River Pointe Post-Acute

Inspectors wroteBased on observation, interview and record review the facility failed to provide adequate supervision to prevent elopement for one resident (Resident 2) of three sampled residents, when Resident 2 left the facility unsupervised and his whereabouts accounted for. This failure resulted in Resident 2 exiting the facility premises, which placed him in a potentially unsafe and perilous place and situation with the risk of being injured or harmed, as he was able to leave the facility without staff being aware.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate food texture was provided for one of three sampled residents (Resident 1), when Resident 1, who was on a puree diet (a diet with food texture of smooth like pudding or mashed potatoes that requires no chewing for one who has difficulty chewing and/or swallowing) received sponge cake. This deficient practice resulted to Resident 1 being hospitalized on [DATE] due to aspiration symptoms (a condition in which food, liquids, saliva, or vomit is breathed into the airway). During a review of Resident 1's admission Record (AR-front page of the chart that contains a summary of basic information about the resident), indicated, Resident 1 was admitted to the facility on [DATE] with multiple diagnoses which included dysphagia (difficulty swallowing). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe administration of supplemental oxygen (a colorless and odorless gas used when a person's body is unable to get enough oxygen from normal air) in accordance with the physician's order for one of three sampled residents (Resident 1), when staff administered supplemental oxygen at 5 liters per minute (L/min, unit of measurement) to Resident 1 continuously without a physician's order. This failure did not reflect Resident 1's treatment needs and placed the resident at risk for oxygen toxicity, worsening of respiratory and cardiac (related to the heart) status, and had the potential to compromise Resident 1's well-being.

Inspectors wroteBased on interview and record review the facility failed to meet the professional standards of quality for one of three sampled residents (Resident 2) when a physician's post-surgical care orders were not implemented for Resident 2. This failure resulted in incomplete post-surgical assessments and monitoring for Resident 2 and placed the resident at higher risk for complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain privacy for a census of 110 residents, when the residents' meal tray tickets (paper slips printed for residents' meals detailing names, food allergies, adaptive eating utensils, and therapeutic diet orders) were thrown in the trash. This failure decreased the facility's potential to protect the residents' private health information.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the recipe for seven residents of a census of 110, when excess broth and milk and unmeasured amounts of food thickener were added to pureed (a smooth, lump-free, and moist consistency similar to pudding, which does not require chewing and is easily swallowed) meals. This failure decreased the facility's potential to serve residents food that was easy to swallow and retained its nutrient value.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and distribute food in accordance with professional standards for food service safety for a census of 110 residents, when:1. Undated and expired food was stored in the kitchen, and 2. Two wet pans were stored with one pan having brown gel-like smudges inside. These failures decreased the facility's potential to prevent the spread of foodborne illnesses among vulnerable residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a copy of advance directive was obtained for one of 31 sampled residents (Resident 45), when a copy of advance directive was not available in Resident 45's medical records. This failure decreased the facility's potential to honor Resident 45's end-of-life wishes.

Inspectors wroteBased on interview and record review, the facility failed to submit in a timely manner a Minimum Data Set (MDS; an assessment tool) for one of 31 sampled residents (Resident 42), when Resident 42's discharge assessment was not submitted since 10/2025. This failure decreased the facility's potential to submit Resident 42's MDS information to the Centers for Medicare and Medicaid Services (CMS) in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the plan of care for one of 31 sampled residents (Resident 30), when Resident 30's communication board was not available for use during provision of care. This failure decreased the facility's potential to meet Resident 30's ability to communicate his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate the food preferences for one resident (Resident 110) of a census of 110, when [NAME] (C) 1 did not provide a protein substitute of similar nutritive value. This failure decreased the facility's potential to provide Resident 110 with an adequate protein substitute.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control measures for one of 31 sampled residents (Resident 25), when Licensed Nurse (LN) 1 did not wear proper personal protective equipment (PPE, protective clothing/gown, gloves, face masks/shield to protect from injury or the spread of infection) while providing care to Resident 25 placed on Enhanced Barrier Precaution (EBP, an infection control method). This failure decreased the facility's potential to prevent the spread of infection among residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call lights were available to use for two of 31 sampled residents (Resident 113 and Resident 121), when:1. Resident 113's call light was not within reach and not suitable to be used; and2. Resident 121's call light was not within reach. These failures decreased the facility's potential to assist residents in a timely manner when needed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow proper infection control practices for one of six sampled residents (Resident 1) when a contracted staff member provided care to Resident 1 without wearing a gown. This failure had the potential to increase the spread of infection for a census of 112.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three residents (Resident 1) from misappropriation of property, when Certified Nursing Assistant (CNA) 1 solicited and borrowed money from Resident 1, and used Resident 1's debit card for personal use. This failure resulted in Resident 1's emotional distress and loss of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 2) received adequate assistance with activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves), when showers were not provided as scheduled. This failure had the potential to result in Resident 2 not attaining his highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure food allergies were honored for one of four sampled residents (Resident 1) when during the lunch meal on 12/21/2025 Resident 1 was served Banana Pie that contained a known allergen. This failure resulted in Resident 1 to have a potentially life-threatening allergic reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assistance with the use of dentures was provided for one of three sampled residents (Resident 1). This failure increased the potential for Resident 1 to refuse meals and lose weight. A review of the admission Record indicated Resident 1 was admitted early December 2025 with diagnosis including generalized muscle weakness. Resident 1's Minimum Data Set (MDS- a federally mandated resident assessment tool) dated 12/10/25 indicated Resident 1 was cognitively intact, had impairment on both upper extremities and required substantial or maximal assistance (helper does more than half the effort) for oral hygiene which included ability to insert and remove dentures into and from the mouth. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was stored in a safe manner for one of three sampled residents (Resident 1). This failure had the potential for diversion or unauthorized use of medication not being securely stored. A review of the admission Record indicated Resident 1 was admitted early December 2025 with diagnosis including generalized muscle weakness. Resident 1's Brief Interview for Mental Status (BIMS- an assessment tool used by facilities to screen and identify memory, orientation, and judgment status of the resident) dated 12/10/25 indicated Resident 1 was cognitively intact with a score of 15. During a concurrent observation and interview on 12/19/25 at 11:16 a.m., three unlabeled medication cups with white cream were observed inside a white plastic rectangular container on top of Resident 1's dresser. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate monitoring and supervision, per care plan, for a 1:1 sitter (responsible to ensure resident safety with constant supervision) for one of three sampled residents (Resident 1) when Resident 1 was left unattended in his room. This failure had the potential to put Resident 1 at risk for falls, injuries and elopement while being unsupervised.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the call light system was fully functional and properly maintained for one of three sampled residents (Resident 1) when Resident 1 pressed the call light button and activated the call light above the resident's room door, the corridor call lights located on the wall and above the double door failed to illuminate. This incomplete functionality of the call light system had potential to delay staff response to Resident 1's needs and impede Resident 1's ability to effectively communicate for assistance when required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was free from physical abuse when Resident 2 struck Resident 1 with her fist, hitting her on the left side of her forehead. This failure resulted in Resident 1's bruised left forehead and fear manifested by crying. During a review of Resident 1's admission Record (AR), dated 10/1/24, the AR indicated Resident 1 was admitted to the facility in late 2024 with diagnoses which included aphasia (a disorder that makes it difficult to speak), cognitive communication deficit and right-side body weakness. During a review of Resident 1's Physician's Orders (PO), dated 10/1/24, the PO indicated Resident 1 was incapable of making her own healthcare decisions. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse when an incident involving two of five sampled residents (Resident 1 and Resident 3) was not reported to the Department .This failure had the potential to place residents at risk for continued or escalating abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 107 when: Staff did not wear appropriate personal protective equipment (PPE) for residents on isolation precaution (measures to reduce transmission of diseases) for COVID-19 (a contagious disease caused by the coronavirus [a type of virus]); and,Licensed Nurse 3 (LN 3) was observed eating by the cart in the hallway. These failures decreased the facility's potential in preventing transmission of diseases among residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing care staff meet certification requirements defined under State law and regulation for one of four sampled staff (Certified Nursing Assistant 4 [CNA 4]) when CNA 4 was scheduled to work with expired CNA certification. This failure had the potential to result in residents not receiving appropriate care based on professional standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 (a contagious disease caused by the coronavirus [a type of virus]) vaccinations were offered to residents and staff when one of four sampled residents (Resident 1), and one out of four sampled staff (CNA 4), had no documented evidence of their COVID-19 vaccination status. This failure had the potential to result in Resident 1 and CNA 4 not to be aware of the risk and benefits of the vaccination and increased their risk of acquiring COVID-19.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional standards of practice were followed for three of six sampled residents (Resident 1, Resident 2, and Resident 3), when: 1. Resident 1 ' s Permethrin (a medication used to treat scabies - a very itchy rash caused by a parasitic mite that burrows in the skin surface) was not given per physician ' s order and Resident 1 ' s Ivermectin (used for infections caused by parasites) order was not carried out as ordered; 2. Resident 2 ' s Permethrin order was not followed as ordered; and 3. Resident 3 ' s Permethrin order was not carried out timely. These failures had the potential to result in Resident 1, Resident 2, and Resident 3 not having the desired effects of the medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for one of six sampled residents (Resident 1) when Resident 1 ' s contact precaution (isolation measures used to prevent the spread of infections transmitted through direct contact or indirect contact) was removed before Resident 1 received treatment for scabies (a very itchy rash caused by a parasitic mite that burrows in the skin surface). This failure decreased the facility ' s potential in preventing transmission of diseases among residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect one of three sampled residents (Resident 1) from abuse when Resident 2 hit Resident 1 on the left hand. This failure resulted in a bruise on Resident 1's left hand and had the potential for Resident 1 to feel unsafe in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow proper infection control practices for one of seven sampled residents (Resident 1) when a Certified Nursing Assistant (CNA) did not put on a protective gown when performing resident care. This failure had the potential to increase the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when: 1. The ice machine was not clean; and 2. Kitchenware was stacked and stored while wet in the clean and ready-to-use storage area; and 3. Fry pans stored in the clean and ready-to-use storage area were not clean; and 4. Food in open packages was not covered and open food items lacked complete label; and 5. Expired food was available for use; and 6. Food thawing processes were not followed; and 7. Outdated resident food brought from the outside was not discarded; and 8. One dietary staff did not have hair fully covered; and 9. Two dietary personnel were not able to demonstrate and verbalize correct concentration testing and concentration range of dishwasher sanitizer; and 10. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure garbage and refuse were disposed of properly when two of the two outside dumpsters were not adequately closed, and the surrounding area was littered with debris for a census of 108. This failure had the potential to expose the residents, visitors, and staff to pests, odor, or disease.

Inspectors wroteBased on observation, interview, and record review, the Dietary Services Supervisor (DS) failed to demonstrate the appropriate competencies and oversight to carry out the functions of the food and nutrition services. These deficient practices had the potential to cause food borne illness for 105 of 108 of the highly susceptible residents who consumed food from the kitchen of the facility as evidenced by: 1. DS was unable the verbalize the proper procedure of thawing meats by using the refrigeration method (cross refer to F812, #6); 2. DS did not have proper knowledge about the correct concentration of the sanitizer for the dishwashing machine (cross refer to F812, #9), and 3. DS did not have knowledge about the proper process for manual dishwashing by the three-compartment sink (cross refer to F812, #10) 4. DS did not have hair fully covered by hair restraint (cross refer to F812, #8)

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Dietary Aide (DA 1) had the appropriate skill set to safely perform the daily operations of the food and nutrition services department when: 1. DA 1 was unable to demonstrate and verbalized the correct use of the test strip and the correct concentration of the sanitizer (Chlorine) for the dishwashing when using the dishwashing machine, and 2. DA 1 was unable to verbalize the correct process of manual dishwashing with three-compartment sink. These failures had the potential to place 105 out of 108 highly susceptible residents who consumed food from the facility at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the planned menu was followed for lunch on 11/6/24 when: 1. Two of four residents (Resident 25 and Resident 38) with large portion diets received incorrect portions of meatballs (5 counts of meatballs instead of 6 counts.) 2. Four of four residents (Resident 6, 29, 38, and 40) with Renal or CKD5 diets (diets for people managing chronic kidney disease) received tapioca pudding instead of cookie as dessert. 3. Three of three residents (Resident 10, 24, and 100) with low fat and low cholesterol (a type of fat, LFLC) diets received whole milk and margarine with wheat roll instead fat free milk and no margarine with wheat roll. 4. Two of two residents (Resident 64 and Resident 81) with finger food diets received rice and tapioca pudding instead of diced/sliced potato and pudding on graham crackers 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services which meet professional standards of quality for two of 22 sampled residents (Resident 11 and Resident 5) when: 1. Resident 11's medications were left on the bedside table unattended. 2. Resident 5's oxygen tubing was left unconnected to the oxygen machine. These failures decreased the facility's potential to safely follow physician's order and cause health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents remained free of accident hazards for a census of 108 when: 1) The facility did not have a smoking policy and procedure and failed to supervise residents (Resident 27 and Resident 61) smoking on facility premises. 2) The facility did not have a smoking care plan for a resident (Resident 61) non-compliant with care. These failures had the potential to result in accidents including resident injury and fire.

Inspectors wroteBased on observation, interview, and record review, the facility had a 20.69% error rate when six medication errors out of 29 opportunities were observed during a medication pass for one of five Residents (Residents 88). This failure resulted in medications not given in accordance with the prescriber's orders and potential to affect the residents' clinical conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 22 sampled residents (Resident 88) was free of a significant medication errors when he received omeprazole (a medication to treat acid reflux) in crushed pill form instead of the physician ordered liquid suspension through his percutaneous endoscopic gastrostomy (PEG - a feeding tube that's inserted through the abdomen wall and into the stomach) tube. This deficient practice had the potential for ineffective use of omeprazole resulting in a blocked PEG tube and decreased absorption of the medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to store discontinued medications and destroyed medications in locked compartments and permit only authorized personnel to have access to the keys in two medication rooms for a resident census of 108. These failures had the potential for medication loss and diversion or misuse of medications from not being securely stored.

Inspectors wroteBased on interview and record review the facility failed to implement action plans in their Quality Assurance and Performance Improvement (QAPI) program for an identified infection control issue for a census of 108 residents. This failure had the potential to affect infection prevention in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 108 residents when: 1. Staff failed to properly store Resident 1's personal items found on the floor 2. Facility staff provided care without wearing all the required personal protective equipment (PPE) for Resident 21 who was on Enhanced Barrier Precaution (EBP) (EBP - infection control intervention designed to reduce transmission of multidrug-resistant organisms, MDROs- bacteria that resist treatment with more than one antibiotic] that requires gown and glove use) 3. Resident 80 and Resident 66 urinals (a hand-held bottle for urination) were not labeled with a resident identifier and the date it was initially used; 4. A blood pressure cuff was not cleaned and sanitized in between resident use; and 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and sanitary environment for one of 22 sampled residents (Resident 66) when: 1. Electrical devices were not checked and safe for use 2. Oxygen tubing was found lying on the floor 3. Power strip and scattered electrical cords were found on the floor and not secured 4. A medical device was plugged into a power strip; and 5. Unclean floors These failures had the potential for Resident 66 to experience a preventable fall, unsafe and unsanitary living conditions. A review of Resident 66's admission Record indicated Resident 66 was admitted late 2023 with multiple diagnosis of obstructive sleep apnea (a disorder that causes you to stop breathing while asleep), acute respiratory failure and history of falling. During an observation on 11/6/24 at 1:37 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the rights of the residents were maintained for three of six sampled residents (Resident 2, Resident 5 and Resident 6) when four facility employees did not wear identification badges (ID). This failure had the potential to cause residents to feel vulnerable and did not promote safety and security measures for all the residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of seven sampled residents (Resident 1) received treatment and care in accordance with professional standards of practice, and facility's policy and procedure (P&P) when Resident 1's physician's order for moisture associated skin damage (MASD) treatment was not followed. This failure had the potential for Resident 1's wound to worsen and for Resident 1 to not achieve their highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident call system in the toilet and bathing area for one of seven sampled residents (Resident 7) when Resident 7 did not have a functional call system in the bathroom. This failure had the potential to jeopardize Resident 7's health and safety when using the bathroom and requring assistance within their room.

Inspectors wroteBased on interview and record review, the facility failed to notify Resident 1's (Res 1) representative (RP) regarding Res 1's room change. This failure had the potential to cause psychosocial distress to Res 1 as well as concern to Res 1's RP due to the lack of notification of a room change.

Inspectors wroteBased on interview and record review, the facility failed to protect one of their residents, Resident 1 (Res 1), from neglect by not providing showers as scheduled. This failure had the potential to cause physical and psychosocial harm to the resident and caused emotional distress to Res 1's representative (RP).

Inspectors wroteBased on observation, interview and record review, the facility failed to provide showers or grooming for one of four sampled residents (Resident 4), when Resident 4 did not have a shower or bath within the month of October 2023. This deficient practice had the potential to result in body odor, skin irritations and infections.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure 2 (Resident #86 and Resident #89) of 8 continent residents reviewed for sharing a bathroom with residents of the opposite gender were treated with respect and dignity. Specifically, Resident #86 verbalized concerns related to a resident of the opposite gender walking in on them while using the commode. Also, the facility failed to ensure 1 (Resident #39) of 3 residents who were dependent on staff for eating was treated with dignity. Specifically, Certified Nurse Assistant (CNA) #1 placed a meal tray in front of Resident #39, left the room, and continued to deliver trays to other residents before returning to feed Resident #39. Additionally, CNA #1 and CNA #2 referred to Resident #39 as a feeder.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure the baseline care plan addressed continuous positive airway pressure (CPAP) therapy and the care/services necessary related to the use of a CPAP machine for 1 (Resident #362) of 5 residents reviewed for baseline care plans.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident who required continuous positive airway pressure (CPAP) therapy had physician's orders for CPAP therapy, CPAP settings, and the necessary care and services related to CPAP use for 1 of 1 (Resident #362) resident reviewed for respiratory services.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure a continuous positive airway pressure (CPAP) mask was cleaned and stored to prevent infection for 1 (Resident #362) of 1 resident reviewed for respiratory services.

Inspectors wroteBased on observations, interviews, record review, and facility document review, it was determined the facility failed to ensure staff donned all necessary personal protective equipment (PPE) before entering the room of a COVID-19 positive resident in accordance with the Centers for Disease Control and Prevention (CDC) guidance for 2 (Resident #356 and Resident #357) of 2 COVID-19 positive residents reviewed for transmission-based precautions (TBP).