Riverside Village Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and comfortable home-like environment, for two of three residents (Residents 1 and 3), when:1. Resident 1's bathroom had black staining to the tile grout next to the toilet, gray colored dust build up to the overhead bathroom fan vent, a black residue ring to the interior of the toilet water tank, black staining to the posterior sink near faucet handles, black and yellow residue to the exterior toilet bowl and peeling paint to the wall near the toilet was observed inside Resident 1's bathroom; and2. Water was actively leaking and pooling beneath/surrounding the toilet, and peeling paint to the wall near the toilet was observed inside Resident 3's bathroom. These failures had the potential to affect the comfort and psychosocial well-being of the residents.

Inspectors wroteBased on interview and record review the facility failed to ensure behavioral health care and services were provided, for one of three residents reviewed (Resident A), when the resident was not provided psychiatric/psychological consult when the resident continues to exhibit behaviors of refusal of care and medications. This failure resulted in Resident A's behavior of continued refusal of meals, medications, and activities of daily living (bathing, toileting, and continence [bladder and bowel function]) care needs, and being sent to the hospital for a further evaluation.

Inspectors wroteBased on interview and record review, the facility failed to monitor emotional distress after an abuse and neglect allegation, for one of three residents reviewed (Resident 1), when the resident alleged abuse and neglect by the nursing staff at the General Acute Hospital (GACH). This failure could result in staff not recognizing Resident 1's emotional distress and being unable to provide necessary psychosocial support.

Inspectors wroteBased on interview and record review, the facility failed to ensure meal substitutes were offered to the residents when the food intake was below 50% (percent), for one of three residents reviewed (Resident 2). This failure had the potential for Resident 2 to have weight loss and affect the resident's overall health condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure accurate reconciliation of medications on admission was conducted for one of three sampled residents (Resident 1), when continuous use of oxygen therapy was not reflected in the physician order for a resident admitted on oxygen. This failure has the potential to result in lack of physician oversight, which could negatively affect the resident's current health condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the necessary care and treatment was provided, for one of five sampled residents (Resident 4), when: 1. Resident 4 ' s left forehead laceration was not evaluated and referred to a physician for suture removal. This failure had the potential for the delay in necessary care and treatment of possible complications related to skin injuries/problems; 2. Resident 4 ' s blood sugar level was not monitored after the insulin medication was discontinued on March 13, 2025. This failure had potential for Resident 4 ' s blood sugar level to be inadequately control which could alter the resident's mental status and affect the resident's overall health condition. 3. Resident 4 ' s baseline weight was not obtained timely after admission on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure scheduled hemodialysis (a treatment using a machine and special filter to clean the blood of a kidney failure person) treatments were provided timely, for one of three residents reviewed (Resident 5), when the transportation to the dialysis center was not arranged. This failure resulted in Resident 5 to missed dialysis treatments while at the facility. In addition, this failure had the potential for Resident 5 to increased risk of medical complications including fluid overload (excess fluid in the blood), edema (swelling), shortness of breath, and high blood pressure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect and dignity when: 1. For Resident 19, Certified Nursing Assistant (CNA) did not fully close the privacy curtain to cover resident's body while providing care; 2. For Resident 47, the staff did not answer call lights in a timely manner, and; 3. For Resident 55, the staff did not respond to resident's requests to provide care. These failures resulted in not ensuring residents' rights to be treated with dignity and respect and could potentially result in negative physical or psychosocial outcomes, such as embarrassment, or changes in mood and/or behavior.

Inspectors wroteBased on interview and record review, for seven of 16 residents reviewed for Advanced Directive (AD - a written statement of an individual's wishes regarding his/her medical treatment) the facility failed to ensure a copy of the AD was readily available in the resident's records when: 1. For Resident 9, the facility did not follow up with resident representative (RR) to obtain a copy of the resident's AD. This failure had the potential for Resident 9's wishes regarding his medical treatment would not be honored; 2. For Residents 29, 30, 39, 55, 160 and 209, a written information regarding formulating an AD was not provided to the resident or RR. This failure had the potential for Residents 29, 30, 39, 55, 160 and 209 to not be aware of how to formulate an AD.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable homelike environment, for two of four residents reviewed for environment (Residents 37 and 14), when the peeled painted walls were observed damaged behind the resident's headboard. In addition, peeled painted walls were observed in rooms [ROOM NUMBER]. This failure had the potential for residents not to experience comfortable and pleasant stay in the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure professional standards of practice during medication administration and the facility's policy and procedure were implemented, for three of 10 residents observed during medication administration (Residents 48, 55, 31, and 161), when: 1. Resident 48's medication was placed on a shelf next to Resident 55, readily available for use. This failure had the potential for Resident 48's medication be administered to Resident 55; 2. The identification of Resident 31 was not verified prior to administering the medications. This failure had the potential for the medications to be administered to the wrong resident; and 3. Resident 161 was not provided privacy while administering the medications. This failure had the potential to affect Resident 161's psychosocial and mental status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sufficient staff were provided to meet the needs of the residents when: 1. For five of 55 residents (Residents 55, 48, 31, 163, and ) complained that staff failed to assist with activities of daily living (ADL- daily care activities) in a timely manner; and 2. The facility did not meet the required minimum of Actual Total CNA Direct Care Service Hours the actual CNA DHPPD of 2.4 hours for the month of March 2025, for 16 out of 31 days reviewed, and for the month of April 2025, for 11 out 30 days reviewed. These deficient practices caused feelings of frustrations and anger, among the residents, and negatively affected the quality of care for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve foods under safe and sanitary conditions when the staff placed a four-ounce (unit of measurement) soup ladle directly on the table instead of the clean container in between serving of the soup for the residents, for . This failure had the potential to put the vulnerable residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection control practices were implemented when: 1. Two used diapers were found on top of resident cabinet drawer in room [ROOM NUMBER]; 2. One direct care staff was observed wearing long artificial finger nails while providing care to the residents; 3. The Certified Restorative Nursing Assistant (CRNA) did not wear personal protective equipment (PPE- equipment used to protect against infection or illness) when providing care to a resident with an active of Methicillin-Resistant Staphylococcus Aureus (MRSA - a bacteria resistant to many antibiotics [medication used to treat infections]) wound infection; 4. The CRNA did not clean and disinfect (use of chemicals to reduce the number of germs or virus particles on surfaces) the Hoyer lift (mechanical device use for lifting) after resident use; 5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional and comfortable environment, when the lint trap of dryer 3 was observed damaged and the lint trap was not cleaned. This failure to maintain a functional environment had the potential to compromise resident safety.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan to address the contractures (shortening and hardening of muscles) of the feet, for one of two residents, (Resident 10). This failure had the potential for Resident 10 not to receive the appropriate interventions tailored to her needs and further worsening of the contractures of the feet.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate care and treatment to manage contractures, for one of one resident reviewed for range of motion (ROM-the full movement potential of a joint) (Resident 10). This failure had the potential for Resident 10 to have further worsening of the feet contractures and contribute to pain and discomfort.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from unnecessary medications for one of five residents reviewed for unnecessary medications (Resident 19) when: 1. Quetiapine (medication used to treat mental illness characterized by disordered thinking, hallucination) was administered without implementing resident-centered non pharmacological interventions prior to administration of the medication; and 2. There was no attempt for gradual dose reduction (GDR - process of slowly and systematically decreasing the dosage of a medication, particularly psychotic medication) with the use of quetiapine. These failures had the potential to result in ineffective behavior management for Resident 19 which increased the potential for unidentified risks associated with the use of medication such as sedation, respiratory depression, and memory loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, for one of one resident reviewed for dental (Resident 22), a dental consultation was provided for the resident. This failure had the potential to result in Resident 23 not receiving the dental services needed to maintain her highest practicable level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident's information was protected from unauthorized use, for one of five residents observed during medication administration (Resident 161), when the electronic health record of Resident 161 was left open and unattended by the licensed nurse. This failure had the potential for Resident 161's record to be disclosed to other people not authorized in the provision of care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure heater equipment in the resident's room was maintained in a safe operating condition, for one of 55 residents (Resident 52), when one baseboard heater cover was observed open, detached and laying on the floor. This failure had the potential to cause a fire and hazardous environment for the residents, staff and visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to safeguard residents ' privacy and confidentiality, for two of two residents (Residents 1 and 2), when the residents were filmed by a staff member and posted on to social media without the residents or resident representative's consent. The deficient practice had the potential to affect the resident psychosocial well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oral care after meals was provided, for one of three sampled residents (Resident 3). This failure had the potential to cause serious health issues and could affect the residents psychosocial well being.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate staff assistance was provided during transfer according to the plan of care, for one of five residents (Resident A). This failure resulted to Resident A to experience physical pain and had the potential for the residents to sustain injury.

Inspectors wroteBased on interview and record review the facility failed to ensure one of three residents' (Resident 1) medication (Hydralazine-used to treat high blood pressure) was administered in accordance with the physician order. The medication was not held for systolic blood pressure (SBP-force of blood pumped out of the heart) below 110 per order. This failure had the potential for Resident 1 to have low blood pressure requiring medical attention.

Inspectors wroteBased on interview and record review, the facility failed to ensure the transfer was appropriate and necessary for one out of three sampled residents (Resident 1), when Resident 1 was transferred to the general acute care hospital (GACH) without documented justification on how needs could not be met at the facility. This failure has the potential to negatively affect resident's needs due to unnecessary transfer.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable environment, for five of 13 sampled residents (Residents 4, 5, 6, 7, and 8) when the airconditioning (AC) unit was not working and the resident's room temperatures exceeded 81degrees Fahrenheit. In addition, the facility failed to report an unusual occurrence of disruption of services when the facility's airconditioning unit was not working. These failures resulted in discomfort for Residents 4, 5, 6, 7, and 8 and had the potential to for the residents to experience dehydration (loss of body fluids), heat stress (condition where the body is under stress from overheating), and heat stroke (when the body cannot control its temperature)

Inspectors wroteBased on interview and record review, the facility failed to ensure two (Resident A and Resident B) of three sampled residents was assessed properly for bladder and bowel continence. This failure resulted in Resident A and Resident B not being identified, assessed and provided appropriate treatment and services to improve or restore as much bladder and bowel function as possible.

Inspectors wrote3. An admission Record indicated the facility admitted Resident #16 on 03/09/2024. Resident #16's Physician Orders for Life-Sustaining Treatment (POLST), prepared on 03/09/2024, revealed in the event the resident was found with no pulse and not breathing, the resident elected Do Not Attempt Resuscitation/DNR (Allow Natural Death). The POLST reflected this information was discussed with the resident, and the resident had No Advance Directive; however, the section of the form for the physician, nurse practitioner, or physician assistant signature was not signed. An admission Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 03/15/2024, revealed the MDS reflected that Resident #16 had a POLST form in their chart that was signed by a physician, nurse practitioner, or physician assistant. [...]

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to provide advance directive information to 1 (Resident #57) of 5 residents reviewed for advance directives.

Inspectors wroteBased on observation, interview, and facility policy review, the facility failed to ensure privacy was provided during resident care for 1 (Resident #46) 1 resident reviewed for privacy.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a care plan was developed to address smoking for 1 (Resident #32) of 1 sampled resident reviewed for smoking and failed to ensure the care plan reflected the level of assistance required with activities of daily living (ADLs) for 1 (Resident #46) of 2 sampled residents reviewed for ADLs.

Inspectors wroteBased on observation, record review, and facility policy review, the facility failed to ensure staff provided assistance with activities of daily living (ADLs) for 2 (Resident #44 and Resident #46) of 2 residents reviewed for ADLs.

Inspectors wroteBased on observation, interview and record review, the facility failed to Establish and maintain safe resident smoking practices, per the facility's Policy & Procedure (P&P) Smoking Policy-Resident, as two residents (Residents1&2) were observed smoking on the patio, without staff supervision. This failure could have resulted in injuries to Residents1&2, while smoking without staff supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure Resident 1 was free from significant medication errors on October 27, 2023, as Licensed Vocational Nurse 1 (LVN1) did not follow the facility's Policy & Procedure (P&P), Administering Medications, as she left Resident 1's medications in his hand, and exited resident's room, before witnessing Resident 1 take his medications. This failure resulted in Resident 1 missing his 8:00 a.m. dose of medications, including Metocarbonal and Cyclobenzaprine (Muscle relaxers, used to relieve muscle spasms).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two residents, (Resident 2)'s call light was within reach. This failure had the potential for Resident 1 to have unmet needs. On October 30, 2023, at 3:05 p.m., observed Resident 2 in her room, sitting in a wheelchair on the right side of her bed. Resident 2's call light was wrapped around the upper right siderail and was dangling onto the floor, outside of Resident 2's reach. On October 30, 2023, at 3:05 p.m., an interview was conducted with Resident 2. Resident 2 asked if she could be assisted to the restroom and back to bed. Resident 2 was asked if she knew where her call light was located, Resident 2 stated no . Resident 2 was asked if she could reach her call light, Resident 2 answered no . On October 30, 2023, at 3:06 p.m., an interview was conducted with the Medical Records Director, (MRD). [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide medication and treatment to address one of three residents' (Resident 1)'s multiple episodes of diarrhea when: 1. Loperamide HCL (medication for diarrhea) was not provided every four hours in accordance with the physician order; and 2. Docusate sodium tablet (medication for constipation) was administered on four occasions when Resident 1 was having loose stools.

Inspectors wroteBased on interview, and record review, the facility failed to ensure one of the three sampled residents (Resident 1) was free from unnecessary medication when Docusate Sodium Tablet (medication used for constipation and or a stool softener) was given on four occasions when Resident 1 was having multiple episodes of diarrhea. This failure had the potential for Resident 1 to suffer prolonged diarrhea.

Inspectors wroteBased on observations, 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; 2. The ice machine was not cleaned and sanitized properly; 3. Thawing meats were in the reach-in refrigerator without label of pull out and used by dates; 4. The microwave in the kitchenette had significant amount of food debris and sauce stings; and 5. The facial hair of Dietary Aide (DA) 2 was not covered. These failures had the potential to cause foodborne illnesses in a medically vulnerable population of 55 out of total census of 58 residents who received food from the kitchen.

Inspectors wroteBased on observation and interview, facility failed to provide a clean environment for the residents and visitors, when two of two garbage disposal bins located outside, by the kitchen, were overflowing and were not securely covered with dumpster lids. In addition, trash was found on the floor next to the garbage disposal bins. This failure had the potential for an unsafe environment for the residents and visitors due to possible pest infestation and spread of diseases in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure result of the most recent survey of the facility was posted and readily accessible to resident, family members, and representatives of the residents. This failure had the potential for residents and family members not to be aware of the survey findings which could affect the decision to stay in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure an Advance Directive (AD-written instruction documentation related to the provision of health care when the resident/individual is no longer able to make decisions) was discussed with the resident and or resident representative upon admission to the facility, for four of 12 residents reviewed (Residents 9, 62, 69, and 120). In addition, the AD was not available in the medical record. This failure had the potential for the residents to not receive their preplanned treatment and services in the event they were incapacitated and or unable to speak for themselves.

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: 1. One Dietary Aides (DA 1)and one [NAME] (Cook 1) were unable to demonstrate and verbalized the process of manual dishwashing by using three-compartment sink; and 2. One [NAME] (Cook 1) was unable to verbalize the proper cool down procedure of cooked meat. These failures had the potential to place 55 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 the menu for the therapeutic diet during lunch meal on June 21 and June 22, 2021, was followed, when: 1. One resident (Resident 53) on NAS (no added salt, diet with no salt packet), CCHO diet (consistent carbohydrate- used in the treatment for diabetes) received regular sugar packet instead of diet sugar packet as indicated on the menu; and 2. Two residents (Residents 45 and 172) on NAS, CCHO, Renal (used in treatment for chronic kidney disease or end stage kidney disease) received ice-cream as dessert instead of half a cup of diet pineapple as indicated on the menu. These failures had the potential to result in compromising the medical and nutrition status of those three residents.

Inspectors wroteBased on interview and record review, the facility failure to implement a policy and procedure on Foods Brought by Family/Visitors that included provisions on facility providing education and information about safe food handling practices to residents, family and visitors, and provisions on facility providing training to all facility personnel regarding safe food handling practices who involved in preparing, handling, serving or assisting the resident with meals or snacks. This failure had the potential to cause foodborne illnesses in a medically vulnerable population of 55 out of 58 residents who could consume food and receive food from family or visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure for two of two residents reviewed for dignity (Residents 69 and 223), were treated with respect and dignity that promotes maintenance or enhancement of their quality of life; when: 1. Resident 69 was not assisted to get up from bed before breakfast as requested; and 2. Resident 223 was not dressed in his preferred clothes. These failures had the potential to result in decline in residents' self-worth and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call lights were within reach for three of sixteen residents (Residents 69, 173, and 224). This failure had the potential to result in residents' needs not met.

Inspectors wroteBased on interview and record review, the facility failed to provide a written Skilled Nursing Beneficiary Notice (SNF ABN- a notice to provide information to residents/beneficiaries if they wish to continue receiving skilled services that may not be paid by Medicare and assume financial responsibility) for two of three residents reviewed for SNF ABN (Residents 6 and 25). This failure resulted in not informing Residents 6 and 25 or their responsible party (RP) of the potential liability for payment in non-covered Medicare Part A services in writing.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident or representative was provided information on bed hold (holding or reserving a resident's bed while the resident was absent from the facility during hospitalization or therapeutic leave) opportunity for one of three residents reviewed for closed records (Resident 44). This failure had the potential to result in the family member not to be given the opportunity to ensure facility bed would remain available for Resident 44's return to receive services needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services for one of two residents reviewed for activities of daily living (ADL- a term used to refer to people's daily self-care activities) (Resident 69), when the physician order for one on one feeding was not followed. This failure had the potential to result in the decline in the resident's ADLs which could lead to a decrease in oral intake and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to assess and evaluate the episodes of increased in heart rate for one of three residents reviewed for closed records (Resident 70). In addition, the physician was not notified of the resident's change in condition. These failure had the potential to result in worsening of the resident's medical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement the physician's order for range of motion (ROM) exercises for one of seven residents reviewed for limited ROM (Resident 63). This failure had the potential to result in decline in the ROM of Resident 63's right wrist.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the care plan for fall was implemented for one of one resident reviewed for falls (Resident 69), when resident's bed was not placed in the lowest position and the call light was not within reach. This failure had the potential for further falls and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assess the appropriateness and continued use of Foley catheter ( flexible tube that passes through the urethra and into the bladder to drain urine) for one of one resident reviewed for catheter (Resident 223). This failure had the potential to predispose Resident 223 to catheter associated urinary tract infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure services was provided for adequate pain management when referral for pain management was not completed for one of two residents reviewed for pain (Resident 63). This failure had the potential to result in Resident 63's pain not managed appropriately.

Inspectors wroteBased on interview and record review, the facility failed to provide the dietary preference for one of three residents reviewed for food preference (Resident 36). This failure had the potential for Resident 36's dietary intake to be inadequate by not making reasonable effort of adjusting resident's food plan and preference.

Inspectors wroteBased on interview, and record review, the facility failed to maintain a complete medical records in accordance to the accepted professional standards and practices, when there was no record of communication between the dialysis center and the facility on one of one resident reviewed for dialysis (Resident 172) on June 16, 2021. This failure had the potential to result in the facility not being aware of any recommendation from the dialysis center for Resident 172, which could affect overall care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate infection control practices were implemented when: 1. A staff was observed going inside the room located in the yellow zone (designated for PUI - person under investigation due to unknown COVID-19 status), without donning an isolation gown; and 2. Two staff were observed wearing a surgical mask under the N95 (respiratory protective device designed to achieve a very close facial fit and very efficient filtration of airborne particles). These failures had the potential to result in transmission of COVID-19 infection between staff and residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure COVID-19 (illness caused by a virus that can be transmitted person to person) testing was conducted on admission for two of three residents on quarantined (Residents 222 and 224), due to COVID-19. This failure had the potential to result in transmission of COVID-19 to the staff and residents in the facility.