River Ridge Center

Inspectors wroteBased on water temperature observations, water temperature log reviews, interviews, and review of facility's Water Temps [temperatures] policy the facility failed to act on identified hazards in a resident's environment and implement interventions to prevent potential accidents/injuries by ensuring that hot water temperatures, accessible to residents did not exceed 120 degrees Fahrenheit for 7 of 9 months reviewed (January 2025 through July 2025) on 3 of 3 units ([NAME] River, Kennebec River and Mousam River). The failure of the facility to ensure that hot water temperatures accessible to residents did not exceed 120 degrees Fahrenheit created the potential for residents to be scalded/burned by the domestic hot water. This created an Immediate Jeopardy (IJ) situation for residents.1. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the facility was Administered in a manner that ensured the resident environment remained as free from accident hazards, as evidenced by Federal findings under 42 CFR S483.25(d), F689- Free of Accident Hazards/Supervision/Devices, on 3 of 3 resident units. This failure to ensure a process was in place to monitor and correct hot water temperatures in excess of 120 degrees Fahrenheit (F) has the potential to affect all 57 residents. During a review of the facility's Hot Water Temperature Logs, from 10/31/24 through 7/18/24, the first recorded excessively high hot water temperature was on 12/2/24 at 121 degrees F. On 12/9/24, the service hall bathroom temperature was recorded at 130 degrees F. During the next 6 months, temperature logs revealed consistently high hot water temperatures. [...]

Inspectors wroteBased on observations and interviews, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in a sanitary, orderly, and comfortable environment on 3 of 3 wings (Mousam River, Kennebec River and [NAME] River) for 2 of 2 facility tours.1. On 7/22/25 at 8:24 a.m., during an interview with the Administrator, the surveyor discussed the thick bubbled and peeling/flaking red paint on multiple doors on Mousam River unit. The Administrator explained the door repairs were part of the Plan of Correction (POC) for a citation back on 5/28/25. The facility had ordered 30 new doors that are due to come in November 2025. However, in the interim, Maintenance is removing the Acrovyn layer, sanding the door down and applying paint, stating that the red painted doors have been completed. [...]

Inspectors wroteBased on Payroll Based Journal staffing (PBJ) report, weekend staffing schedules and interview, the facility failed to ensure sufficient direct care staff were scheduled and on duty to meet the needs of residents that reside in the facility for weekends of the first quarter 2025 (October 1 - December 31, 2024) and second quarter 2025 (January 1 - March 31, 2025). The Center for Medicare & Medicaid (CMS) PBJ Report revealed the facility triggered for low weekend staffing during the first quarter of 2024 and second quarter of 2025. Review of the first quarter of 2024 weekend staffing schedules indicated 8 weekend days where there was an insufficient number of direct care staff. Review of the second of 2025 weekend staffing schedules indicated 2 weekend days where there was an insufficient number of direct care staff. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use in 2 of 3 medication storage rooms reviewed (Kennebunk River and Mousam River Units). 1. On 7/24/25 at approximately 10:00 a.m., a surveyor observed the medication storage room on the Kennebunk River Unit with the unit nurse manager. The emergency intravenous medication and supply stock, stored in a large plastic tote, was noted to contain 2 prepackaged syringes of Heparin lock flush 500 units/5 ml (milliliter), with expiration dates of 4/30/25. In addition, observation of the medication storage refrigerator noted 1 vial of Insulin Lispro 100 units/ml prescribed to a resident who had been discharged on 4/16/25. The unit manager confirmed the findings at the time of the observations.2. [...]

Inspectors wroteBased on observations, interviews, record reviews, and facility policy, the facility failed to ensure that a resident's choices for food preferences were followed for 3 of 4 residents (Resident #22, #43, and #75) 1. On 7/22/25 at 12:53 p.m. the surveyor observed Resident #22 being served a ham sandwich. Resident #22 stated he/she does not like or want pork and has met with the dietician to discuss his/her preferences but, “they still keep giving me pork”. Review of the dietary slip on the resident’s food tray only indicated, “NO EGG EVER” On 7/22/25 at 1:05 p.m., during an interview, Certified Nurses Aid (CNA) #6 stated, they keep sending it (pork) and “we keep telling the kitchen”. The surveyor observed the CNA calling the kitchen to request a substitution for resident #22’s ham sandwich. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that its Quality Assurance Process Improvement (QAPI) committee systematically identified and addressed a known safety concern related to elevated water temperatures in resident areas, despite prior awareness documented by the Safety Committee.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed that ensure staff were educated and knowledgeable about Enhanced Barrier Precautions (EBP) in 3 out of 3 units surveyed for Infection Control and Prevention. (Kennebunk River Unit, Mousam River Unit and [NAME] River Unit) Facility Policy Titled IC308 Enhanced Barrier Precautions states: In addition to Standard Precautions, Enhanced Barrier Precautions (EBP) will be used (when Contact Precautions do not otherwise apply) for novel or targeted multi-drug resistant organisms (MDROs). Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce the transmission of novel or multi-drug resistant organisms. It employs targeted personal protective equipment (PPE) use during high contact patient/resident (hereinafter patient) activities. [...]

Inspectors wroteBased on record review and interview, the facility failed to revise the care plan to reflect a resident's current status for 1 of 2 residents reviewed for insulin use (#46). On 7/21/25 at 11:32 a.m., a surveyor asked Resident #46 if he/she received insulin. Resident #46 stated he/she used to receive insulin twice daily and now receives none, and didn't know why this had changed. A review of the clinical record revealed diagnoses including Type 2 Diabetes Mellitus and long term use of insulin. The MDS (Minimum Data Set) 3.0 admission Assessment, dated 4/25/25, Section C, Cognitive Patterns, noted a BIMS (Brief Interview of Mental Status) score of 15, indicating Resident #46 is cognitively intact. Section N, Medications, noted Resident #46 received insulin injections. The current care plan, with a revision date of 5/15/25, for the focus area of: The resident has a diagnosis of diabetes: [...]

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to maintain a complete medical record for 5 of 5 Residents reviewed for unwitnessed falls. A surveyor reviewed the facility policy Titled Centers' Nursing Policies - NSG215 Falls Management last reviewed on 3/15/24 under Section 5.3 ; Any patient who sustains an injury to the head from a fall and/or has a fall unwitnessed by staff will be observed for neurological abnormalities by performing neurological check, per policy. A surveyor reviewed the facility policy Titled Centers' Nursing Policies - NSG204 Neurological Evaluation last reviewed 2/1/23 reads; Neurological evaluation will be performed as indicated or ordered. When a patient sustains injury to the head or face and/or an unwitnessed fall, neurological evaluation will be performed: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to report a fall with suspicion of negligence and significant injury within the required time frame for 1 out of 1 resident. (Resident #6)

Inspectors wroteBased on record reviews, the facility failed to ensure that a resident received adequate supervision when resident was left unattended in a raised bed. This action resulted in resident fall d injury for 1 of 6 residents reviewed for falls (Resident #6). In addition, the facility failed to ensure that the resident environment was free of accidents and hazards.

Inspectors wroteBased on observations, interviews, record reviews and the facility's Food Storage: Cold Foods, Food Storage: Dry Goods and the Food Preparation policy and Procedures, all revised on 2/2023, the facility failed to ensure that foods in the dry storage room, the walk-in refrigerator and freezer were labeled and/or dated, stored appropriately and not expired. In addition, the facility failed to ensure all foods were held at appropriate temperatures for 1 of 1 day of survey.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to follow the facility's Infection Control Policies and Procedures to prevent the introduction and spread of Coronavirus Infectious Disease 2019 (COVID-19) into the facility. This has the potential to affect all residents at the facility (52 residents).

Inspectors wroteBased on review of resident council meeting minutes, interviews and facility policy, the facility failed to document results of the grievances voiced by members of the Resident Council for 6 of 8 months reviewed. In addition, the facility failed to ensure that all residents that wished to attend resident Council meetings were present (Resident's #18, #24, and #49).

Inspectors wroteBased on interviews, record review, and facility policy, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours that included the instructions needed to provide minimum healthcare information necessary to care for 4 of 22 Residents reviewed for care plans (#22, #201, #204, and #301)

Inspectors wroteBased on observation and interview, the facility failed to adequately date and properly dispose of open biologicals according to manufacturer specifications in 3 of 3 units, [NAME] River, Mousam River and Kennebunk River.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident's choice in the area of bathing were being followed for 1 of 2 sampled residents (Resident #200).

Inspectors wroteBased on observation and interview, the facility failed to adequately provide housekeeping and maintenance services necessary to maintain the building in good repair and sanitary condition for 1 of 3 units for 3 of 3 survey days (Kennebunk River Unit).

Inspectors wroteBased on record review and interviews, the facility failed to review and revise the care plan to reflect the current needs of a resident in the area of infection control. (#46)

Inspectors wroteBased on record reviews, interviews and the facility's Resident Smoking Policy, the facility failed to complete an assessment of resident capabilities and deficits to determine resident safety for 2 of 2 residents reviewed for smoking. (Resident #22, and #301).

Inspectors wroteBased on observation, interview, and record review, the facility failed to be free of medication error rate of 5% or more. There was a total of 2 medication errors out of 27 opportunities. The medication error rate was 7.41%.

Inspectors wroteBased on observations, and interviews, the facility failed to ensure that the residents' wheelchairs were maintained in good repair to provide safe and functional use for 2 of 2 residents observed (#5 and #301). 1. On 8/15/22 at 11:38 a.m., observation of Resident #5's wheelchair's foot board had pieces missing along the edge with bare foam and rubber showing, creating an uncleanable surface. The wheelchair also had a heavy amount of food waste along the side and base. At this time, the wheelchair conditions were confirmed with the Mousam River Registered Nurse Unit Manager. 2. On 8/15/22 at 2:37 p.m., 8/16/22 at 1:37 p.m., and 8/17/22 at 10:00 a.m., observations of Resident #301's wheelchair with the right-side armrest missing. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that a Minimum Data Set, Version 3.0 (MDS) was accurately coded for 2 of 3 residents reviewed for infections. (#46 and #201)

Inspectors wroteBased on observations and interviews, the facility failed to ensure the resident environment was clean and homelike in 3 of 3 resident units and 5 of 8 common areas during 1 of 4 days of survey.

Inspectors wroteBased on observations and interviews, the facility failed to ensure proper storage of medications on 1of 3 units (Kennebunk Unit) during 1 of 4 survey days.

Inspectors wroteBased on interview and record review, the facility failed to issue a written transfer/discharge notice to residents or their representative for a facility-initiated transfer/discharge for 2 of 3 sampled residents transferred/discharged to an acute care facility (Residents #33 and #57).