Riverside Health Care Center

Inspectors wroteBased on staff interviews, record review, and review of policies titled, Preadmission Screening PASARR/PASSR, the facility failed to refer one of 10 residents (R)(R7) for level two pre-admission screening and resident review (PASARR) out of 10 residents identified with level two PASARR. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, interviews with staff, record review and review of the facility policies titled, Activities of Daily Living and Prevention of Pressure Injuries, the facility failed to ensure one of six sampled residents (R13), who required assistance with repositioning, was repositioned in accordance with the resident's turning schedule and interventions. This deficient practice placed the resident at risk for poor hygiene, decreased quality of life, and worsening pressure ulcers. Review of the facility's policy titled, Activities of Daily Living revised December, 2025 revealed the following: 1. [...]

Inspectors wroteBased on observations, interviews with staff, record review and review of the facility policy titled, Activities of Daily Living, the facility failed to follow physician orders related to diet by failing to provide a meal tray to one of 150 residents on an oral diet (R13). This deficient practice placed the resident at risk for decreased quality of life.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Respiratory Therapy Equipment, the facility failed to ensure proper maintenance and monitoring of oxygen equipment in accordance with professional standards of practice for two of 28 sampled residents (R) (R109 and R1) reviewed for respiratory care related to maintaining a clean oxygen concentrator and filter. This deficient practice had the potential to result in decreased oxygen delivery, increased risk of respiratory compromise, and exposure to contaminants, which could adversely affect the residents' health and safety.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Hand Hygiene, the facility failed to perform appropriate hand hygiene while passing lunch meal trays between each resident on one of three units. The deficient practice had the potential to place residents at risk of cross-contamination and the transmission of infectionsFindings include:Review of the facility policy titled, Hand Hygiene, dated February, 2026, revealed that handwashing /hand hygiene shall be regarded by this Center as a means of preventing the spread of infections. The subsection titled, Policy Interpretation and Implementation revealed under number 2. e. stated, Associates must perform appropriate handwashing procedures under the following conditions, between passing out meal trays at lunch. [...]

Inspectors wroteBased on observations, family, resident and staff interviews, record review, and review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, the facility failed to provide adequate supervision to prevent accidents for one of three residents (R) (R1) reviewed for falls with major injury. Actual harm occurred on 8/17/2025 when Certified Nursing Assistant (CNA) AA transferred R1 unassisted from his bed to the wheelchair resulting in R1 sustaining a fall during transfer that resulted in a closed displaced spiral fracture of the right femur.

Inspectors wroteBased on observations, family, resident and staff interviews, record review, and review of the facility's policy titled, Accident and Incident Prevention, Reporting, and Response, the facility failed to provide adequate supervision to prevent accidents for one of three residents (R) (R1) reviewed for falls with major injury. Actual harm occurred on 8/17/2025 when Certified Nursing Assistant (CNA) AA transferred R1 unassisted from his bed to the wheelchair resulting in R1 sustaining a fall during transfer that resulted in a closed displaced spiral fracture of the right femur.

Inspectors wroteBased on observations, staff interview, and review of the facility's policy titled, Medication Storage, the facility failed to ensure all medication labels were legible and that expired medications were disposed of after expiration date on one of five medication carts and in two of three medication storage rooms on (100 Hall and 300 Hall).

Inspectors wroteBased on observations, record review, resident and staff interviews, and review of the facility's policy titled, Self-Administration of Medication, the facility failed to ensure one of 56 sampled residents (R) (R150) was assessed for self-administration of medications prior to leaving medications at her bedside. This deficient practice had the potential to place R150 at risk of medical complications and a diminished quality of life. Findings Include: A review of the facility's policy titled, Self-Administration of Medication, dated April 2022, revealed the General Guidelines section included, 1. A resident may not be permitted to administer or retain any medication in his/her room unless so ordered, in writing, by the attending physician and approved by the Interdisciplinary Care Plan Team. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Care Plan Policy, the facility failed to develop a comprehensive person-centered care plan for one of 12 residents (R) (R120) with an indwelling urinary catheter and one of 26 R (R147) receiving oxygen (O2). This deficient practice had the potential to place R120 and R147 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and a review of the facility's, Care Plan policy, the facility failed to revise the comprehensive care plan to include a new sacral pressure injury with measurable goals and interventions for one of three residents (R) (R206) reviewed with pressure ulcers. The facility also failed to update the care plan for R47, whose oxygen treatment had been discontinued but was still listed on the care plan.

Inspectors wroteBased on observations, staff interviews, records reviews, and review of the facility's policy titled, Oxygen Administration, the facility failed to ensure a physicians order for oxygen administration was obtained for one residents R (R147), the facility also failed to ensure two of 26 residents (R254 and R69) oxygen was administered as ordered by the physician.

Inspectors wroteBased on staff interviews, record review, and review of facility's policy titled Abuse Prevention Policy, the facility failed to ensure that a Georgia Criminal History Check System (GCHEXS) Fingerprint check was conducted for two [Certified Nursing Assistant (CNA) BB and CNA CC] of ten employee files selected for review. The facility census was one hundred and forty-eight residents.

Inspectors wroteBased on record review, document review, and interviews, the facility failed to ensure a Registered Nurse (RN) was on duty eight consecutive hours per day seven days a week. This had the potential to affect all 134 residents residing in the facility.

Inspectors wroteBased on observations, record review, interview, policy review and review of Centers for Disease Control (CDC) guidelines and Quality Safety and Oversight Group (QSO) memo, the facility failed to implement an effective Infection Control Program to prevent the spread of infections, including COVID-19 virus by not posting signage related to the current COVID-19 outbreak upon entering the facility. In addition, the facility failed to ensure staff changed gloves during wound care for one resident (R) (R#60) of 10 residents reviewed for infection control.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure an effective pest control program was in place to maintain the facility free of pests. The census was 134.

Inspectors wroteBased on observations, record review, interviews, and document review, the facility failed to provide comfortable water temperatures in the residents' bathrooms and shower rooms in 11 of 38 rooms, and one broken shower head. The census was 134.

Inspectors wroteBased on observations, interviews, record review and policy review, the facility failed to ensure two residents (R) (R#60 and R#101) were treated with dignity. Specifically, staff failed to sit while feeding R#60, and served R#101 meals on Styrofoam plates with plastic silverware. The sample size was 33.

Inspectors wroteBased on observation, record review, interview, and review of the policy titled Social Service - Respect and Dignity Policy, the facility failed to ensure that one resident (R) (R#125) was free from misappropriation of resident's property of 33 sampled residents.

Inspectors wroteBased on record review, interviews, and review of the policy titled Care Plan Policy, the facility failed to develop a person-centered comprehensive care plan related to behaviors for one resident (R) (R#58) of 33 sampled residents.

Inspectors wroteBased on record review, interviews, and policy review, the facility failed to assess one resident (R) (R#102) of 33 sampled residents, for a bladder training program to determine appropriate services to restore or maintain bladder continence.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to address significant weight gain for one resident (R) (R#48) of five sampled residents reviewed for nutritional status.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure clean oxygen concentrator filters and oxygen tubing and a breathing treatment mask were stored in a sanitary manner for three of six residents (R) (R#68, R#28 and R#116). The sample size was 33.

Inspectors wroteBased on observations, record review, interviews, and policy review, the facility failed to ensure prescribed medications were available for administration for one resident (R) (R#112) of five sampled residents.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to ensure one resident (R) (R#58) of five sampled residents reviewed for unnecessary medications did not receive an antipsychotic medication without clinical indication for its use. Specifically, the facility failed to identify and implement interventions to aid in the reduction or prevention of behaviors before administering Haldol (an antipsychotic medication).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure there medication error rate was less than 5%. A total number of 28 medication opportunities were observed. There were six errors for two of five sampled residents (R) (R#32 and R#112) observed during medication pass, resulting in a medication error rate of 21.43%.

Inspectors wroteBased on observations, interviews, and review of the policy titled Storage of Medications and Biologicals, the facility failed to dispose of loose medications found in the drawers of three of three medication carts (Carts A, B, and C) observed out of the six medication carts in the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to obtain dental services for two residents (R) (R#132 and R#) reviewed for dental services. The sample is 33.

Inspectors wroteBased on record review, interview, and review of the policy titled Infection Control Prevention and Control Antibiotic Stewardship, the facility failed to follow and implement an effective antibiotic stewardship program (ASP) by ensuring one of five residents (R) (R#24) reviewed for antibiotic usage, was prescribed an antibiotic for urinary tract infection (UTI) without having met the criteria for the use of an antibiotic.

Inspectors wroteBased on observations, record review, interviews, and review of the policy titled Call System/Light Policy, the facility failed to ensure that the call light communication system was functioning adequately to allow one resident (R) (R#102) to call staff for assistance. The sample size was 33.