not received therapy services in two weeks. On 09/27/23 at 9:00 AM, Surveyor interviewed Certified Nursing Assistant (CNA) J regarding the brace that R18 was supposed to be wearing per therapy.…

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.