Riverdell Care Center

Inspectors wroteBased on observation, interview and record review, the facility staff failed to prepare and serve food in accordance with the nutritionally calculated recipes to all residents. The facility census was 47.1. Review of the facility's standardized recipe for spaghetti with meat sauce showed staff directed to use 12.5 pounds of ground beef for 50 servings of meat sauce. Observation on 05/27/26 during the lunch meal, showed [NAME] H served residents portions of spaghetti noodles and meat sauce combined. Observation showed the cook did not offer residents additional protein. During an interview on 05/27/26 at 12:31 P.M., [NAME] H said he/she prepared the spaghetti for the noon meal following the recipe for 50 servings. The cook said he/she used 10 pounds of beef to prepare 50 servings even though he/she knew the recipe called for 12.5 pounds. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for five (Resident #2, #8, #14, #20 and #40) of twelve sampled residents. The facility census was 38. 1. Review of the facility's policy titled Comprehensive Care Plan dated May 2026, showed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/22/26, showed staff assessed the resident as cognitively impaired. Review of the resident's care plan, dated 05/26/26, showed the care plan did not contain use of signage above the resident's bed. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure four (Resident #8, #14, #17, #20) out of eight sampled residents who are unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene and grooming. The facility census was 47. 1. Review of the facility's policy titled Shaving the Resident, dated 2001, showed the purpose of shaving is to promote and to provide skin care. The policy did not contain direction or guidance for when to shave a resident. Review of the facility's policy titled Care of Fingernails/Toenails, dated 2001, showed the purpose of nailcare is to clean the nail bed, to keep nails trimmed, and to prevent infections. Nail care includes daily cleansing and regular trimming. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to clean a mechanical lift after use for three residents (Resident #14, #20, and #39). The census was 47.1. Review of the facility's Using a Mechanical Lifting Machine Policy, dated 2001 (no month), showed staff are to disinfect lift surfaces and wipe with a clean towel until dry. The policy did not contain guidance for when to cleanse the lift.2. Observation on 05/26/26 at 1:14 P.M., showed Certified Nurse Aide (CNA) E and the Assistant Director of Nursing (ADON) transferred Resident #14 from his/her wheelchair to the bed with the mechanical lift. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide assistance during meals for one resident (Resident #40) with visual impairment out of two sampled residents. The facility census was 54.1. Review of the facility policy titled Care of Visually Impaired Residents, dated 2001, showed staff are directed to describe the place setting and location of food on the plate according to the clock face (meat at 12:00, potato at 6:00, etc.) while dining. Review of the facility policy titled Meal Assistance, dated 2001, showed staff will serve trays and help residents who required assistance with meals. Residents who cannot feed themselves will be fed with attention to safety, dignity, comfort and dignity. Adaptive devices will be provided for residents who need or request them. 2. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to ensure medications were stored and labeled to facilitate consideration of precautions and safe administration of eye drops, inhalers, and nasal spray. The facility census was 47.1. Review of the facility's Storage of Medication Labeling and Storage Policy, dated 2001, showed:-The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manor;-If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;-Multi-dose vials that have been opened or accessed are dated and discarded withing 28 days unless the manufacturer specifies a shorter or longer date for the open vial. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure the dish washer machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. The facility census was 46. 1. Review of the facility's Sanitization policy, revised November 2022, showed dishwashing machines are operated according to manufacturer's instructions. General recommendations for low temperature dishwashers (chemical sanitization) are wash temperature of 120 degrees Fahrenheit (F) and final rinse with 50 parts per million (ppm) hypochlorite (chlorine). Review of the facility's Dish Machine - PPM Sanitizer Record Logs for the period of 10/01/24 through 12/12/24 showed staff documented morning and afternoon machine temperatures of 98 degrees F on all days. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to position an indwelling catheter of one resident (Resident #11) out of two sampled residents off the floor. The facility census was 46 1. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility staff failed to propell two residents (Resident #7, and #44) when staff did not use wheelchair footrests. Facility staff failed to provide safe mechanical lift transfers for three residents (Resident #15, #21, and #33), and failed to store hazardous materials in a safe manner in one shower room, one dining room and one storage cabinet. The facility census was 46. 1. The facility did not provide a policy for wheelchair safety. 2. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent wheelchair; -Diagnosis of cerebrovascular accident, bipolar, schizophrenia, and macular degeneration. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, ceilings, and floors. The facility census was 46. 1. Review of the facility's Homelike Environment policy, date February 2021, showed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include a clean, sanitary, and orderly environment. 2. Observation on 12/10/24 at 10:30 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in the tile around the toilet. Observation showed the tiles lifted from the floor. [...]

Inspectors wroteBased on observation, interview, and record review, facility staff failed to store medications in one out of two medication storage rooms in a safe and effective manner. The facility census was 46. 1. Review of the facility's policy titled Medication Labeling and Storage, dated February 2023, showed if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. 2. Observation on 12/11/24 at 10:17 A.M., showed the 100 hall medication storage room contained the following: -One bottle of Aspirin 325 milligram (mg) with an expiration date of 09/24; -One bottle of Magnesium Oxide 400 mg with an expiration date of 09/24; [...]