Riverside

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 25 sampled residents (R49). R49 was observed to have a cup of medications left on her bedside table for her to take independently. R49 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently. Evidenced by:The facility policy titled, Self-Administration of Medication states, in part, Facility, in conjunction with the interdisciplinary care team, should assess and determine with respect to each resident whether self-administration of medications is safe and appropriate .to ensure safe and appropriate self administration, facility should educate residents to ensure that resident is able to: [...]

Inspectors wroteBased on interview and record review, the facility did not immediately notify and consult with the resident's physician when a change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 25 sampled residents (R94). R94 was sent to the ED (Emergency Department) with a change in condition. The facility did not consult with PA E (Physician Assistant) or any provider regarding R94's abnormal lab results. As evidenced by The facility policy, Change of Condition Notification, updated 1/2026, documents, in part, as follows: Purpose: Notification of a provider and family/POA (Power of Attorney) of changes in a resident's condition or health status. [...]

Inspectors wroteBased on interview and record review, the facility did not recognize, evaluate and address the nutritional and hydration needs of 1 of 3 Residents (R50) to reduce the risk of continued weight loss. R50 did not have appropriate interventions put into place to prevent continued weight loss. R50 had an unintentional weight loss of 8.4 pounds/5.77% over 1 month, indicating a severe weight loss. This is evidenced by: Facility policy titled, Identification of Residents at Nutritional Risk, undated, states in part, Policy: Nutrition risk is determined by the presence of characteristics that are associated with an increased likelihood of poor nutritional status. This includes various non-acute or chronic diseases and conditions, unintended weight change, inadequate or inappropriate food/fluid intake, dependence, disability. Procedure: A. [...]

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 2 of 3 medication carts. Surveyor observed R2's latanoprost eye drops on the medication cart with no open date during medication storage task. Surveyor observed R47's brimonidine eye drops on the medication cart with no open date during medication storage task. Evidenced by:The facility policy entitled Medication Administration, dated 1/2026, states, in part: . Purpose: The following guidelines have been established for the staff to assure the safe administration of all medications, without jeopardizing the health and safety of all residents. Procedure: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 13 resident (R6) reviewed for hospice. R6 was receiving hospice services, and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Plan of Care, dated 7/1/96, with last review date of 1/2026, states, in part: Purpose: Hospice Staff and the nursing home staff will establish one individualized Plan of Care for the Hospice resident/family in the nursing home setting. The Plan of Care will be developed by both staff - Hospice and nursing home. Procedure:. 1. Nursing home resident becomes Hospice. a. Hospice will meet with family and resident for admission assessment and collaborate with nursing home staff. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect a resident's right to be free from physical abuse. The facility did not protect residents (R) from physical abuse by a staff member or protect the resident immediately after the abuse occurred. This affected 1 of 4 residents (R1) reviewed for abuse. On 01/06/25, Certified Nursing Assistant (CNA) D witnessed CNA C strike R1 across the face. CNA D left CNA C alone with R1 to report the incident to nursing staff. R1 was left alone with CNA C for approximately 15 minutes. This left R1 at risk for further physical abuse from CNA C. The facility's failure to protect vulnerable residents from physical abuse created a finding of immediate jeopardy that began on 01/06/25. Surveyor notified the Nursing Home Administrator (NHA) and Director of Nursing (DON) of the immediate jeopardy on 01/14/25 at 2:55 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not ensure that 4 of 6 residents (R) reviewed for pressure injuries (PI) (R58, R89, R9, and R28) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R58 was admitted with multiple PIs and was at risk for PI development. R58 developed an unstageable PI. The facility did not reposition R58 for several hours. R89 was at risk for PI development. The facility failed to evaluate the effectiveness of current interventions R89 had in place. The facility did not reposition R89 for several hours and did not off-load heels and coccyx. R9 and R28 have existing PIs. R9 and R28 were not repositioned to promote healing of existing PIs or prevent pressure injuries from developing.

Inspectors wroteBased on observation, interview and record review, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff touched ready to eat foods with contaminated gloves when preparing and serving toast to two residents (R66 and R57). Staff carried uncovered food trays in the hallway for R62, R393, R43, R20, R42, R392 and R73.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. During the 4-day survey Surveyors had multiple observations of staff not following the Centers for Disease Control (CDC) guidance for Personal Protective Equipment (PPE) use during a COVID-19 outbreak. This had the potential to affect all 18 residents residing on the dementia unit. Surveyor observed staff not performing hand hygiene after changing soiled gloves during cares for R64.

Inspectors wroteBased on observation, interview and record review, the facility did not maintain confidentiality of resident medical record information for 12 of 12 sampled and supplemental residents reviewed. Surveyor observed resident (R79, R142, R83, R33, R45, R54, R15, R20, R73 and R39) dietary information on index cards in plastic upright holders on tables in the [NAME] dining room. The resident information was easily read by the Surveyor when passing by the tables in the dining room. During the three-day survey, Surveyors had three observations of computer screens left open and unattended on medication carts with resident (R) identifiable information visible. (R23, R1.) This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled HIPPA Privacy Rule dated December 2019. The policy in part reads: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure each residents' drug regimen was free of unnecessary medications for 1 (R23) of 3 sampled residents reviewed for unnecessary medications related to monitoring of prophylactic antibiotic use. R23 has been on a prophylactic antibiotic for an excessive duration without adequate assessments/monitoring for continued use. This is evidenced by: R23 was admitted to the facility on [DATE] and has diagnoses that include, in part: Alzheimer's disease, dementia and history of recurrent urinary tract infections (UTI). On 08/08/23, at 10:00 AM, Surveyor reviewed R23's Electronic Health Record (EHR). Review of EHR shows R23 has a physician's order for cephalexin capsule 250 mg with instructions to give 250 mg (1 capsule) daily for prophylaxis related to prevention of UTI with start date of 05/27/21. [...]

Inspectors wroteBased on observation and interview, the facility did not ensure all drugs and biologicals were stored in locked compartments and did not ensure only authorized personnel had access to the keys. This occurred for 1 of 6 medication carts observed. During the three-day survey, observations were made of medication carts left unlocked with the keys on top of the cart when unattended and out of view of staff. One observation was made of resident medications left on top of the medication cart when the cart was unattended and out of view of staff.

Inspectors wroteBased on observation, interview and record review, staff did not perform hand hygiene when warranted during cares for 3 (R79, R58, R67) of 7 residents observed for cares. Certified Nursing Assistants (CNA) I and J did not perform hand hygiene when warranted during R79's morning cares. CNA D did not perform hand hygiene before putting on gloves to empty a catheter for R67. This is evidenced by: Surveyor requested and received the facility policy titled Standard Precautions with most recent date of 4/26/23. The policy in part reads: Purpose: Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection and are to be used to care for all residents regardless of diagnosis or presumed infection status. Hand Hygiene: Employees must wash their hands for at least 20 seconds .under the following conditions: [...]