Riverside Heights Healthcare Center, LLC

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify adverse effects of psychotropic medications (drugs that affect brain activities associated with mental processes and behavior) for one of six residents reviewed (Resident 44), when Resident 44 was administered Risperdal (an antispychotic medication) and was observed with a facial chewing motion. This failure had the potential for Resident 44 to have irreversible adverse effects such as extrapyramidal symptoms (EPS, movement disorders caused by certain medications, particulary antipsychotics).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment for one of two residents reviewed for oxygen administration (Resident 20), when the physician's order for oxygen administration was not followed. This failure had the potential to result in respiratory distress and decline in the resident's health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure one out of five sampled residents (Resident 18) was free from unnecessary medications when Resident 18 received an antihypertensive medication (used to manage high blood pressure) outside of the prescribed blood pressure (BP) parameter four times in April 2025. This failure increased the potential for Resident 18 to experience side effects such as low BP, leading to further heart related complications.

Inspectors wroteBased on observation, interview, and record review, the facility had a medication error rate of 8% when two medication errors occurred out of 25 opportunities during the medication administration for two of four residents (Residents 28 and 52). The facility did not administer the residents' prefilled insulin (medication for diabetes) pen injection according to the manufacturer's instructions. This failure had the potential to result in Residents 28 and 52 not receiving the full therapeutic benefit of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure refrigerated medications and biologicals were stored at temperatures in accordance with facility policy and manufacturer's specifications when one of two medication refrigerators was identified with documented temperature readings below the normal range on multiple days between January to June 2025. This failure had the potential for residents to receive ineffective medications which could result in the residents not receiving the full benefit of the medications, leading to further health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe storage, preparation, and distribution of food when the kitchen staff performed the chlorine (a sanitizing solution) testing of the dishwashing machine with expired test strips. This failure had the potential to result in foodborne illness to a vulnerable facility population.

Inspectors wrote2. On June 16, 2025, at 9:35 a.m., Resident 18 was observed lying in bed, awake, alert, and able to make his needs known. Resident 18 was receiving oxygen (O2) at 3 LPM (liters per minute - a unit of measurement) via the nasal cannula attached to an O2 concentrator (a machine that supplies oxygen). The nasal cannula was labeled with Resident 1's name, room number and date of 6/6/25. A wheelchair was observed at the foot of Resident 18's bed. Resident 18 stated he was using the wheelchair when he was up. An O2 cannula with no date was observed attached to a portable O2 tank. The O2 cannula was observed hanging on the back of the wheelchair, exposed to the environment. On June 16, 2025, at 9:46 a.m. Registered Nurse (RN) 2 was observed assisting Resident 18 in the room. In a concurrent interview with RN 2, she stated Resident 18's nasal cannula was dated 6/6/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care and treatment in accordance with the facilities policy and procedures for two of five residents (Resident 1 and Resident 4) reviewed for oxygen treatment. This failure had the potential to result in ineffective oxygen therapy, respiratory distress, and decline in the residents ' health condition.

Inspectors wroteBased on observation, interviews, document review, and record review, the facility failed to ensure they did not place a fitted sheet on the low air loss mattress for 1 (Resident #42) of 1 sampled resident reviewed for pressure ulcer/injury.

Inspectors wroteBased on interviews, record review, document reviews, and facility policy reviews, the facility failed to conduct outbreak testing as directed by the Centers for Disease Control and Prevention when 1 (Resident #119) of 15 sampled residents tested positive for COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety when: 1. Several various size of metal sheet pans were stacked and stored wet; and 2. The ice machine was not cleaned and sanitized properly per manufacturer's guidance. These failures had the potential to cause foodborne illnesses in a medically vulnerable resident population who consumed food in the facility. The facility census was 58.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure expired medications were removed from storage and not readily available for use, when: 1. One unopened bottle of milk of magnesia (MOM - medication to treat constipation) expired on April 2021, and one unopened bottle of an iron supplement syrup (medication to treat low iron) expired on February 2021; and 2. One open bottle of multivitamins expired on February 2021, and the multivitamins from the expired bottle were administered to Residents 1, 9, 475, 476, and 477. These failures increased the possibility for the residents to receive expired medications with decreased efficacy, and for Residents 1, 9, 475, 476, and 477 to receive medications unsafely.

Inspectors wroteBased on interview and record review, the facility failed to ensure two food service personnel were able to safely and effectively carry out the functions of the food and nutrition services when one [NAME] and one Dietary Aide (DA) were unable to demonstrate and verbalize the process of manual dishwashing by using a two-compartment sink. This failure had the potential to place 51 out of 58 highly susceptible residents who received food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was being following for the therapeutic diet for lunch on May 18, 2021 when: 1. Two residents (Resident 76 and 564) on regular puree (regular diet modifies in texture of a smooth and moist consistency and able to hold its shape. Foods usually in soft and smooth state such as pudding or mashed potatoes) diet did not receive sauce on the puree chicken as indicated on the menu; 2. Two residents (Resident 475 and 469) on regular CCHO (consistent carbohydrate) diet (a diet used in the treatment for diabetes) did not receive diet gelatin dessert as indicated on the menu; and 3. One resident (Resident 53) on CCHO Large portion received extra one and half ounces of regular barbeque (BBQ) chicken. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 21 residents reviewed for care and treatment (Residents 4 and 470) maintained their highest practicable physical well-being when: 1. Resident 4's skin injuries on his face and chin areas were not identified, assessed, and referred to the physician. This failure had the potential to delay care and treatment for Resident 4 which could result in skin infections and worsening of the skin injuries. 2. For Resident 470, the facility did not identify and assess a dark bluish discoloration on the left neck and a yellow-greenish fading discoloration on the right jaw timely. This failure had the potential for Resident 470 to not receive care and treatment for the facial discolorations and a delay in an investigation to determine the cause of the discoloration.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of one resident reviewed for oxygen therapy (Resident 50), to ensure the oxygen nasal cannula tubing (a two-pronged tubing connected to the nose) was labeled indicating the date the nasal cannula tubing was changed. This failure had the potential to result in the nasal cannula tubing to not be changed timely, which could allow infectious organisms to grow causing an infection to Resident 50.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control precautions to prevent cross-contamination (transfer of bacteria or other contaminants from one surface to another) when: 1. One facility staff was observed wearing artificial fingernails while assisting in feeding Resident 31 ; and 2. One facility staff did not perform hand hygiene and did not disinfect the blood pressure cuff in between uses for Residents 29 and 39. These failures had the potential to increase the risk of cross-contamination which could result in the development and transmission of infection to a vulnerable population of 58 residents in the facility.