Riverside Commons Rehab and Nursing Center, LLC

Inspectors wroteThis citation pertains to intake 3034793. Based on observation, interview and record review, the facility failed to lock one resident's bed and failed to stop repositioning a resident at their request during a brief change for one (R504) of three residents reviewed for falls, resulting in R504 falling from the bed, injuring their head and knee with subsequent hospitalization related to a fracture.

Inspectors wroteThis citation pertains to intake 3034793. Based on interview and record review, the facility failed to perform a post-fall assessment in a timely manner and failed to ensure a radiology exam was completed for one (R504) of four residents reviewed for a change in condition resulting in the delay of medical care/treatment.

Inspectors wroteThis citation pertains to intake 3034793. Based on interview and record review the facility failed to ensure an X-Ray was completed in a timely manner for one resident (R504) of three residents reviewed for physician orders, resulting in radiology orders not being executed for R504 after a fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area and maintain cleanliness of ice machines resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/07/2026 at 9:17 AM observed a container with unidentified food inside and no date or label in the main walk-in cooler. Dining Director (DD) A removed the bin to be labeled. According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store insulins in accordance with pharmacy and manufacturer's recommendation in two of six medication carts reviewed for safe storage of medications and biologicals resulting in the potential for decreased efficacy of the insulin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist the resident in developing and implementing an advance directive upon admission for one (R118) of five residents reviewed for advance directives.

Inspectors wroteBased on interview and record review, the facility failed to immediately report an injury of unknown origin to the State Agency for one vulnerable resident (R83) of one resident reviewed for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide toileting assistance in a timely manner for one (R43) of two residents reviewed for ADLs (Activities of Daily Living), resulting in R43 having an incontinence episode in the bed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide nebulizer treatments as ordered for one resident (R57) of three residents reviewed for respiratory care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promptly notify the health care provider of laboratory results for one (R118) of one resident reviewed, resulting in a potential delay in treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to communicate transmission-based precautions for one resident (R48) of four residents reviewed for infection prevention and control, resulting in the potential for spread of infection among residents, staff, and visitors.

Inspectors wroteThis citation pertains to intake 2961759. Based on interview and record review, the facility failed to implement interventions and skin treatments as prescribed to prevent the development or worsening of pressure ulcers for two (R703 and R708) of five residents reviewed for pressure ulcers resulting in R703 and R705 developing stage 3 pressure ulcers (total loss of skin, exposing fatty tissue) to the coccyx area while in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Properly clean and sanitize a thermometer stem prior to insertion into prepared food; 2. Ensure items stored in resident refrigerators were properly labeled with resident's name and expiration date; 3. Ensure pans were properly cleaned and allowed to air dry before stacking. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased likelihood for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a bedpan timely for one incontinent resident (R11) of one resident reviewed for dignity, resulting in verbalizing feelings of embarrassment and frustration.

Inspectors wroteBased on interview and record review, the facility failed to notify in a timely manner the Resident Representative (RR) for one resident (R24) of a change in condition requiring treatment, resulting in the RR not having the opportunity to participate in medical decisions regarding R24's health.

Inspectors wroteBased on interview and record review, the facility failed to obtain a medication for a rare cardiac condition in a timely manner for one resident (R143).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe wheelchair transport for one (R15) of seven residents reviewed for accident hazards, resulting in a fracture with subsequent wound, pain, and decreased activities of interest due to the inability to participate.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain sanitary conditions in the kitchen and its support spaces resulting in an increased potential for cross contamination of food and foodborne illness, potentially affecting the facility's total census of 76 residents.

Inspectors wroteThis citation has three deficient practices. Deficient practice #1. Based on interview and record review, the facility failed to establish a comprehensive Infection Control Program that conducted annual review of policies/procedures and calculated monthly facility acquired infection (FAI) rates, resulting in the potential for staff to be unaware of current national standards of practice for infection control and prevention and missed opportunities to identify trends in FAI, resulting in the potential delay in implementing corrective actions.

Inspectors wroteBased on interview and record review, the facility failed to ensure two residents (R17 and R31) out of five residents reviewed for immunizations, were currently educated and offered a pneumonia immunization, resulting in the potential for development and spread of pneumonia among vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the first-floor shower room was maintained in a clean and sanitary manner, resulting in the residents' environment not being homelike and the potential for spread of harmful pathogens. This deficient practice has the potential to affect all 27 residents who reside in rooms 125 to 145.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a catheter bag (a collection device for urine) was not visable to others for one (R262) of one resident reviewed for dignity with catheter usage, resulting in the R262's dignity not being preserved and the potential for the feelings of embarrassment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident and the legal representative formulated an Advance Directive to grant and/or withhold life sustaining treatment (Cardiopulmonary Resuscitation/CPR, Artificial Nutrition/Peg Tube, Artificial Hydration/ IV, and Diagnostic Testing) according to their wishes upon admission for two residents (R314 and R59) of 14 sampled residents reviewed for advance directives, resulting in the potential of denial of the resident's right to have life sustaining or withheld decisions honored.