Riverside Health & Rehab Center

Inspectors wroteBased on a review of facility policies, observations, and staff interviews, it was determined that the facility failed to properly label and date food, clean and sanitize food service items/dishes, and maintain cleanliness in the Main Kitchen.

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to provide concern forms assessable to resident's and visitor's from a wheelchair on one of six nursing units (700 Hall Memory Unit), failed to have a grievance box and forms accessible for four of four grievance boxes (Front Hall, Activities Room, Nurses Station 1, and Nurses Station 2) and failed to provide residents with the grievance official contact information (name, business address, email address, and business telephone number) for three of four grievance boxes (Nurses Station 1, Nurses Station 2, and 700 Hall Memory Unit).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual and clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were accurate and fully completed for seven of thirteen residents (Resident R1, R50, R89, R94, R95, R103, and R114).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain controlled substances were accounted for accurately for seven of thirteen residents (Resident R1, R5, R32, R53, R60, R113, R115).

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make certain that medications and medical supplies were properly stored and/or disposed of in two of three medication rooms (700-Hall medication room and [DATE]-Hall medication room).

Inspectors wroteBased on review of Quality Assurance attendance records, and staff interview, it was determined that the facility failed to conduct Quality Assessment and Assurance (QAA) meetings at least quarterly with all the required committee members for two of four quarterly meetings (second and third quarters). Findings Include:Review of Quality assurance and Performance Improvement sign in sheets and attendance records for 2025, failed to reveal a quarterly meeting with at least three other staff, one of whom must be the facility's administrator, owner, board member, or other individual in a leadership role who has knowledge of facility systems and the authority to change those systems. During an interview on 1/8/26, at 12:20 p.m. [...]

Inspectors wroteBased on facility policy, observations, and staff interviews it was determined that the facility failed to prevent the potential for cross-contamination during medication administration for two of four Licensed Practical Nurses (LPN) (Employees E5 and E11). Review of facility General Dose Preparation and Medication Administration dated 9/12/25, indicated, Medications should not come in contact with any surface except for the medication cup and, Facility staff should avoid touching the medication with bare hands when opening a bottle or unit dose package. During an observation on 1/6/26, at approximately 8:30 a.m. LPN Employee E5 was observed opening bottles of over the counter medications, pouring the tablets into the palm of her hand, then placing the tablets in the medication cup. During an observation on 1/8/26, at approximately 9:00 a.m. [...]

Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on infection control for two of ten staff members Nurse Aide Employee E9 and Dietary Aide Employee E10).

Inspectors wroteBased on clinical record review, staff interview, and observation, it was determined that the facility failed to provide an environment and care to promote dignity during medication administration for each resident's quality of life for one of four residents observed (Resident R52).

Inspectors wroteBased on review of facility policy, facility documents, and staff interviews, it was determined that the facility failed to provide in a timely manner, notice of Medicare non coverage (payment) for one of three residents (Resident R600).

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to ensure equipment was in safe operating condition for one of two crash carts (carts maintained with equipment used in emergencies) (700-Hall crash cart).

Inspectors wroteBased on review of facility policy, staff education records, and staff interviews, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Nurse Aide Employees E8 and E9).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility to ensure that the resident and/or their representative received written notice of the facility bed-hold policy at the time of transfer for two of three residents reviewed for hospitalization. (Residents R1 and R102). Findings Include: Review of federal regulation S483.15(d) Notice of Bed-Hold Policy, indicated, facilities must provide written information about these policies to residents prior to and upon transfer for such absences. This information must be provided to all facility residents, regardless of their payment source. These provisions require facilities to issue two notices related to bed-hold policies. The first notice could be given well in advance of any transfer, i.e., information provided in the admission packet. [...]

Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on resident rights for three of ten staff members (Employee E8, E9, and E10).

Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on Quality Assurance and Performance Improvement (QAPI) for three of ten staff members (Employee E8, E9, and E10).

Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on compliance and ethics for three of ten staff members (Nurse Aide Employees E8 and E9, and Dietary Employee E10).

Inspectors wroteBased on review of facility personnel in-service training records, and staff interview, it was determined that the facility failed to provide training on behavioral health for three of ten staff members (Nurse Aide Employees E8 and E9 and Dietary Aide Employee E10).

Inspectors wroteBased on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).

Inspectors wroteBased on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included dialysis care and interventions needed to provide effective and person-centered care for three of seven residents (Resident R1, R2, and R3). Based on review of clinical records, facility policy, and staff interviews, it was determined that the facility failed to develop a baseline care plan that included dialysis care and interventions needed to provide effective and person-centered care for three of seven residents (Resident R1, R2, and R3).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews it was determined that the facility failed to make certain consistent dialysis communication was maintained for three of six residents (Residents R1, R3, and R4).

Inspectors wroteBased on a review of observations and staff interviews, it was determined that the facility failed to ensure the dish machine was in proper working order in the Main Kitchen.

Inspectors wroteBased on review of facility policy, clinical records, facility documents, and staff interview, it was determined that the facility failed to fully investigate injuries during care for and an injury of unknown origin possible neglect for three of four residents (Resident R1, R2, and R3).

Inspectors wroteBased on review of observations and resident and staff interviews it was determined that the facility failed to provide Activity of Daily Living (ADL) assistance for three of five of residents (R4, R5, and R6). The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record indicated Resident R4 was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on review of facility policies and documents, clinical record review, and staff interview, it was determined that the facility failed to provide adequate supervision to prevent falls for two of four residents (Resident R1 and R2). Review of the facility policy, Fall Management dated 1/2/24, indicated if risks are identifed, preventative measures will be put in place and care planned. All falls will be reviewed and investigated. Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS, periodic assessment of resident care needs) dated 4/10/25, included diagnoses of atrial fibrillation (disease of the heart characterized by irregular and often faster heartbeat) and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). Review of Section C: [...]

Inspectors wroteBased on a review of facility policy, clinical record review, and staff interviews, it was determined that the facility failed to notify the resident representative of changes in condition for one of four residents (Resident R1).

Inspectors wroteBased on clinical record review, and staff interviews, it was determined that the facility failed to implement a physician ordered follow-up MRI Scan for one of three residents reviewed with brain cancer (Resident R1).

Inspectors wroteBased on facility review of policy, manufacturer's instructions, clinical records and staff interviews, the facility failed to notify physicians of elevated or decreased Capillary Blood Glucose (CBG) levels, failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood sugar) resulting in immediate jeopardy for 14 of 22 residents (R6, R8, R22, R32, R38, R39, R44, R56, R57, R59, R65, R79, R150, R195). Findings Include: Review of facility policy Diabetic Protocol dated 1/2/24, indicated provider and staff will work together to give appropriate treatment to manage diabetes. The provider will follow up on any acute episodes associated with significant blood glucose level changes and deterioration of previous glucose control and document resident status at subsequent visits until the acute situation is resolved. [...]

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set assessments were completed in the required time frame for six of 24 residents (Resident R67, R147, R148, R153, R248, and R249).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that that quarterly Minimum Data Set (MDS- periodic review of resident care needs) assessments were completed within the required time frame for three of eight residents reviewed (Resident R44, R52, and R76).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to revise/update care plans for two of eight residents to accurately reflect the current status of the resident (Residents R5 and R195).

Inspectors wroteBased on a review of facility documentation, cited deficiencies from previous surveys, review of plan of correction documentation, and staff interview, it was determined that the facility's Quality Assurance and Performance Improvement (QAPI) program failed to correct previously cited deficiencies. This has the potential to affect 26 of 84 residents.

Inspectors wroteBased on review of clinical record, facility policy, and staff interview, it was determined that the facility failed to develop a baseline care plan that included diabetes care and interventions needed to provide effective and person-centered care for four of fourteen residents (Resident R22, R32, R44, R150, and R195) .

Inspectors wroteBased on review of Resident Assessment Instrument (RAI) User's Manual, facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop comprehensive care plans to meet resident care needs for five of fourteen residents (R22, R32, R44, R150, R195).

Inspectors wroteBased on policy review, documentation and review of Centers for Disease Control (CDC) guidelines for Legionella (bacteria that causes disease found in contaminated water) control, and staff interviews it was determined that the facility failed to maintain a comprehensive program for water management to monitor the potential development and spread of Legionella and failed to implement control measures for Legionella within the facility for ten of twelve months (April 2024 through January 2025).

Inspectors wroteBased on review of facility policy, facility documents, clinical records, and staff interview, it was determined that the facility failed to identify and investigate incidents of possible neglect and abuse for two of three residents (Residents R1 and R2).

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that the facility failed to make certain significant medications are administered as ordered by the physician for one of four residents (Resident R3).

Inspectors wroteBased on facility documents, resident observations, resident and staff interviews, and grievance review, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of 16 of 25 residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, and R16). Findings Include: Review of the Facility Assessment dated 1/2/24, indicated the facility will provide necessary person-centered care and services. During an observation on 2/17/24, at 12:13 p.m., Resident R1 had unkempt, greasy appearing hair. Resident R1 was eating lunch, still wearing a gown. During an interview and observation on 2/17/24, at 12:16 p.m., when asked if there were enough nursing staff to care for the residents, Resident R2 stated that she had no concerns. [...]

Inspectors wroteBased on review of facility policy and clinical records and staff interview, it was determined that the facility failed to provide the opportunity to formulate an advance directive (a written instruction such as a living will or durable power of attorney for health care for when the individual is incapacitated) for eight of eight residents reviewed (Resident R5, R6, R44, R57, R65, R70, R76, R188).

Inspectors wroteBased on review of facility documentation, resident and staff interviews, it was determined the facility failed to make certain residents were notified of the procedure for filing a grievance, failed to have grievance boxes and forms labeled for resident use on one of three nursing units (200/300/400 hall), and failed to make certain the current grievance official's name and contact information was posted.

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to notify physicians of increased and decreased Capillary Blood Glucose (CBG) levels and failed to assess residents for hyperglycemia (high blood glucose) and hypoglycemia (low blood glucose), for five of seven Residents (Residents R6, R44, R57, R65, and R236).

Inspectors wroteBased on review of facility policy, clinical records and staff interviews, it was determined that facility staff failed to maintain ongoing communication with the dialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for two of three residents reviewed (Resident R57, and R239).

Inspectors wroteBased on observation, clinical record review, observation, resident and staff interview, it was determined that the facility failed to respect residents' rights in the handling and protection of their personal property and clothing for one of three residents reviewed. (Residents R188).

Inspectors wroteBased on a review of the facility's abuse prohibition policy, clinical records and staff interviews it was determined that the facility failed to ensure that one of three residents reviewed was free from misappropriation (Resident R188)

Inspectors wroteBased on review of facility policies, clinical records, and staff interviews, it was determined that the facility failed to develop and implement a comprehensive care plan to meet care needs for two of 24 residents (Residents R10 and R12).

Inspectors wroteBased on review of facility policy and clinical record review and resident and staff interviews, it was determined that the facility failed to make certain that showers were consistently provided for two of six residents (Resident R31, and R65).

Inspectors wroteBased on a review of facility policy, facility provided documents and staff interview it was determined the facility failed to report an incident of an elopement to the State Survey Agency within five working days for one of four residents (Resident R1).

Inspectors wroteBased on a review of facility policy, resident clinical records, and staff interviews, it was determined the facility failed develop and implement a base line care plan within 48 hours of the resident's admission that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality of care.

Inspectors wroteBased on review of facility policy, facility provided documents, resident clinical record, alarm contractor documentation, staff interviews, and staff witness statements, it was determined the facility failed to provide a safe environment and adequate supervision to an elopement risk resident, and to maintain mechanical and electrical equipment in a safe operating condition creating the opportunity for the elopement of a one of four residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records and staff interview, it was determined that the facility failed to obtain and document a physician's discharge order for four of five residents discharged (Residents R1, R2, R3, and R4).