Riverside Valley of Journey

Inspectors wroteBased on observation and staff interview the facility failed to follow Physicians orders and maintain standard of nursing care for tube feeding syringe and graduate. This was a random opportunity for discovery. Resident Identifier: # 1 Facility Census: #84Findings include:a) Resident #1On 12/18/25 at 3:10 PM observation found the tube feeding syringe and graduate container at bedside used for tube feeding flushes, residual checks and tube feeding administration were not dated. The resident had a current order for:1) Enteral Feed Order: every day and night shift Check tube placement before initiation of formula, medication administration and flushing tube. 2) Jevity 1.5 237 mls 6 times daily to provide 2139 Kcals, 90gr protein, 720 ml free water. Flush with 60 mls water before and after feeding for a total of 1800 mls six times a day. [...]

Inspectors wroteBased on observation, record review and staff interview the facility failed to ensure a Resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing. This was true for one (1) of three (3) pressures reviewed for care. Resident Identifier: #1 Facility Census: #84Findings include:1) Resident #1On 12/18/25 at 9:50 AM observation found that Resident #1 had the following wound treatments for the left thigh and sacrum ordered by the Physician. Left Thigha) Cleanse area to left thigh with vashe (wound cleanser) pat dry, apply silvasorb, cover with calcium alginate, and cover with foam dressing. Change daily and as needed (PRN), every day shift for wound care. Sacrumb) Wound to sacrum. Cleanse with in house wound care (IHWC). Pat dry. [...]

Inspectors wrotee) Resident #139 A review of Resident #139's medical record on 07/02/25 found the resident was sent to the hospital on [DATE] after facility staff discovered he was smoking an illegal drug in his room at his facility. The resident reported to staff that he had swallowed the drug therefore they sent him to the emergency room via ambulance. The initial review of the reportable incident found the only issue identified was the residents illegal drug use in the facility. An interview with Nursing Home Administrator (NHA) on the morning of 0702/25 confirmed the resident was sent to the hospital on [DATE] and he was not permitted to return to the facility. When asked if they issued the resident a 30 day discharge notice the facility initially was uncertain if they did or not. [...]

Inspectors wroteb) Resident #55 A review of Resident #55's medical record found she suffered an unwitnessed fall on 12/11/24 and 12/18/24. According to the incident reports neurological assessments were initiated on both occasions. In the afternoon of 07/7/25 the Director of Nursing (DON) was asked to provide the surveyor with a copy of the neurological assessments for Resident #55 on 12/11/24 and 12/18/24. Later in the afternoon the DON confirmed there were no neurological assessments found for the fall on 12/11/24. She did provide the neurological assessments for 12/18/24. A review of the neurological assessments for 12/18/24 found they were incomplete. The assessment consists of 25 occasions were a neurological assessment should be completed beginning with the initial assessment and proceeding as follows: 1. Initial 2. 15 minute evaluation #1 3. !5 minute evaluation #2 4. 15 minute evaluation #3 5. [...]

Inspectors wroteBased on observation and staff interview the facility failed to ensure food was stored and prepared in a safe and sanitary manner. This failed practice has the potential to effect more than an isolated number of residents. Facility Census: 84. Findings Include: a) Initial tour of the Kitchen An initial tour of the kitchen upon entrance of the facility on 07/01/25 at 9:00 AM found the walk-in refrigerator had one gallon of milk with best by date June 26, 2025. Certified Dietary Manager CDM #16 reported that the milk deliverer will take it back when he comes to deliver fresh milk if it was date and placed seperately from the food good for consumption. I expressed that it was not currently separate from the milk in date to be used and she marked it and separated it for pick up and set it aside. b)Tour of the nourishment rooms on the floors on 07/02/25. [...]

Inspectors wroted) Resident #24 On 07/01/25 at 1:16 PM, Nursing Assistant (NA) #91 was observed removing Resident #24's tray from her room. It did not appear that the resident had eaten much of the food. The silverware on the tray had not been unwrapped from the napkin. When questioned, NA #91 stated the resident was able to feed herself. On 07/02/25, review of Resident #24's electronic health records, specifically the task report for amount eaten/fluids consumed at meals, showed documentation the resident had eaten 76 to 100 percent (%) of lunch on 07/01/25. The medical records also confirmed the resident could feed herself after set up. The resident had a Brief Interview for Mental Status (BIMS) score of 15, indicating the resident was mentally intact. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate care plan in the area of psychotropic medications. This deficient practice had the potential to affect one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #51. Facility census: 84.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure Activities of Daily Living (ADL) care was provided to dependent residents. One (1) of two (2) residents reviewed for the care area of Activities of Daily Living had not received twice weekly showers. Resident Identifier: #74. Facility Census: 84. a) Resident #74 Review of the facility's shower schedule showed Resident #74 was to receive showers on Mondays and Thursdays. Review of Resident #74's bathing task reports for May 2025 showed the resident had received a shower on 05/19/25, a full body bed bath on 05/19/25, and partial baths on the remaining Mondays and Thursdays of the month. [...]

Inspectors wroteb) Resident #12 The facility's policy titled Resident Self-Administration of Medication, with implementation date 02/01/24 and revision date 02/14/24 stated as follows: - A resident may only self-administer medications after the facility's interdisciplinary team (IDT) has determined which medications may be self-administered safely. The results of the assessment by the IDT would be recorded on the Medication Self-Administration Assessment Form. - Medications for self-administration must be stored in a manner that prevents access by other residents. - Nurses and Aides are required to report to the charge nurse on duty any medication found at the bedside not authorized for bedside storage. On 07/02/25 at 7:52 AM, medication administration to Resident #12 by Registered Nurse (RN) #9 was observed. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents did not receive foods they were allergic to. This was true for one (1) of three (3) residents reviewed for food allergies. This was found to be an issue of past non-compliance that began on 12/13/24 and ended on 12/19/24. Resident Identifier: #189. Facility census: 84.

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide physician-ordered adaptive eating equipment to Resident #24. This was a random opportunity for discovery. Resident Identifier: #24. Facility census: 84.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to establish and 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. Contact precautions were not followed for a resident with shingles. This was a random opportunity for discovery. Resident Identifier: #46. Facility census: 84.

Inspectors wroteBased on observation, policy review and staff interview the facility failed to provide a clean comfortable home like environment. These practices were found in more than a limited area of the facility. residents reviewed for environment during the Long-Term Care Survey Process. Sixteen (16) resident rooms had a black substance on the heating/cooling unit. Windowsills and doorjambs were covered in a black substance. The resident's bathroom was not maintained in a sanitray conditin. Room Numbers: #99, #100, #101, #102, #103, #104, #105, #107, #131, #132, #133, #134, #136, #138, #109, #110. Resident identifiers: #43, #75, #32, and #69. Facility census: 80. Facility census: 80.

Inspectors wroteBased on staff interview and record review the facility failed to complete a comprehensive assessment for mood and behavior. This was true for six (6) of 25 residents reviewed during the Long-Term Survey Process. Resident identifiers: #44, #47, #34, #71, #4 and #54. Facility Census: 80. Findings Included: a) Resident #44 On 07/31/24 during record review of Resident #44 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/19/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. During an Interview on 07/31/24 at 1:55 PM the Cooperate Nurse verified the section C and D was not completed for Resident #44s 06/19/24 MDS assessment. b) Resident #47 On 07/31/24 during record review of Resident #47 MDS review of Quarterly Minimum Data Set (MDS) assessment 06/30/24, Section C, cognitive pattern, was not assessed and section D, Mood, was not assessed. [...]

Inspectors wroteBased on record review and staff interviews the facility failed to identify Major Depressive disorder on Preadmission Screening and Resident Review (PASSR). This was found true for two (2) of five(5) residents reviewed during the long term care survey process. Facility Census: 80 Resident identifiers: #22, and #26.

Inspectors wroteBased on observation, U.S. Pharmacopeia, and staff interview, the facility failed to ensure all medical supplies in the medication storage room were stored in accordance with manufacturers recommended standards. This failed practice had the potential to affect more than a limited number of residents. Facility Census:

Inspectors wroteBased on record review and staff interview, the facility failed to transmit residents assessments for a discharge. This failed practice was found true for one (1) of two (2) residents reviewed under the Facility Tasks during the Long Term Care Survey and hat the potential to affect a limited number of residents residing in the facility. Facility census:80. Resident Identifier:

Inspectors wroteBased on staff interview and record review the facility failed to complete a new Preadmission Screening and Resident Review (PASARR) for Resident #20 when the original PASARR had expired. This failed practice was found true for (1) one of (5) five residents reviewed for PASARR during the Long-Term Care Survey Process. Resident identifier: #20. Facility census: 80.

Inspectors wroteBased on record review, and staff interview, the facility failed to ensure a Resident had a person-centered comprehensive care plan developed and implemented to meet his / her other preferences and goals, and address the resident's medical, physical, mental, and psychosocial needs. This practice affected one (1) of (24) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was developed for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident Identifiers: #44. Facility census: 80.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan for one (1) of 24 residents. Resident #53 regarding the cardiopulmonary (CPR) status. Resident Identifiers: #53. Facility Census: 80. Findings Include: a) Resident #53 On [DATE] at 11:40 AM, a record review was completed for Resident #53. The review found a focus area of I choose to have CPR. An intervention was listed as I prefer to be left alone with my family. On [DATE] at 11:55 AM, the Director of Nursing (DON) was notified. The DON stated, I don't know why this intervention is under this focus area .we will get it corrected.

Inspectors wroteBased on investigation, record review and interview, the facility failed to develop a discharge summary which included a recapitulation of the resident's stay, a final summary of the resident's status, reconciliation of all pre and post discharge medications, and develop a post-discharge plan of care, including discharge instructions. Resident identifier #85. Facility Census: 80.

Inspectors wroteBased on record review and staff interview, the facility failed to maintain an accurate and complete record for transfers to an acute care facility for Resident #15. This is true for two (2) of three (3) residents reviewed under the care area of hospitalizations. Resident identifier: #15. Facility Census: 80.

Inspectors wroteBased on observation, record review and staff interview, the facility failed to maintain an appropriate infection control program during meal service for Resident #15. This was a random opportunity for discovery. Facility Census: 80.

Inspectors wroteBased on observation and staff interview the facility failed to incorporate an effective pest control program. One (1) room had gnats. Facility census: 80. a) room [ROOM NUMBER] A On 07/29/24 12:13 PM during the initial tour there were gnats all over the over bed table including his drinks and pudding. On 07/29/24 at 12:15 PM during an interview Nurse Aide #3 verified the gnats and stated that they do have an issue with gnats in this room. She stated that she would get someone to clean the room.

Inspectors wroteBased on observation and staff interview the facility failed to notify residents of a menu change. This was a random opportunity of discovery. This failed practice has the potential to affect all residents, as all residents residing in the facility currently receive a diet. Facility census: 84.

Inspectors wroteBased on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date food items that were opened. The facility also failed to complete dishwasher temperature logs. This failed practice had the potential to affect all residents, as all residents residing in the facility at this time receive an oral diet. Facility Census:

Inspectors wroteBased on record review, resident interview and staff interview, the facility failed to follow Physicians orders for medication and treatment orders. This was true for five (5) of eight (8) medication administration Resident records reviewed. In addition, one (1) resident was not served the portions of food as ordered by the physician. Resident Identifiers: #17, #40, #66, #75, #79 and #1. Facility Census: #84. Findings Included: a) On 11/21/23 at 11:43 AM, Resident #17 stated she doesn't always get her medications on time. On 11/21/23 at 1:10 PM record review of Medication Administration Audit Review Reports for eight (8) residents found the following medications/treatments administered late according to the standard practice of care to administer medications/treatments one hour prior or one hour after the scheduled time. [...]

Inspectors wroteBased on observation, resident interview and staff interview, the facility failed to provide a safe, clean, and homelike environment for Resident #25 and #29. These were random opportunities of discovery. Resident identifiers: #25 and #29. Facility Census: 84. Findings Included: a) Resident #25 On 11/21/23 at 10:57 AM, an initial interview was conducted with Resident #25. Resident #25 stated, there is something on my curtain .I've told them, but they don't do anything about it .I've only been here one (1) week. An observation of a dry brown substance the length of the privacy curtain and approximately six (6) inches in width was made. On 11/21/23 at 11:24 AM, Scheduler #51 confirmed there was a dry brown substance on the privacy curtain. Scheduler #51 stated, I will put a work order in. On 11/21/23 at 11:30 AM, the Administrator was notified. [...]

Inspectors wroteBased on observation and staff interview the facility failed to provide a therapeutic diet as ordered by the physician for a resident with diagnosis of adult failure to thrive. This was a random opportunity for discovery. Resident identifier: #1. Facility census:

Inspectors wrotea) Resident #12 During an interview and observation on 02/06/23 at 2:49 PM, Resident #12 states that he don't / can't get out of bed. He stated that no activities are provided for him. Resident #12 does have a television available. A review of the current care plan with the initiated date of 01/13/23 showed activities care plan: Focus: --Prefers to be called ---- and is dependent for emotional, intellectual, physical, and social needs. Resident #12 has an Activities of Daily Living (ADL) self-care performance deficit related to limited mobility, generalized weakness, Atherosclerotic Heart Disease (ASHD), history of falls,Pulmonary Embolism ( PE), Congestive Heart Failure (CHF), and Epilepsy. Goal: --Resident #12 will attend or participate in activities of choice one or two times weekly by next review date. [...]

Inspectors wroteBased on observation, policy review and staff interview the facility failed to store food in accordance with professional standards for food safety. The facility failed to label and date food items that were open. The facility also failed to keep kitchen equipment clean and sanitized. The facility also failed to complete the dishwasher and refrigerator temperature log. This failed practice had the potential to affect more than a limited number of residents currently receiving nourishment from the facility's kitchen. Facility Census: 80 Findings Included: A review of a facility policy titled Food Storage: Cold Foods with a revision ate on 04/18 read as following. Procedures 4. An accurate thermometer will be kept in each refrigerator and freezer. A written record of daily temperatures will be recorded. 5. [...]

Inspectors wroted) Resident #20 During an observation during the initial interview on [DATE] at 12:50 PM Nurse Aide (NA) #68 delivered Resident # 20 lunch meal tray. The resident stated he did not want it, NA #68 stated its meatloaf. Do you not even want to try it? NA #68 offered him an alternative to the lunch meal Resident # 20 stated, No I will be fine. NA #68 took the tray and left the cup of coffee and a glass of juice. During a review on [DATE] at 9:00 AM Resident #20's medical record revealed a documentation under the nutrition task of the amount eaten on [DATE] at 12:17 PM - 76-100 % consumed. During an interview on [DATE] at 9:47 AM NA #68, stated Resident # 20 did refuse his lunch meal yesterday, Not sure what I documented for his percentage consumed I would have to look. This surveyor revealed the documentation of 76-100 % eaten. NA #68 stated I probably confused him with another Resident. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure five (5) of five (5) residents reviewed were informed about the benefits and risks of pneumococcal vaccines and had the opportunity to receive pneumococcal vaccines unless medically contraindicated, refused, or already immunized. This deficient practice had the potential to affect more than a limited number of residents at the facility. Resident identifiers: #2, #61, #33, #65, #12. Facility census: 80.

Inspectors wroteBased on resident interview, medical record review, and staff interview, the facility failed to ensure the resident could make choices that were important to him. Resident #61's preferred to have his prosthetic leg kept in his room, but it was kept in the physical therapy department. This deficient practice had the potential to affect one (1) of seven (7) residents reviewed for the care area of choices. Resident identifier: #61. Facility census: 80.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure a complete and accurate Minimum Data Set (MDS) assessment for one (1) of 29 residents reviewed in the long-term care survey process. Resident identifier: #6. Facility census: 80.

Inspectors wroteBased on record review and staff interview, the facility failed to revise a care plan under the care area of hospice and end-of-life care. This was true for one (1) of 29 residents reviewed for care planning. Resident Identifier: #325. Census: 80. Findings Included: a) Resident #325 On 02/06/23 at 2:10 PM, a record review was completed for Resident #325. The care plan interventions dated 08/19/22 listed hospice referral indicated and notify MD (medical doctor) and/or Hospice for potential changes or needs for treatment changes. (Typed as written.) The record review found no active physician's order indicating the resident was currently under hospice services. The facility matrix was also reviewed and hospice services were not indicated. An interview with Social Services (SS) #84 on 02/07/23 at 11:54 AM took place. SS #84 confirmed the resident was not under the care of hospice services. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice. Physician's orders for fingerstick blood glucose levels were not followed for one (1) of three (3) residents reviewed for the care area of insulin. Resident identifier: #61. Facility census: 80.

Inspectors wroteBased on observation, record review, resident and staff interview the facility failed to provide respiratory care by not providing their Bi-Pap as ordered. This was true for two (2) of two (2) residents reviewed for the Respiratory Oxygen care area. Resident Identifiers: #33 and #70. Facility Census: 80. Findings Included: a) Resident #33 On 02/06/23 at 2:46 PM Resident #33 states she is to have a Bi-Pap but she doesn't know where it is. The Bi-Pap was not in her room. This was confirmed with Registered Nurse (RN) #24 on 02/06/23 at 2:47 PM. During an interview on 02/07/23 at 10:05 AM, RN Unit Manager #61 stated due to COVID needs, the Resident was moved from room [ROOM NUMBER] to her current room, #132 on 01/17/23 and is moving back to 129 today. Upon investigation the BiPap was located in the overnight drawer in her old room [ROOM NUMBER]. [...]

Inspectors wroteBased on observation, record review, and staff interview, the facility failed to provide medication administration in accordance with professional standards of practice. Resident #35. Facility Census: 80. Findings Included: a) Resident # 35 On 02/07/23 at 9:16 AM, a medicine cup with multiple pills with no label was found in the medicine cart. There was no way to identify pills which were opened and poured in the medicine cup. Licensed Practical Nurse (LPN) #91 stated I tried to give them to the resident but she said she was sick and couldn't take them right now. LPN #91 stated I can get rid of them and pull some more for the resident. On 02/07/23 at 9:20 AM, Unit Manager (UM) #61 was notified and confirmed the pills were poured into the medicine cup without any type of label. UM #61 stated I'll dispose of them. [...]

Inspectors wroteBased on record review and staff interview, the facility failed to clarify two (2) of five (5) residents reviewed for the care area of immunizations wishes to receive COVID-19 vaccinations. Resident identifiers: #12, #65. Facility census: 80.