River View Rehab Center

Inspectors wroteBased on interview and record review the facility failed to protect a resident from sexual abuse for (R4). This failure affected (R4 &R5) reviewed for sexual abuse in the sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent the physical and verbal abuse of residents at the facility for five of six residents (R1, R2, R4, R5, and R6 ) reviewed for abuse in a sample of 9. This failure resulted in R6 experiencing psychosocial harm, feeling unsafe and expressing desire to leave the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to report resident injuries sustained during altercations and perform thorough investigations of resident abuse allegations. This applies to 4 of 4 residents (R1, R2, R4, R5) reviewed for abuse in a sample of 9.

Inspectors wroteBased on interview and record review, the facility to prevent abuse between two residents, resulting in R2 requiring an emergency room evaluation and sustaining bleeding above the eye, lip and bruising to the temple area. This applies to 2 of 5 residents (R1, R2) reviewed for abuse in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to prevent a resident from being abused by another resident in accordance with facility policy. This applies to 1 of 5 resident (R5) reviewed for abuse in the sample of 9.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect R2's right to be free of abuse from another resident. This applies to 1 of 4 residents (R2) reviewed for physical abuse.

Inspectors wroteBased on interview and record review, the facility failed to assess for, report, and document a resident's acquired pressure wounds prior to the wounds becoming unstageable. This failure resulted in R3 acquiring unstageable pressure injuries to the sacrum measuring 8 x 7 x 0.1 cm (centimeters, measuring length x width x depth) and right medial heel measuring 5.5 x 6 cm x unknown depth. This applies to 1 of 3 residents (R3) reviewed for pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to follow their policy for an involuntary discharge. This applies to 1 of 3 residents (R1) reviewed for resident rights in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL (Activities of Daily Living) care for residents who need assistance. This applies to 4 of 4 residents (R26, R29, R53, and R59) reviewed for ADL's in a sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to safely store medications. This applies to 5 of 5 residents (R23, R75, R80, R89, and R140) reviewed for medication storage in a sample of 37.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an appropriate size bed to meet resident needs. This applies to 1 of 3 residents (R70) reviewed in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and homelike environment. This applies to 1 of 1 resident (R179) reviewed for environment in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received oxygen therapy as ordered by physician. This applies to 2 of 3 residents (R130 and R69) reviewed for respiratory care in a sample of 37.

Inspectors wroteBased on interview and record review, the facility failed to assist a resident in obtaining emergency dental services. This applies to 1 of 3 residents (R34) reviewed for dental services in a sample of 37.

Inspectors wroteBased on observation, interview, and record review, the facility failed to remove expired food items from resident refrigerators and failed to provide a thermometer. This applies to 3 of 5 residents (R75, R110, and R181) reviewed in a sample of 37.

Inspectors wroteBased on interview and record review, direct care staff member failed to follow the facility's policy and procedures and immediately notify the nurse after a resident fall. This failure led to a delay of assessment by the nursing staff for the resident within the required time frame. This applies to 1of 3 residents (R1) reviewed for falls in a sample of 8.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from mental abuse for 3 of 8 residents (R2, R3, R6) reviewed for abuse in the sample of 14. This failure resulted in R2 feeling fearful of R1 and socially isolating due to R1's threats against him. This failure resulted in R6 suffering mental anguish related to R1's threats to physically harm and kill R6. This failure resulted in R3 being fearful of physical and mental retaliation from R1. These failures resulted in an Immediate Jeopardy. The Immediate Jeopardy began on 3/17/25 when R2 reported to V1 Administrator that sometime late February (2025) R1 had threatened to kill him. These failures resulted in R2, R3, and R6 experiencing psychosocial harm. The Immediate Jeopardy was identified on 3/31/25. V1 Administrator was notified of the Immediate Jeopardy on 3/31/25. [...]

Inspectors wroteBased on interview and record review the facility failed to follow their abuse policy by not completing pre-admission screening of residents to ensure resident safety for 6 of 6 residents (R4, R10, R11, R12, R13, R1) reviewed in the sample of 14. The failure has the potential to affect all 179 residents in the facility.

Inspectors wroteBased on interview and record review the facility failed to initiate discharge planning for 1 of 3 residents (R1) reviewed for discharge planning in the sample of 14.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to: 1. Protect a resident's right to be free of sexual and mental abuse from staff and other residents. This failure resulted in R1 being inappropriately touched by V8 (CNA-Certified Nursing Assistant) in the shower and being subjected (verbally and via phone message) to inappropriate and lewd comments of a sexual nature about R1's body. This failure also resulted in R1 being exposed to R6, who formerly sexually abused R1. R6 was in close proximity to R1 without supervision. These failures caused R1 to experience emotional distress and feel unsafe in the facility and caused her to discharge herself AMA (against medical advice). 2. Protect a resident's right to be free from physical abuse by a resident and failed to protect residents from further abuse from the abusive resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to report and thoroughly investigate resident allegations of abuse per facility policy. This applies to 2 of 5 residents (R1 and R7) reviewed for abuse in a sample of 16.

Inspectors wroteBased on interviews and record reviews, the facility failed to permit a resident to return to the facility after he was transferred to the hospital. This applies to 1 of 3 residents (R5) reviewed for involuntary discharge in a sample of 16.

Inspectors wroteBased on interview and record review the facility failed to ensure it was free from physical abuse to 3 of 3 residents (R1, R2 and R3) reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy for grievance resolution and failed to ensure a grievance was resolved within 72 hours. This applies to 1 of 3 residents (R1) reviewed for grievances in the sample of 6.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received assessment and treatment for a rash identified four months ago. This applies to 1 of 3 residents (R1) reviewed for improper nursing care in the sample of 6.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident received foot care, including toenail clipping, and failed to ensure a resident was examined by a podiatrist as shown in the facility's foot care policy. This applies to 1 of 3 residents (R1) reviewed for foot care in the sample of 6.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a dependent residents fingernails were trimmed and hands cleaned for 1 of 1 residents (R20) reviewed for activities of daily living in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a fluid restriction was in place for 1 of 2 residents (R30) reviewed for fluid restrictions in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure relieving interventions were in place for 2 of 6 residents (R57, R20) reviewed for pressure ulcers in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess a resident with contractures and failed to ensure a hand splint was in place for a dependent resident with contractures for 1 of 1 residents (R20) reviewed for splints in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to accurately assess a resident for smoking safety, failed to implement safe smoking interventions, and failed to accurately assess a resident for community pass. This applies to 3 of 10 residents (R33, R90, R91) reviewed for safety in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide catheter care for a resident with a suprapubic catheter for 1 of 3 residents (R30) reviewed for catheters in the sample of 35.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the oxygen tubing was connected to the oxygen concentrator for the delivery of as needed oxygen to 1 of 1 resident (R48) reviewed for oxygen in the sample of 35.

Inspectors wroteBased on observation, interview, and record the facility failed to ensure medications were not left at a residents bedside and medications were given on time for 3 of 7 residents (R133, R153, & R90) reviewed for medications in the sample of 35.

Inspectors wroteBased on interview and record review, the facility failed to protect R1 from physical abuse from R2. This failure resulted in R1 needing emergency medical care and treatment after R1 was assaulted by R2. This applies to 1 of 5 residents (R1) reviewed for abuse.

Inspectors wroteBased on the interview and record review, the facility failed to report abuse allegations to the state agency. This applies to 2 of 5 residents (R5 and R6) reviewed for abuse in a sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to protect residents from sexual abuse. This applies to 1 of 2 residents (R1) reviewed for abuse in a sample of 7.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident was free from physical abuse by a facility staff member. This applies to 1 of 3 residents (R1) reviewed for abuse in the sample of 3.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from physical abuse. This applies to 1 of 2 residents (R1 and R2) reviewed for abuse in the sample of 5.

Inspectors wroteBased on interview and record review, the facility failed to have a process in place to ensure agency staff receive abuse training during orientation to the facility as shown in the facility's Abuse Prevention Training Program. This failure resulted in V3 (Agency LPN-Licensed Professional Nurse) working at the facility without receiving abuse training and physically abusing R1. This failure has the potential to affect all 156 residents residing in the facility. The Immediate Jeopardy began on January 7, 2024 when V3 (Agency LPN) worked at the facility without receiving abuse training and physically abused R1. V1 (Administrator) was notified of the Immediate Jeopardy on January 25, 2024 at 2:12 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by V3 (Agency LPN-Licensed Practical Nurse). This failure resulted in R1 experiencing physical abuse by a staff member (V3). This applies to 1 of 3 residents (R1) reviewed for staff-to-resident abuse in the sample of 3. The Immediate Jeopardy began on January 7, 2024 when V3 (Agency LPN) worked at the facility without receiving abuse training and physically abused R1. V1 (Administrator) was notified of the Immediate Jeopardy on January 25, 2024 at 2:12 PM. The surveyor confirmed by observation, interview, and record review that the Immediate Jeopardy was removed on January 25, 2024, but noncompliance remains at Level Two because additional time is needed to evaluate the implementation and effectiveness of the in-service training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly label and date food items and practice proper sanitation of ice machine scooper in the kitchen. This applies to all residents who receive oral nutrition and foods prepared in the facility kitchen and use ice from kitchen ice machine.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents with nail care and shaving. This applies to 6 of 32 residents (R14, R22, R33, R44, R125, R137) reviewed for ADL's (Activities of Daily Living) in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure thermometers were in residents' personal refrigerators, to monitor and record temperatures daily, sanitize, and remove expired food items from resident refrigerators. This applies to 5 of 5 residents (R26, R33, R74, R83, R118) in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling and storage of an oxygen tank. This applies to 1 resident (R78) in a sample of 32.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with a malnutrition diagnosis and weight loss received his diet as ordered. This applies to 1 of 3 residents (R57) reviewed for portion sizes.