Riverview Care Center

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 3 residents reviewed for transfers by failing to follow Resident #1's plan of care. The deficient practice resulted in actual harm for Resident #1 on 04/08/2026 when Resident #1 was transferred from a wheelchair to a bed without utilization of a mechanical lift. Resident #1's care plan indicated she was totally dependent in transferring with the use of a mechanical lift and two person assist. S4CNA reported Resident #1, sitting in her wheelchair, wrapped her arms around CNA's waist area, S4CNA put her arms under Resident #1's arms, lifted Resident #1 and transferred Resident #1 to her bed. S4CNA and S3LPN reported during the transfer, Resident #1's arms popped and Resident #1 complained of pain. [...]

Inspectors wroteBased on record review and interviews, the facility failed to refer a resident with newly evident or possible severe mental disorder, intellectual disability, or a related condition to the appropriate state agency for a Level II PASARR evaluation for 1 (#10) of 1 resident reviewed for PASARR.

Inspectors wroteBased on record review and interviews, the facility failed to develop an individualized comprehensive care plan for 1 (#59) out of 41 total sampled residents reviewed. The facility failed to develop a problem and approach for Resident #59's limited range of motion, restorative care and application of splint/brace.

Inspectors wroteBased on observation, record review and interviews the facility failed to maintain, store, prepare, distribute, and serve food under sanitary conditions. The facility failed to ensure all staff entering the kitchen wore a hair restraint that covered all hair including hair nets and beard covers.

Inspectors wroteBased on record review and interviews the facility failed to develop a post-discharge plan of care for 1 (#116) of 4 resident reviewed for closed records. Review of the facility's Discharge, Transfer and Planning Policy (Latest revision date 08/25, Latest Review Date 09/25) revealed in part: Discharge PlanningDischarge planning shall be initiated by the Social Service Director/Designee with anticipated discharges and on all skilled level care admissions documented in the resident's clinical record. Anticipated means the discharge was not due to an emergency (hospitalization for acute condition) or death. The community shall develop and implement an effective discharge planning process. The discharge plan shall focus on the residents' discharge goals and the preparation of residents to be active partners for post discharge care. [...]

Inspectors wroteBased on record review and interview the facility failed to ensure the plan of care had been revised for 1(#7) resident out of a total of 41 residents reviewed for plan of care. The facility failed to revise a resident's plan of care for code status change.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing for 1 (#59) of 1 resident investigated for pressure ulcers. The facility failed to follow the recommendations of the consulting Wound Care Nurse Practitioner.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to provide an environment that is free from accident hazards with assistive devices to prevent avoidable accidents for 1 (#59) of 2 (#54, #59) residents reviewed for accident hazards.

Inspectors wroteBased on record review and interviews the facility failed to provide services that met professional standards for 1 (#1) of 3 (#1, #2 and #3) sample residents reviewed for impaired cognition and at risk of elopement. S3LPN (licensed practical nurse) failed to implement elopement precautions for Resident #1 when the admission elopement screening completed by S3LPN indicated Resident #1 was at high risk of elopement. The deficient practice resulted in an Immediate Jeopardy on 06/06/2025 at approximately 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 was found to be an elopement risk upon admission to the facility on [DATE] when S3LPN (licensed practical nurse) completed an elopement risk assessment. [...]

Inspectors wroteBased on record review and interviews the facility administration failed to have an adequate system in place to ensure adequate supervision for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for impaired cognition and at risk of elopement. The deficient practice resulted in an Immediate Jeopardy on 06/06/2025 at approximately 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 was found to be an elopement risk upon admission to the facility on [DATE] when S3LPN (licensed practical nurse) completed an elopement risk assessment. S3LPN failed to implement elopement precautions for Resident #1 including notifying the physician and responsible party, placement of a wander guard, and updating the care plan to reflect Resident #1 was an elopement risk. [...]

Inspectors wroteBased on observations and interview the facility failed to ensure the most recent survey results were posted in a place readily accessible to the residents, family or visitors to review.

Inspectors wroteBased on record reviews, observations, and interviews, the facility failed to ensure correct use and maintenance of bed rails by ensuring residents were accurately assessed for the risk of entrapment from bed rails and an informed consent was obtained from resident or resident representative prior to installation for 15 (#10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106) out of 17 (#10, #18, #20, #24, #30, #36, #51, #53, #57, #66, #75, #96, #101, #104, #106, #167, #367) residents reviewed for bed rails.

Inspectors wroteBased on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by 1) having dirty equipment, and food preparation items used to prepare and/or distribute resident meals in the kitchen, 2) Resident meal plates and saucers stored in an upright position, and 3) the flour scoop was left inside the flour storage container.

Inspectors wroteBased on record review and interview the facility failed to ensure 1 (#87) of 5 (#9, #10, #30, #87, #317) residents reviewed for unnecessary medications were informed of the risks, benefits, and side effects of an antipsychotic medication prior to the start of the medication.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that a resident was free from physical restraints imposed for purposes of discipline or convenience for 1 (#74) of 1 (#74) residents investigated for restraints. The facility failed to ensure: 1) Resident #74 had a written consent for a self-releasing seatbelt, pommel cushion, scoop mattress and side rails and was able to intentionally remove those items in the same manner as they were applied by the staff, 2) a physician's order was in place for the use of restraints.

Inspectors wroteBased on record review and interview, the facility failed to accurately assess the residents discharge status for 1 (#116) of 1 (#116) resident reviewed for resident assessments out of a total sample of 31 residents.

Inspectors wroteBased on record review, observation and interviews the facility failed to ensure residents who were unable to complete their ADL (Activities of Daily Living) received the necessary services to maintain proper grooming for 2 (#20 and #104) of 3 (#20, #36, #104) residents reviewed for ADLs. The facility failed to ensure Resident #20 and #104 received nail care.

Inspectors wroteBased on record review, observation and interviews the facility failed to ensure it was clinically appropriate for a resident to self-administer medications for 1 (Resident #1) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. This deficient practice had the potential to affect any of the 117 residents residing in the facility according to the 03/04/2024 Resident Census List provided by the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the comprehensive care plan had been implemented for 1 (#6) of 6 (#1, #2, #3, #4, #5, #6) sampled residents. The facility failed to ensure the hospice care plan had been implemented for Resident #6 by failing to ensure hospice had been notified of Resident #6's 02/07/2024 fall.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure 1 (#28) of 5 (#21, #28, #43, #44, #103) residents reviewed for accidents received necessary care to prevent accidents/falls. The deficient practice resulted in actual harm for Resident #28 on 06/12/2023 at 10:30 a.m. when Resident #28 suffered a major injury during a transfer from the bed to the shower chair. S6 CNA (Certified Nursing Assistant) and S7 CNA transferred Resident #28 without using a lift. S6 CNA and S7 CNA lowered Resident #28 to the floor when the shower chair slid out from under Resident #28. S6 CNA noticed Resident #28 was sitting on the floor with her legs folded under her. Resident #28 was transported to the emergency room (ER) on 06/12/2023 at 10:58 p.m. and was diagnosed with a right distal femur fracture. [...]

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure the resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident for 1 resident (#43) of 1 resident investigated for choices.

Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure residents who were unable to complete Activities of Daily Living (ADLs) received the necessary services to maintain proper grooming and hygiene for 1 (#107) of 3 (#80, #107, #110) residents reviewed for ADLs. The facility failed to ensure Resident #107 received nail care.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure there was a sufficient number of skilled licensed nurses, nurse aides, and other nursing personnel to provide care and respond to each Resident's basic needs. The facility failed to provide the minimum required staffing hours for 2 of 24 weekend days.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure the physician was notified of behaviors exhibited by 1 resident (#96) of 1 resident investigated for behaviors.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure all patient care equipment was maintained in safe operating condition for 1 resident (#43) out of 101 residents with mobility in a chair all or most of the time according to the Resident Census and Condition of Residents dated 09/11/2023. The facility failed to ensure Resident #43's wheelchair locked properly.