Riverside Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure labeling and dating of perishable food products stored in the kitchen walk-in cooler, in the refrigerator in the Nutrition Room and failed to ensure a resident refrigerator was maintained in accordance with facility policy.

Inspectors wroteBased on observation, interview and record review the facility failed to provide medication according to professional standards of practice for 1 resident (R31) of 7 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure beverages were served to residents at a palatable temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 1) ensure hand hygiene prior to resident care, 2) ensure proper Personal Protective Equipment (PPE) usage for Enhanced Barrier Precautions (EBP), 3) prevent contamination of supplies during dressing change and resident care for 2 residents (R7 and R5) of 12 residents reviewed for Infection Control. Findings Include:R5Review of the Medical Record reflected R5 admitted to the facility with diagnoses that included Dementia and Seizure Disorder. The Minimum Data Set (MDS- a tool used to assess a resident's care needs) dated 2/2/2026 was reviewed. Section H of this MDS that pertained to Bowel and Bladder revealed R5 was always incontinent of urine. Section GG - Functional Abilities, reflected R5 was dependent for toileting hygiene. [...]

Inspectors wroteThis citation pertains to intake #2704144. Based on interview and record review, the facility failed to ensure one resident (R1) was provided dignified care of one resident reviewed for dignity.

Inspectors wroteBased on interview and record review, the facility failed to notify the guardian and responsible party of Care Conferences for two residents (R9 and R5) of two residents reviewed for Care Conferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly assess 2 residents (R5 and R38) out of 2 residents reviewed for self-administration of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide accommodation of needs and ensure call lights were left in reach of dependent residents for two residents (R4 and R19) of two residents reviewed for call light accessibility.

Inspectors wroteThis citation pertains to intake #2704144. Based on interview and record review the facility failed to ensure one resident's (R1) grievance was addressed of two residents reviewed for concern/grievance resolution.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently supervise residents requiring supervision with smoking potentially affecting all residents who currently smoke.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were administered in accordance with physician orders without errors for 2 (R5 and R32) of the 7 residents observed during the medication administration task. This resulted in a facility medication error rate of 12.2% (5 errors out of 41 opportunities).

Inspectors wroteBased on interview and record review the facility failed to meet requirements for the medical director's quarterly attendance of the quality assessment and assurance committee meetings.

Inspectors wroteThis citation pertains to intake #1322431. Based on observation, interview, and record review the facility failed to implement care planned interventions and ordered treatments for pressure ulcer prevention for 1 resident (R102) of 3 residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively clean and maintain food service equipment affecting 38 residents. Findings Included: On 03/24/2025 at 08:32 a.m. an initial tour of food services was conduced with Dietary [NAME] I. The following items were observed: Cardboard box, containing dinex cup lids, was observed to be on the floor in the dry storage room. The base boards, on the wall that the door swung into, was observed to have black substance on it the entire length of the wall. The door jam of the dry storage room was observed to be rusted along the floor. Observation of the freezer, which staff called the vegetable freezer, revealed soiled bottom shelf that appear to be dried liquid film. Observation of 7 pots and pans contained dark colored substance on the inside of the pains. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure updated and accurate advanced directive information was in place for two residents (R7 and R39) of 38 residents reviewed for advanced directives (legal documents that allow a person to identify decisions about end-of-life care ahead of time), resulting in the potential for a resident's preferences for medical care to not be followed by the facility or other healthcare providers.

Inspectors wroteBased on interview and record review the facility failed to ensure that an accurate and timely Notice of Medicare Non-Coverage (NOMNC) was provided for three Residents (#5, #8, #35) and an accurate Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) was provided for two Residents (#8 #35) out of three residents reviewed for Beneficiary Notification. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a Baseline Care Plan with necessary healthcare information for one (R37) of 14 reviewed.

Inspectors wroteBased on observation, interview and record review, the facility failed to prevent constipation and ensure medication orders specified dosing and route instructions for one (Resident #15) of one reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment and provide adequate supervision of smoking or screening them with form named PHCM Smoking risk to determine if they can smoke independently for two of two sampled residents (Resident #5 and Resident #2) reviewed for accidents and safety. Resident #2 (R2) During an interview and observation on 03/26/25 at 4:23 PM, R2 stated he had to turn in his lighter and cigarettes to nursing staff every time he goes inside, and he can get them back whenever he wants to go back outside. R2 also stated he can go outside anytime he wants to smoke. Did not respond to writer asking him if he had a lighter and marijuana hide outside from everyone. R2 stated he is independent with smoking, so he can come and go as he pleases. Observation of burn marks on his hoodie sweatshirt. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure recommended laboratory monitoring was in place for one (R15) of five reviewed.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide clinical justification for the continued use of PRN (as needed basis) psychotropic medication (valium) for one resident (#23) out of five residents reviewed for the potential of unnecessary medication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5% for one of four residents (Resident #37) reviewed for medication administration, resulting in an 10.34% medication error rate and potential side effects as a result of the errors.

Inspectors wroteThis citation has two deficient practice statements DPS A and DPS B. DPS A. Based on observation and interview the facility failed to ensure that accepted infection control protocols related to hand hygiene and glove use for one resident (#13) out of one resident sampled for infection control.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure daily nurse staffing information was posted for 38 facility residents, as well as visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a clean homelike environment for all residents exposed to insects/pests and that ate their meals in the dining room.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards of nursing practice for medication administration for 4 residents (Resident #18, #6, #16, and #88), reviewed for the provision of nursing services, resulting in lack of blood pressure assessments prior to medication administration, medication errors, and mismanagement of controlled substances.

Inspectors wroteBased on observation and interview, the facility failed to secure smoking materials per protocol.

Inspectors wroteThis citation is related to intake # MI00140670 Based on observation, interview, and record review, the facility failed to accommodate the needs of four residents (Resident #10, Resident #20, Resident #19 and Resident #18) out of 6 residents reviewed, resulting in (a) call lights placed out of reach of the residents and (b) a resident not receiving timely incontinence care.

Inspectors wroteThis citation pertains to intake #'s: MI00140117, MI00140120, MI00140122, MI00140239, MI00140670, MI00140239, MI00140348, and MI00137588 This citation has 2 Deficient Practice Statements. Deficient Practice Statement A: Based on interviews and record review, the facility failed to protect the resident ' s(s ' ) right to be free from mental abuse, verbal abuse and physical abuse by a resident when the facility failed to implement interventions to prevent escalating behaviors for one resident (R1) of four residents reviewed for abuse, resulting in R8 verbally abusing R1, R1 getting in a physical altercation with R13 and R11, and emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to follow professional standards when utilizing a central line catheter (CVC) for the delivery of antibiotics to one resident (Resident #17) out of one resident reviewed for central line catheter (CVC) access, resulting in the potential for bloodstream infections, air embolism (an air bubble that travels to the heart or lungs like a blood clot) and occlusions (blockage).

Inspectors wroteThis citation pertains to intake #'s: MI00140670, MI00141505, MI00140348, and MI00140239 Based on observation, interview, and record review, the facility failed to (a) provide adequate supervision to prevent a resident to resident altercation, (b) provide a nursing assessment to a resident after an unwitnessed fall that resulted in an injury, (c) accurately and thoroughly complete documentation (Event Reports) for a resident with multiple falls, (d) provide adequate staffing to supervise residents, and (e) safely secure smoking materials, for 4 of 6 residents reviewed for accidents and supervision (Resident #10, Resident #14, Resident #19, and Resident #1) resulting in an injury to R10, an unassessed head injury after a fall for R19, and R1 attempting to start a fire inside the facility.

Inspectors wroteThis citation pertains to intake #: MI00140348 Based on interview and record review, the facility failed to 1.) ensure Certified Nursing Assistants (CNAs) yearly performance review was conducted, and 2.) failed to develop and implement appropriate and effective in-service training programs based on the yearly performance evaluation for 5 of 6 CNAs reviewed for competencies/education, resulting in the potential for CNA's to not be able to safely provide necessary care and services to residents, a lack of training, and the potential for unmet care needs for residents residing at the facility.

Inspectors wroteThis citation pertains to intake #: MI00140348 Based on interview and record review, the facility failed to 1.) permit a resident to return to the facility following hospitalization, 2.) provide documentation that the facility had fully evaluated the resident, and did not base the discharge on the resident's status at the time of transfer, and 3.) notify the residents guardian in writing of their appeal rights for 1 resident (Resident #1) reviewed for facility initiated transfers, resulting in Resident #1 being denied return to the facility, the inability of Resident #1's guardian to appeal the involuntary discharge, and the potential for R1 to have feelings of sustained confusion, anger, and frustration. The reasonable person would be distressed at the prospect of not returning to their home after a hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure portable oxygen equipment was properly installed and readily accessible for 1 resident (Resident #16) out of a total sample of 20 residents reviewed, resulting in the potential for complications from hypoxia and hypoxemia and anxiety due to delayed oxygen administration.