Riverside Center for Rehabilitation and Nursing

Inspectors wroteBased on observation and interviews conducted during the survey, the facility failed to provide food and drink that were palatable, attractive, and at a safe and appetizing temperature. Specifically, for three (4) of the three (4) meals reviewed (Breakfast meal 04/09/2026 and two (2) Lunch meals) on 04/06/2026 and 4/10/2026. Specifically, food and drinks were not served at a palatable and appetizing temperature or taste. Findings Include: Facility policy titled Resident Meal Service, reviewed 04/2026, documented the facility would provide each resident with nourishing, palatable, and attractive meals. Residents who refuse meals were to be offered an alternative meal off the facility alternative meal list. Residents were to be provided with a variety of food and liquid items. Meal tickets were to be checked for accuracy prior to serving residents. Observation: [...]

Inspectors wroteBased on observation and interviews conducted during the survey, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Specifically, unwrapped or contained pork was thawed in still water that contained carrots floating on the water surface, items were stored in the refrigerators without being labeled or dated with an open or preparation date, beverages were prepared and placed in walk in freezer for cooling, and personal food was stored the small slide open top freezer. Findings Include: Facility Policy titled CCS Food Storage Criteria (undated) documented Storage Guidelines. Refrigerator storage documented items were to be labeled and unlabeled items were to be discarded. Freezer storage was for long term storage and not for cooling foods. [...]

Inspectors wroteBased on resident observation, record reviews and staff interviews during the survey, the facility failed to ensure that the accuracy of the Minimum Data Set data submitted for one resident. The Minimum Data Set assessment did not accurately reflect the residents' conditions for one (1) of 19 residents reviewed. Specifically, Resident #11 diagnosed with Contractures, documented on the Quarterly Minimum Data Set dated 3/11/2026 no impairment to the upper or lower extremities. This resulted in misrepresentation of the resident's status during the assessment period.

Inspectors wroteNumber of residents sampled: 19Number of residents cited: 1 Based on record reviews and interviews, the facility failed to obtain a Level II evaluation recommended by the Pre-admission Screening and Resident Review. Specifically, for Resident #55, a Level II evaluation was not obtained in the presence of significant mental illness.

Inspectors wroteBased on observations, record reviews and interviews during survey, the facility failed to develop and implement person-centered comprehensive care plans for residents in accordance with professional standards for two (2) (Residents #3 and #34) of 19 residents reviewed for comprehensive care plans. Specifically, there was no comprehensive care plan to address Resident #3's dementia diagnosis and, separately, to address Resident #34's use of a Continuous Positive Airway Pressure machine.

Inspectors wroteBased on observation, record review and interview during the survey, the facility failed to ensure that a resident received necessary treatment and care in accordance with professional standards of practice for one (1) of 19 residents reviewed for quality of care. Specifically, Resident #11 had a physician-ordered splint for their left wrist and hand. On 4/10/2026 at 9:05 AM and 12:15 PM, Resident #11 was observed without the splint. This placed the resident at risk for decline in physical functioning. Finding is: [...]

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure residents received adequate supervision for one (1) (Resident #16) of eight (8) residents reviewed. Specifically, Resident #16 was assessed to have a high risk for falls, severely impaired cognition, and a history of falls. Resident #16 was care planned to be in a supervised area when out of her room. This resident was left unattended in a day room and fell on [DATE].

Inspectors wroteBased on observation, interview and record review during the survey, the facility failed to provide appropriate treatment and services for a clinically justified indwelling urinary catheter, provide adequate oversight and maintain proper infection control practices for one (1) of 2 residents (Resident # 26). Specifically, Resident #26 was observed on 04/10/2026 at 8:32 AM with a urinary drainage bag on the floor and not utilizing a leg bag as indicated, staff interviews revealed the staff considered the resident independent in changing the leg bag. This deficient practice placed the resident at increased risk for contamination and infection. Findings Include: The Catheter Care Policy and Procedure last reviewed date 4/2026 documented the procedure for Catheter Care and the responsible disciplines as the Certified Nursing Assistant, Licensed Practical Nurse and Registered Nurse. [...]

Inspectors wroteBased on observation, record review, and interviews during the survey, the facility failed to ensure appropriate respiratory care and services were provided for 1of 2 residents (Resident # 34) reviewed for Respiratory Care. Specifically, Resident # 34 had a diagnosis of Obstructive Sleep Apnea (a sleep disorder characterized by repeated interruptions in breathing during sleep) and required the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that delivers a constant stream of pressurized air to keep the airways open during sleep, used to treat sleep apnea). The medical record had no documented evidence of a necessary physician's order and had no documented evidence of an implemented care plan to address the resident's need for CPAP therapy and equipment maintenance. [...]

Inspectors wroteNumber of residents sampled: 5Number of residents cited: 1The policy and procedure titled Physician Orders, revised 12/2025, stated orders for medications must include Name and strength of the drug,Number of doses, start and stop date, and/or specific duration of therapy;Dosage and frequency of administration;Clinical condition or symptoms for which the medication is prescribed;Any interim follow-up requirements. The policy and procedure titled Medication Administration, revised 12/2025, stated medications must be administered in accordance with the order. [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey, the facility did not ensure each resident was treated with respect and dignity and cared for in a manner and in an environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality for 2 (North and South Units) of 2 units reviewed for dignity. [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 07/06/23 through 07/12/23, the facility did not provide effective housekeeping services on two (2) of 2 resident units and the core area. Specifically, floors were soiled with dirt next to walls, in corners, along door thresholds, and where door frames meet the floor in room #'s 117-N, 113-S, 115-S, 117-S, and #121-S, and in the corridors on the North Unit, South Unit, and Core Area; the floors were soiled with dirt in the activities room and activities room office, South Unit nurse station, social worker office, South Unit Nurse Manager office, and South Unit utility closet; ceiling tiles were water-stained in room #'s 106-N, 107-N, 105-S, 112-S, and the South Unit supply room, the North Unit Clean Workroom, and the physical therapy room; [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 07/06/23 through 07/12/23, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, in the main kitchen, the automatic dishwashing machine (dish machine) was not functioning; the facility did not have chemical sanitizer to manually wash and sanitize food contact surfaces (sanitizer), such as cups; the microwave oven, shelving, and kitchen drawers were soiled with food particles; and the walk-in refrigerator floor and dry storage area floor were soiled with dirt including in the corners and next to walls. In the North Unit Kitchenette, the inside of the refrigerator door and cupboards were soiled with food particles. [...]

Inspectors wroteBased on interview and record review it was determined that the facility did not designate one or more individual(s) as the infection preventionist(s) (IP)(s) responsible for the facility's IPCP. Specifically, the facility did not ensure there was a designated individual as their Infection Control Preventionist from April 28 th to July 7th, 2023. This was evidenced by: The Infection Control Policy and Procedure date 5/15/2023, documented the following: 1 The facility will ensure that an adequate Infection control program is in place for the prevention and control of infections. 2. The Infection Control Nurse (ICN) will investigate and implement methods and procedures to control the spread of infection. 3. The ADON/IP (Assistant Director of Nursing/Infection Preventionist) will complete facility surveillance and review at facility QUPI meetings. 4. [...]

Inspectors wroteBased on observation and interviews during the recertification survey dated 07/06/23 through 07/21/23, the facility did not equip bedrooms to assure full visual privacy for each resident on two (2) of 2 resident units. Specifically, the privacy curtain for resident #21 was partially pulled and allowed the resident's urinary catheter bag to be seen from the opened door (a dignity bag was not provided); the urinary catheter bag would still be seen if the privacy curtain was fully pulled as the curtain extended about ¾ the distance from the ceiling; the distance between the floor and the bottom of the privacy curtains in all semi-private rooms on the North Unit and South Unit was 22-inches of open space between floor and bottom of privacy curtain; [...]

Inspectors wroteBased on observation, record review, and interviews during the recertification survey dated 07/06/23 through 07/12/23 the facility did not maintain a pest-free environment and an effective pest control program on one (1) of 2 units, the Core Area, and the administration areas. Specifically, small black flies were noted by the elevator in the Core Area, in the corridor by room #s 101-N, 109-N, and 112-N; and the North Unit Nurse Manager was swatting at a fly in their office. This is evidenced as follows: During observations on 07/06/23 at 12:28 PM, small black flies were found when exiting the elevator onto the second floor Core Area and in the Board Room (the Board Room is the surveyor meeting space). During observations on 07/06/23 10:02 AM, a small black fly was observed flying in the corridor by room [ROOM NUMBER]-N; the North Unit Nurse Manager was swatting at a fly in their office; [...]

Inspectors wroteBased on observation, record review and interview during the recertification survey the facility did not ensure there was evidence that all alleged violations of neglect were thoroughly investigated for 1 (Resident #38) of 1 residents reviewed for an allegation of neglect. Specifically, for Resident #38, the facility did not provide evidence of an investigation to rule out neglect after Resident #38 complained of not receiving medications on 6/5/2021 and after multiple licensed facility staff members were aware that a Licensed Practical Nurse did not provide several doses of medications to residents on the South Unit on 6/4/2021. This was evidenced by: Resident #38: [...]

Inspectors wroteBased on record review and interviews conducted during a recertification survey, the facility did not ensure residents received treatment and care in accordance with professional standards of practice for 6 (Residents #'s 17, 37, 38, 41, 57, and #64) of 21 residents reviewed. Specifically, the facility did not ensure Resident #'s 17, 37, 38, and #41's medications were administered as ordered and medications not administered were reported to the physician, for Resident #'s 17 and #57, the facility did not ensure the physician was notified when blood glucose levels were not checked and insulin coverage was not administered and for Resident #64, medication was not administered adhering to the pharmacist instructions. This is evidenced by: [...]

Inspectors wroteBased on medical record review and staff interview during the recertification survey, the facility did not ensure that residents and/or their designated representative were fully informed of their right to an expedited review of a service termination. Specifically, a resident who received Medicare Part A services did not receive timely notification (2-day notification) of the termination of services with the Notice to Medicare Provider Non-coverage (NOMNC), form CMS-10123. This was evident for 1 of 3 sampled residents reviewed for Beneficiary Protection Notification.