Riverside Landing Nursing and Rehabilitation

Inspectors wroteBased on observation and interview the facility failed to ensure a staff members utilized appropriate personal protective equipment when entering a resident's contact isolation room. This had the potential to affect the remaining 13 residents (#11, #12, #13, #16,#18, #19, #22, #23, #26, #29, #30, #34, and #40) on the hall. The facility census was 39.

Inspectors wroteBased on record review, review of residents' code status maintained in files at the nurses' station, staff interview, and policy review, the facility failed to ensure residents' code status were consistent between what was documented in the electronic medical record (EMR) and what was kept on file at the nurses' station. This affected two residents (#2 and #12) of two residents reviewed for advanced directives.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on record review, review of a facility investigation file, interview, and policy review, the facility failed to ensure medications were properly secured to prevent a resident with cognitive impairment and wandering behavior from accessing the medication and ingesting an unknown quantity of the medication. This affected one resident (#6) of three residents reviewed for accidents/ supervision.

Inspectors wroteBased on record review and interview the facility failed to follow ordered drug parameters for a resident's diuretic medication and failed to follow a medication hold order for a resident prior to surgery. This affected two residents (#8 and #34) of six residents reviewed for unnecessary medications. The facility census was 39.

Inspectors wroteBased on observation, record review, staff interview, and policy review, the facility failed to ensure their medication error rate was less than five percent. The facility had two errors out of 25 opportunities for a medication error rate of 8 percent. This affected two residents (#22 and #35) of three residents reviewed for medication administration.

Inspectors wroteBased on observation and interview, the facility failed to store and prepare foods in a safe and sanitary manner. This had the potential to affect all 35 residents residing in the facility. The facility census was 35.

Inspectors wroteBased on review of the facility's cycle menu/ spreadsheet, observation, and staff interview, the facility failed to ensure residents were served meals in a form that met their needs. This had the potential to affect seven residents (Resident #1, #10, #16, #19, #23, #41, and #95) of seven residents who the facility identified as being on a mechanical soft diet.

Inspectors wroteBased on review of a facility self reported incident (SRI), review of the facility's related investigation, staff interview, and policy review, the facility failed to ensure a resident was free from physical abuse when another resident with a history of aggressive behaviors struck the resident in the face. This affected one (Resident #1) of two residents reviewed for abuse.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure residents did not have psychotropic medications ordered on an as needed basis (prn) limited to an initial 14 day order and only extended with a face to face evaluation of the resident with a clinical rationale as to why the prn psychotropic medication should be extended. They also failed to ensure non-pharmacological interventions (NPI's) were attempted prior to the use of an anti-psychotic medication intramuscularly (IM) ordered on a prn basis. This affected two (Resident #13 and #37) of five residents reviewed for unnecessary medications.

Inspectors wrote3. Review of Resident #1's medical record revealed the resident was admitted to the facility on [DATE]. His diagnoses included adult onset diabetes mellitus. Review of Resident #1's quarterly MDS assessment dated [DATE] revealed the resident was coded as having received an insulin injection during the seven day assessment period (05/19/25- 05/25/25). Section N. ) of the MDS (Medications) coded the resident as having received one insulin injection during the last seven days. Review of Resident #1's medication administration record (MAR) for May 2025 revealed there was no evidence of the resident having been given any insulin between 05/19/25 and 05/25/25. The resident was only noted to have received Trulicity that was given as a subcutaneous (SQ) injection, but Trulicity was not considered to be an insulin. [...]

Inspectors wroteBased on record review, staff interview and policy review, the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) Identification Screen submitted to the state Department of Medicaid was completed accurately to reflect all the resident's mental illness diagnoses. This affected one (Resident #17) of one residents reviewed for PASRR.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan for catheter care. This affected one resident (#6) of one sampled for catheter use. The facility census was 42.

Inspectors wrote3. Review of Resident #37's medical record revealed she was admitted to the facility on [DATE]. Her diagnoses included hypertension and urinary retention. Review of Resident #37's active care plans revealed the resident had a care plan in place for receiving diuretic therapy related to acute renal failure. The care plan was initiated on 04/28/24. The goal was for the resident to be free from any discomfort or adverse reactions while receiving diuretic therapy through the review date. The target date was 08/13/25. Interventions included the need to administer medications as ordered. Review of Resident #37's active physician's orders revealed the resident did not have an order in place for the use of any diuretics. Review of her discontinued orders revealed the resident had not been on a diuretic medication since 06/26/24, when a diuretic had been discontinued. [...]

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure a resident's pressure ulcer was assessed weekly for measurements and evidence of healing. This affected one (Resident #28) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on record review and interview, the facility failed to provide recommended restorative programs for a resident. This affected one resident (#9) of two residents reviewed for rehabilitative services. The facility census was 42.

Inspectors wroteBased on record review, staff interview, and policy review, the facility failed to ensure pharmacy recommendations were appropriately implemented when agreed upon by the physician. This affected one (Resident #37) of five residents reviewed for unnecessary medications/ monthly medication regimen reviews.

Inspectors wroteBased on record review and interview, the facility failed to follow protocols for the use of an antibiotic to treat a urinary tract infection. This affected one resident (#6) of one residents reviewed for catheter use. The facility census was 42.

Inspectors wroteBased on review of the staffing daily posting, review of the schedule, review of timecards, review of the facility assessment, review of the quality assurance/performance improvement (QAPI), and interview the facility failed to ensure there was a Registered Nurse (RN) for eight consecutive hours and a full time Director of Nursing (DON). This had the potential to affect all 46 residents residing in the building.

Inspectors wroteBased on record review and interview, the facility failed to ensure enhanced barrier precautions were in place and failed to properly map infections in the facility. This had the potential to affect all 46 residents in the facility.

Inspectors wroteBased on record review, facility self-reported incident (SRI) review, policy review and interview, the facility failed to ensure residents were free from abuse. This affected five residents (#2, #6, #17, #20, and #21) of seven residents reviewed for abuse. The facility census was 46.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure physician's orders for the use of over the counter and narcotic pain medication ordered on an as needed (prn) basis for pain included parameters on when to use those medications, failed to ensure another resident only received prn narcotic pain medications for pain levels specified in the parameters of the physician's orders, failed to ensure a physician was notified when a resident's systolic blood pressure was outside the parameters provided by the physician with use of a beta-blocker, and failed to ensure a resident's use of prn Vistaril was clearly identified in the medical record to show the reason it was being given when the Vistaril was being used for both allergies and anxiety. This affected four (Resident #3, #14, Resident #41, and #42) of six residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, review of the cycle menu for Week 1, and staff interview, the facility failed to ensure residents received all food items for each meal in accordance with the cycle menu. This had the potential to affect all but six residents (Resident #6, #17, #18, #20, #25, and #42) who the facility identified as being on a pureed diet. The facility's census was 46.

Inspectors wroteBased on observation, review of the pureed food recipes, and staff interview, the facility failed to prepare pureed food in a manner that conserved the nutritional value of the food being pureed in accordance with the recipes. This affected six residents (Resident #6, #17, #18, #20, #25, and #42) of six residents who the facility identified as being on a pureed diet.

Inspectors wroteBased on observation, taste testing of the pureed food, and staff interview, the facility failed to ensure pureed food was prepared in the form that met the needs of the residents. This affected six residents (Resident #6, #17, #18, #20, #25, and #42) of six residents who the facility identified as being on pureed diets.

Inspectors wroteBased on observation and interview the facility failed to ensure lunch meals were served in a sanitary manner. This potentially affected all 46 residents that reside in the building.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents met infection criteria for appropriate antibiotic use. This affected three (Residents #7, #17, and #24) of 10 residents reviewed for infection control. The facility census was 46.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to provide care in a dignified manner for Resident #3 related to the use of a urinary catheter. This affected one resident (#3) of two residents reviewed for catheters. The facility census was 46.

Inspectors wroteBased on observation, record review, facility policy review and interview, the facility failed to ensure residents were provided a clean, comfortable and homelike environment. This affected three residents (#3, #17, and #23) of three residents reviewed for environment. The facility census was 46.

Inspectors wroteBased on record review, observations, interview and facility policy review, the facility failed to ensure Resident #1 was free of restraints. This affected one resident (#1) of one resident reviewed for restraints. The facility census was 46.

Inspectors wroteBased on record review, review of facility self-reported incidents (SRI's), staff interview, and review of the facility policy, the facility failed to report allegations of abuse to the state agency in a timely manner for Residents #8 and #2, and an injury of unknown origin for Resident #17. This affected three (#8, #2, and #17) of six residents reviewed for abuse. The facility census was 46.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Minimum Data Set (MDS) assessments were completed accurately to reflect a resident's dental status, vision status, proper diagnoses, and medications received. This affected three residents (#8, #23, and #31) of 22 residents reviewed for assessments.

Inspectors wroteBased on record reviews, interviews and facility policy review, the facility failed to ensure Pre-admission Screening and Resident Reviews (PASRRs) reviews for Residents #6 and #17 were accurate. This affected two residents (#6 and #17) of two residents reviewed PASRRs. The facility census was 46.

Inspectors wroteBased on record review, observations, interviews, and facility policy review, the facility failed to provide nail care for Resident #1, who was dependent on staff for assistance with hygiene. This affected one resident (#1) of three residents reviewed for personal hygiene. The facility census was 46.

Inspectors wroteBased on record review, interview and facility policy review, the facility failed to ensure residents were provided timely care when a change of condition was noted, failed to ensure specialist appointments were made, and failed to ensure the bowel protocol was implemented timely. This affected one resident (#41) of two reviewed for hospitalization, one resident (#27) of six reviewed for pain management, and one resident (#32) of one reviewed for constipation.

Inspectors wroteBased on medical record review, review of therapy notes, and interview the facility failed to ensure range of motion (ROM) services were implemented per plan of care and failed to ensure therapy services were provided when a resident had a noted decline. This affected two residents (#8 and #41) of four residents reviewed for positioning/restorative.

Inspectors wroteBased on record review, observation, staff interview and facility policy review, the facility failed to ensure Resident #14, who had a history of falls, had fall prevention interventions in place according to the physician's orders and plan of care. This affected one resident (#14) of four residents reviewed for accidents.

Inspectors wroteBased on record review and interview, the facility failed to ensure tube feeding was administered as ordered by the physician and failed to ensure new orders were implemented timely. This affected one resident (#44) of one resident reviewed for tube feedings.

Inspectors wroteBased on medical record review, review of transit receipt, and interview the facility failed to ensure a resident was referred to pain management clinic timely. This affected one (Resident #8) of six resident reviewed for pain.

Inspectors wroteBased on observation, staff interview, and policy review, the facility failed to ensure insulin flexpens were properly dated after they had been removed from the refrigerator and was used for the first time. This affected three residents (Resident #10, #13, and #16) whose insulin flexpens were found when reviewing two of two medication administration carts used by the facility for the storage of medications.

Inspectors wroteBased on record review, interview, and policy review the facility failed to ensure laboratory testing was completed as ordered. This affected one (Resident #41) of two reviewed for hospitalization.

Inspectors wroteBased on medical record review and interview, the facility failed to ensure dental services were arranged in a timely manner. This affected one (Resident #8) of two reviewed for dental services.

Inspectors wroteBased on record review, observation, resident interview, staff interview, and review of the alternate meal menu, the facility failed to ensure a resident was provided a nutritious meal of choice when she declined the main meal being served for the lunch meal on 04/23/24. This affected one resident (Resident #37) of one residents reviewed for alternate meal choices.

Inspectors wroteBased on record review and interview, the facility failed to administer the pneumococcal vaccine to a resident who consented to receiving it. This affected one (Resident #21) of five residents reviewed for vaccinations. The facility census was 46.

Inspectors wroteBased on record review and interview, the facility failed to offer vaccinations for COVID-19. This affected three (Resident #3, #8, and #21) of five residents reviewed for vaccinations. The facility census was 46.

Inspectors wroteBased on review of personnel files, review of the facility assessment, and interview the facility failed to ensure the activities director was qualified. This had the potential to affect all 46 residents residing in the building.

Inspectors wroteBased on record review, observation, resident interview, staff interview, review of the facility menu, and review of the food committee minutes the facility failed to ensure meals, snacks and alternate menu items were offered and provided to the residents per their preferences and requests. This had the potential to affect all the residents residing at the facility who received food prepared in the kitchen. The facility census was 42.

Inspectors wroteBased on record review, staff interview, and review of the facility's catheter care protocols, the facility failed to ensure a resident's dressing to his midline catheter was changed in accordance with his physician's orders. This affected one resident (#50) of three residents reviewed for dressing changes.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident received treatments to her pressure ulcer consistently as ordered by the physician. This affected one resident (#47) of three residents reviewed for wound care.

Inspectors wroteBased on record review, observation, staff interview, and policy review, the facility failed to ensure fall prevention interventions were implemented to prevent avoidable falls. This affected one resident (#25) of three residents reviewed for falls.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a resident receiving Coumadin (an anticoagulant) had Prothrombin (PT)/ International Normalized Ratio (INR) levels monitored consistently as ordered by the physician. This affected one resident (#25) of three residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure the resident's physician was notified of laboratory test results timely after they were obtained. This affected one resident (#25) of three residents reviewed.