River Heights Healthcare Center

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to ensure residents were free from verbal abuse when a registered nurse used profane, intimidating, and demeaning language toward two (2) of 10 residents reviewed for abuse. Resident #1 and Resident #4. Based on corrective actions taken by the facility on 6/3/26, the State Agency determined the deficiency to be Past Non-Compliance, and the facility was in compliance on 6/4/26 prior to survey entrance on 6/15/26.

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure residents were treated with respect and dignity from a staff member for six (6) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20, #19, #29, #18, #47.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to promote and facilitate resident self-determination by restricting residents' right to freely congregate in the activity room during evening hours for three (3) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20 and #40.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two (2) of (16) sampled residents reviewed (Resident #7 and Resident #9).

Inspectors wroteBased on observations, interviews, record review and facility policy review the facility failed to implement physician orders related to colostomy care and suprapubic catheter care for one (1) of (1) care observations. Resident #9Findings Include:A record review of the facility's policy Compliance Risks--Resident Quality of Care and Quality of Life revised January 2025, revealed Compliance with the Medicare and Medicaid Requirements of Participation for resident quality of care and resident quality of life is consistent with the goals of the overall compliance and ethics program .On 5/5/26 at 2:00 PM, during an interview, Licensed Practical Nurse (LPN) #1 stated Resident #9 performs his own catheter care. On 5/5/26 at 3:27 PM, during an interview and observation with Resident #9 stated he performs his own catheter care and colostomy care. [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure pain management was provided consistent with professional standards of practice for one (1) of (1) sampled residents reviewed for pain management. (Resident #1).

Inspectors wroteBased on interview, record review, and facility policy review the facility failed to ensure that complete and accurate direct care staffing information was electronically submitted to the Centers for Medicare & Medicaid Services (CMS) through the Payroll-Based Journal (PBJ) system within the required timeframe for one (1) of four (4) quarters reviewed, FY (Fiscal Year) Quarter 1 2026 (October 1-December 31). Findings Include:A review of the facility policy Reporting Direct Care Staffing Information (Payroll-Based Journal) with a revision date of August 2022 revealed, Direct care staffing information is reported electronically to CMS through the Payroll-Based Journal system. Policy Interpretation and Implementation 1. Complete and accurate direct care staffing information is reported electronically through the PBJ system in a uniform format specified by CMS .10. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review the facility failed to ensure staff adhered to Enhanced Barrier Precaution (EBP) protocols during high-contact resident care activities for one (1) of (1) residents reviewed. (Resident #7)

Inspectors wroteBased on interview, facility policy review, and record review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to sustain corrective action to prevent recurrence of previously cited deficiencies, specifically, the facility was cited for failing to ensure infection control standards were adhered to related to proper use of Enhanced Barrier Precautions (EBP) during care in June 2025 and was again cited for the same deficient practice on the current survey, demonstrating that QAPI failed to sustain ongoing monitoring and oversight to prevent recurrence for one (1) of eight (8) deficiencies cited. F880.

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to provide dignity to a resident, as evidenced by leaving an indwelling urinary catheter bag and tubing uncovered for one (1) of three (3) residents with a catheter reviewed.

Inspectors wroteBased on staff interviews, record review, and facility policy review, the facility failed to notify a resident representative of the risk and benefits for the initiation of a new psychotropic medication for one (1) of two (2) residents reviewed for psychotropic medication use. Resident #31 Findings Include: Review of the facility policy titled Psychotropic Medication Use with a revision date of 2/2025 revealed under, Informed consent or refusal: 1. Prior to initiating the use of, increasing the dose of, or switching to a different psychotropic medication, the staff and physician will review the following with the resident/representative prior to obtaining documented consent or refusal: . b. the indications and rationale for the recommendation; c. the potential risk and benefits (including possible side effects, adverse consequences, and the black box warning); and d. [...]

Inspectors wroteBased on observation, staff interviews, record review, and facility policy review, the facility failed to provide a safe, homelike environment as evidenced by an unsanitary bathroom for one (1) of the thirty resident shared bathrooms observed. room [ROOM NUMBER], and room [ROOM NUMBER]

Inspectors wroteBased on facility investigation review, record review and staff interview, the facility failed to protect the residents' right to be free from sexual abuse by other residents for one (1) of six (6) residents reviewed for abuse. Resident #49.

Inspectors wroteBased on staff interviews, record reviews and facility policy review, the facility failed to timely submit the quarterly Minimum Data Set (MDS) assessment for one (1) of 22 resident MDS assessments reviewed for timely submissions: Resident #17.

Inspectors wroteResident #49 Record review of Resident #49's care plans revealed an alteration in ADL's related to general weakness , impaired mobility dated 12/26/23 with an intervention of Total Assist times one (1) staff with eating. On 6/3/25 at 7:30 AM an observation revealed Resident #49's breakfast tray was sitting on her bedside table. The resident was lying in bed with her head covered and continued observation revealed that no staff entered the room to assist the resident or set tray up until 8:00 AM. On 6/3/25 at 8:00 AM during interview with CNA #1 she verified that Resident #49 had to be assisted by staff during meals. Interview with Licensed Practical Nurse (LPN) #1 on 6/3/25 at 8:05 AM she confirmed that Resident #49 should have been assisted with breakfast when the tray was delivered. [...]

Inspectors wroteResident #49 An observation on 6/3/25 at 7:30 AM revealed Resident #49's breakfast tray sitting on her bedside table, not opened or set up. The resident was in bed with her head covered with a blanket. Continued observation revealed that staff finally came in to assist the resident with breakfast at 8:00 AM. An interview with CNA #1 on 6/3/25 at 8:00 AM verified that Resident #49 has to be assisted with meals. She revealed that staff know they are not supposed to leave trays in the rooms of residents that need assistance, if they cannot feed them at that time. She stated that if a resident needs to be fed you are supposed to sit down and feed the resident when you bring the tray into the room. She stated that the tray should have been left on the cart until she was available to assist the resident. She verified that the food could get cold and that residents may not want to eat it. [...]

Inspectors wroteBased on observation, resident and staff interviews, record review, and facility policy review, the facility failed to provide the necessary foot care to maintain skin integrity and prevent complications for one (1) of three (3) residents reviewed that needed assistance with foot care. Resident #7 Findings Include: Review of the facility policy titled Foot Care with a revision date of 10/2022 revealed under, Policy Statement: Resident receive appropriate care and treatment in order to maintain mobility and foot health. Also revealed under, Policy Interpretation and Implementation: 1. Residents are provided with foot care and treatment in accordance with professional standards of practice. 2. Overall foot care includes the care and treatment of medical conditions to prevent foot complications from these conditions. [...]

Inspectors wroteBased on observations, staff interviews, record review, and facility policy review, the facility failed to provides an environment that is free from accident hazards as evidenced by failure to implement interventions to reduce fall hazards for one (1) of 40 residents sampled, Resident #15.

Inspectors wroteBased on resident and staff interviews, record review, and facility policy review, the facility failed to ensure an accurate trauma-informed care assessment was completed for one (1) of two (2) residents reviewed for Post-Traumatic Stress Disorder (PTSD). Resident #44 Findings Include: Review of the facility policy titled Trauma Informed Care and Culturally Competent Care with a revision date of 8/2022 revealed under, Purpose: To guide staff in providing care that is culturally competent and trauma-informed in accordance with professional standards of practice. To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Also revealed under, Resident Assessment: 1. Assessment involves an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers . [...]

Inspectors wroteBased on interview, record review and facility policy review, the facility failed to ensure the Facility Assessment was updated to include a comprehensive evaluation of the resident population and the necessary resources, including staffing levels and competencies, required to meet resident needs under both routine and emergency conditions for three (3) of three (3) survey days.

Inspectors wroteBased on observations, staff interviews, record reviews, and facility policy review, the facility failed to help prevent the possible transmission of infections when staff failed during medication administration to ensure a multi-use glucometer was properly cleaned and disinfected and failed to use Enhanced Barrier Precautions (EBP) during catheter care (Resident #55) for two (2) of three (3) infection control practices observed.

Inspectors wroteBased on staff and resident interview, record review and facility policy review the facility failed to prevent resident to resident sexual abuse for two (2) of five (5) residents reviewed for sexual abuse. Resident # 1 and Resident #3.

Inspectors wroteBased on resident and staff interview, record review and facility policy review the facility failed follow the person centered care plan to use a full body lift as indicated, causing a dislocated shoulder for Resident #1. This was for one (1) of four (4) resident care plans reviewed. Findings Include Record review of the facility policy titled, Care Plans, Comprehensive, Person Centered with no revision dated revealed Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident . [...]

Inspectors wroteBased on observation, resident and staff interview, record review and facility policy review the facility failed to prevent an accident that resulted in an injury, as evidenced by a staff member using a lift the physician had not ordered for one (1) of four (4) residents reviewed that required a lift. Resident #1 Findings Include Review of the facility policy titled, Modified Lifting Policy with no revision dated revealed .Policy Interpretation and Implementation .3. Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart and on the Resident Care Sheet. This information should be referred to prior to lifting/transferring or assisting each resident . An interview and observation on 4/17/24 at 9:10 AM, revealed Resident #1 lying in bed with a total lift sling underneath her. [...]

Inspectors wroteBased on record review, staff interviews and facility policy review, the facility failed to accurately code the Minimum Data Set (MDS) assessments for a Preadmission Screening and Resident Review (PASRR) for two (2) of 16 sampled residents. Resident #4 and Resident #15. Findings Include: A record review of the facility policy Certifying Accuracy of the Resident Assessment, revised December 2009 revealed Policy Statement: All personnel who complete any portion of the Resident Assessment (MDS) must sign and certify the accuracy of that portion of the assessment . Resident #4 A record review of Resident #4's annual MDS with a Assessment Reference Date (ARD) of 5/26/2023, indicated a No to A1500, Is the resident currently considered by the state level II PASRR process to have serious mental illness . A record review of Resident #4's Summary Findings Report, dated 10/20/2022, revealed . [...]

Inspectors wroteBased on staff interview, record review and facility policy review the facility failed to submit a Discharge Minimum Data Set (MDS) assessment timely in accordance with the current federal and state submission timeframes for one (1) of 16 resident MDS assessments reviewed.