Riverside Nursing and Rehabilitation Center

Inspectors wroteBased on review of medical records, interviews with staff, residents, and family, review of video footage from electronic monitoring device, and policy review, the facility failed to provide adequate supervision to prevent two cognitively impaired residents (#49 and #160) from continuing to engage in sexually aggressive behaviors in the female resident's room (#160). This resulted in Immediate Jeopardy and the potential for serious, physical, mental, and/or psychosocial negative outcomes for two residents (#49 and #160) when the facility failed to supervise and intervene to prevent Resident #49 from entering Resident #160's room and engaging in sexual activity. On 04/28/25, Resident #49 entered Resident #160's room numerous times throughout the day. Resident #49 was observed touching Resident #160's breast outside the shirt and kissing her lips. [...]

Inspectors wroteBased on review of documentation from an employment agency, review of documentation from Board of Executives of Long-Term Services and Supports (BELTSS), interview with Board Administrator at BELTSS, and staff interview, the facility failed to ensure Administrator had a valid Nursing Home Administrator (NHA) license. This had the potential to affect all the residents. The facility census was 164. Interview on 08/05/25 at 10:09 A.M. with Regional Director of Operations (RDO) #750 confirmed the facility had employed interim NHA #630 from 05/12/25 through 06/10/25. RDO #750 stated interim NHA #630 had been hired through an employment agency and provided documentation interim #630 had an active NHA license. Interview on 08/06/25 at 4:15 P.M. with Board Administrator #635 stated BELTSS was notified of a concern about the validity of interim NHA #630's license. [...]

Inspectors wroteBased on review of the Resident Council Minutes, and staff and resident interviews, the facility failed to ensure the residents had access to the state and local advocacy organizations. This affected three residents (#117, #59 and #128) and all residents residing on the South and [NAME] units. The census was 164. Review of the monthly Resident Council Minutes from 08/15/24 through 07/07/25 revealed there was no evidence the state or local advocacy group contacts were reviewed at monthly Resident Council meetings. Observation on 08/07/25 at 2:30 P.M. of secured [NAME] and South units revealed no evidence of postings or available documents of state or local advocacy group contacts. Interviews with Residents #128, #59 and #117 during a surveyor led Resident Council Meeting on 08/05/25 at 2:06 P.M. revealed they did not know of any contact information of state or local advocacy groups. [...]

Inspectors wroteBased on observations and staff and resident interviews, the facility failed to ensure a clean, comfortable, and homelike environment. This affected five (Residents #14, #36, #20, #65, and #112) of nine residents reviewed for environment. The facility census was 164.1. Review of the medical record for Resident #14 revealed an admission date of 11/25/24 with medical diagnoses of Parkinson's disease, schizophrenia, bipolar disorder, and hypertension. Review of the medical record for Resident #14 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/16/25, which indicated Resident #14 was cognitively intact and required supervision with toilet hygiene, bed mobility, and transfers, and partial/moderate staff assistance with bathing. Observation and interview on 08/05/25 at 7:25 A.M. [...]

Inspectors wroteBased on review of the Resident Council Minutes, staff and resident interviews, and policy review, the facility failed to ensure concerns were addressed in a timely manner or resolved. This affected three residents (#117, #59 and #128) of three residents reviewed for Resident Council Meetings. The census was 164. Review of the monthly Resident Council Minutes from 08/15/24 through 07/07/25 revealed the following concerns: [...]

Inspectors wroteBased on review of medical records and staff interviews, the facility failed to timely report an allegation of resident to resident sexual abuse to the State Agency (SA). This affected two (#49 and #160) residents of ten reviewed for abuse. The facility census was 164. Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing. [...]

Inspectors wroteBased on review of medical records and staff interviews, the facility failed to timely investigate an allegation of resident to resident sexual abuse. This affected two (#49 and #160) residents of ten reviewed for abuse. The facility census was 164. Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing. [...]

Inspectors wroteBased on medical record review, staff interview, and policy review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASARR) was completed accurately upon admission. This affected one (#07) resident out of two residents reviewed for PASARR. The facility census was 164. Review of the medical record for Resident #07 revealed an admission date of 10/18/24 with medical diagnoses of diabetes mellitus, hypertension, post traumatic stress disorder (PTSD), bipolar disorder, and chronic kidney disease. Review of the medical record for Resident #07 revealed a quarterly Minimum Data Set (MDS) assessment, dated 06/09/25, which indicated Resident #07 was cognitively intact and required partial/moderate staff assistance with toilet hygiene, supervision with bed mobility and transfers, and set-up assistance with eating and bathing. [...]

Inspectors wroteBased on medical record review, staff interviews, and policy review, the facility failed to develop comprehensive care plans in a timely manner. This affected two (Residents #160 and #49) of 32 residents sampled for care plans. The census was 165. 1. Review of the medical record for Resident #160 revealed an admission date of 06/01/22. Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder. Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four. This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing. [...]

Inspectors wroteBased on medical review, staff interview, and policy review, the facility failed to monitor a resident's weight as ordered. This affected one (#01) resident out of four residents reviewed for nutritional status. The facility census was 164. Review of the medical record for Resident #01 revealed an admission date of 07/09/19 with medical diagnoses of left hemiplegia, chronic obstructive pulmonary disease, left above the knee amputation (AKA), hypertensive heart and chronic kidney disease. Review of the medical record revealed Resident #01 had discharged to the hospital on [DATE] and readmitted to the facility 07/08/25. Review of the medical record for Resident #01 revealed a quarterly Minimum Data Set (MDS) assessment, dated 07/18/25, which indicated Resident #01 was cognitively intact and was dependent upon staff for toilet hygiene, bathing, and bed mobility. [...]

Inspectors wroteBased on observation, interview, medical record review, and policy review, the facility failed to ensure enteral feeding supplies were replaced according to professional standards. This affected one (Resident #11) of two residents sampled for enteral feedings. The census was 164. Review of the medical record revealed Resident #11 was admitted to the facility on [DATE]. Diagnoses included Parkinson's disease, unspecified major depressive disorder, unspecified moderate dementia with psychotic disturbance, and generalized anxiety disorder. Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #11 had severely impaired dementia, had self-directed behaviors, did not wander, and did not reject care. Review of the care plan dated 02/24/23 revealed Resident #11 had g-tube status. [...]

Inspectors wroteBased on medical record review, Nurse Practitioner (NP) interview, and policy review, the facility failed to administer medication as ordered which resulted in a significant medication error. This affected one (#02) resident out four residents reviewed for medication administration. The facility census was 164. Review of the medical record for Resident #02 revealed an admission date of 02/09/23 with medical diagnoses of right hemiplegia, chronic obstructive pulmonary disease, end stage renal disease, dependence on dialysis, and bipolar disorder. Review of the medical record for Resident #02 revealed a Minimum Data Set (MDS) assessment, dated 07/07/25, which indicated Resident #02 was cognitively intact and was dependent upon staff for toilet hygiene, showers/bathes, transfers and bed mobility. [...]

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NONCOMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, staff interviews, review of facility investigation, and review of facility policy, the facility failed to ensure a resident was properly transferred from the bed to the wheelchair. This resulted in Actual Harm when Resident #04 was transferred without the use of a Hoyer (mechanical lift) by Certified Nursing Assistant (CNA) #200 and the resident sustained a left femoral head fracture requiring hospital admission and surgical repair. This affected one (#04) of three residents reviewed for accidents. The census was 169.

Inspectors wroteBased on observations, staff interviews, record review, review of facility policy and review of online resources from the Centers for Disease Control (CDC), the facility failed to provide a safe and sanitary environment. This had the potential to affect all 44 Residents (#128, #129, #130, #131, #132, #133, #134, #135, #136, #137, #138, #139, #140, #141, #142, #143, #144, #145, #146, #147, #148, #149, #150, #151, #152, #153, #154, #155, #156, #157, #158, #159, #160, #161, #162, #163, #164, #165, #166, #167, #168, #169, #170, and #171) who resided on the 200-hall (East). The facility census was 172.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide a safe, clean, and homelike environment. This affected four (#10, #128, #138, and #149) out of the five residents reviewed. The facility census was 172.

Inspectors wroteBased on observation, staff interview, record review, and facility policy review, the facility failed to treat residents with dignity and respect. This affected two (#70 and #73) out of three residents reviewed. The facility census was 172.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure a resident's guardian and physician were notified timely following a change in condition. This affected one (#10) out of three residents reviewed. The facility census was 172.

Inspectors wroteBased on observations, staff interviews, and facility policy review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. This affected one (#68) of the five residents reviewed for dining. The facility census was 172.

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment. This affected seven (Residents #34, #170, #153, #136, #10, #131, and #171) of seven residents reviewed for homelike environment. The census was 170.

Inspectors wroteBased on observation, interview and policy review, the facility failed to ensure a refrigerator was provided for residents to use if they wished. This affected six (Residents #71, #43, #69, #173, #88 and #90) of six residents reviewed for the storage of resident food. The census was 170.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure a resident was able to use his electric wheelchair and failed to ensure a resident could leave the building unattended. This affected one (Resident #173) of one resident reviewed for resident rights. The facility census was 170.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure the residents were treated with dignity and respect. This affected three (Residents #153, #143 and #39) of three residents reviewed for dignity and respect. The facility census was 170.

Inspectors wroteBased on observation, medical record review, staff and resident interview the facility failed to ensure choices were respected. This affected one (Resident #27) of one resident reviewed for choices. The facility census was 170.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure a resident cleansed in the proper manner after he was incontinent. This affected one (Resident #137) of three residents reviewed for incontinence. The facility census was 170.

Inspectors wroteBased on observation, record review, interview and policy review, the facility failed to ensure a resident was medicated for pain during a dressing change. This affected one (Resident #50) of three residents reviewed for pressure ulcers. The facility identified four residents with pressures ulcers in the facility. Th census was 170.

Inspectors wroteBased on medical record review, review of the facility investigation, resident interview, staff interview, and review of the facility policy, the facility failed to provide appropriate supervision and assistance with resident transfers which resulted in Actual Harm on 06/03/24 when Resident #66 was transferred out of a shower chair into bed by two staff members without the use of a Hoyer lift as ordered, resulting in the resident sustaining a fracture to the left humerus during the transfer. This affected one (Resident #66) of three residents reviewed for accidents. The facility census was 169 residents.

Inspectors wroteBased on medical record review, staff interview and review of the facility policy, the facility failed to ensure residents were free of significant medication errors. This affected one (Resident #169) of three residents reviewed for medication administration. The facility census was 169 residents.

Inspectors wroteBased on record review, staff interviews and policy review, the facility failed to ensure staff accurately documented the administration of a resident's narcotic medications in the medical record. This affected one (#802) out of three residents reviewed for medication administration. The facility census was 172.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident met criteria for admission to the facility's secure unit and was in the least restrictive environment available. This affected one (#6) of three residents reviewed who resided in the secure or locked unit. The census was 173.

Inspectors wroteBased on observations, medical record review, resident interviews, staff interviews, policy review, and review of the Agency for Clinical Innovation Urology Network, the facility failed to ensure physician ordered treatments were completed for surgical and non pressure wounds; failed to accurately monitor and asses wounds; and provide care and treatment of a resident with a nephrostomy tube. This affected three (#50, #51, and #157) residents out of the four residents reviewed for wound care. The facility census was 170.

Inspectors wroteBased on observations, medical record review and staff interview, the facility failed to ensure physician ordered pressure wound treatments were completed. This affected one ( #50) of three residents reviewed for wounds. The facility census was 170.

Inspectors wroteBased on observation, medical record review, staff interview and review of the Agency for Clinical Innovation Urology Network website, the facility failed to ensure staff was educated and trained to provide care for a nephrostomy tube. This affected one (#50) of one resident in the facility identified as having a nephrostomy tube. The facility census was 170.

Inspectors wroteBased on observation, record review, resident interview, staff interviews and review of policy, the facility failed to ensure medications were available for administration. This affected two (#52 and #56) of six residents records reviewed for medications. The facility census was 170.

Inspectors wroteBased on observation, medical record review, staff interview, policy review, and [NAME] journal review, the facility failed to change gloves and/ or wash hands between cleansing wound and applying treatment; and change gloves between different wounds to prevent possible cross contamination. This affected one (#157) of three residents reviewed for wound care. The facility census was 170.

Inspectors wroteBased on medical record review, staff and resident interviews, and policy review, the facility failed to provide adequate staff assistance when transferring a resident who required two persons assist with transfers resulting in a fall without injuries. This affected one (#58) out of the three residents reviewed for mechanical (hoyer) lift transfers. The facility census was 166.

Inspectors wroteBased on observation, staff interview, medical record review, and policy reviews, the facility failed to ensure infection control procedures were followed when administering medications. This affected one (#53) out of the two residents observed for medication administration. The facility census was 166.

Inspectors wroteTHE FOLLOWING DEFICIENCY REPRESENTS AN INCIDENT OF PAST NON-COMPLIANCE THAT WAS SUBSEQUENTLY CORRECTED PRIOR TO THIS SURVEY. Based on medical record review, resident and staff interviews, review of the facility's Self-Reported Incident (SRI) and investigation, and review of the facility policy, the facility failed to prevent the misappropriation of the resident's funds by staff. This affected one (Resident #1) of three residents reviewed for misappropriation and abuse.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary environment for residents. This affected five Residents (#3, #30, #48, #63, and #155) of five residents reviewed for environment. The census was 168.

Inspectors wrote3. Record review of Resident #35 revealed an admission date of 07/20/17 with pertinent diagnoses of chronic obstructive pulmonary disease with exacerbation, acute respiratory failure with hypoxia, acquired absence of left leg below knee, chronic combined systolic congestive and heart failure, delusional disorders, gastroesophagael reflux disease, schizophrenia, peripheral vascular diseases, hyperlipidemia, allergic rhinits, lactose intolerance, brief psychotic disorder, insomnia, hereditary and idiopathic neuropathy, and benign prostatic hyperplasia. Review of the 03/14/22 annual Minimum Data Set (MDS) assessment revealed the resident was cognitively intact and required extensive assistance for bed mobility, dressing, toilet use, and personal hygiene. He uses a walker, wheelchair and prosthetic limb to aid in mobility. The Resident was frequently incontinent of bowel and bladder. [...]

Inspectors wroteBased on observations, staff interviews, and review of facility policy, the facility failed to ensure food was stored in a safe and sanitary manner. This affected all residents but two residents (#38 and #129) residing in the facility who received meals from the kitchen. The facility census was 168.

Inspectors wroteBased on medical record review and staff interview, the facility failed to issue appropriate Medicare beneficiary liability protection notices to residents. This affected two Residents (#39 and #60) of two reviewed for receiving Medicare Part A services. The census was 168.

Inspectors wroteBased on medical record review, staff interview, and review of facility policy, the facility failed to provide bed hold notices to resident/resident representatives within 24-hours of transferring the resident to the hospital. This affected one (#129) of six residents reviewed for hospitalization. The facility census was 168.

Inspectors wroteBased on staff interview and medical record review, the facility failed to monitor acceptance of nutritional supplements. This affected one (Resident #48) of four residents reviewed for nutritional supplements. The facility identified 14 residents with unplanned significant weight loss or gain. The facility census was 163.

Inspectors wroteBased on resident and staff interview, review of facility policy and medical record review, the facility failed to monitor and assess for new onset of pain. This affected one (Resident #137) of one resident reviewed for pain management. The facility identified 67 residents on a pain management program. The facility census was 163.

Inspectors wroteBased on record review, review of facility policy and staff interview, the facility failed to asses and monitor the resident's vital signs before and after dialysis. This affected one (Resident #34) of one resident reviewed for dialysis treatment. The facility identified two residents receiving dialysis services. The facility census was 163.

Inspectors wroteBased on record review, resident and staff interview, and policy review, the facility failed to ensure dental recommendations were scheduled/provided in a timely manner. This affected one (#10) of four residents reviewed for dental services. The facility census was 163.