Riverview Health & Rehab Ctr

Inspectors wroteBased on observations, record reviews, staff interviews, and review of the policy titled Falls - Clinical Protocol, the facility failed to ensure residents were free from accident hazards and falls for three of three residents (R55, R109, and R148) reviewed for fall assessments. In addition, the facility failed to ensure there were no free standing oxygen cylinder tanks in R148's room and in the facility's Medication Storage Room located near resident rooms. These practices created potential accident hazards and failed to ensure appropriate safety measures were in place for residents.1. Review of the facility's policy titled Falls-Clinical Protocol, reviewed 1/21/2026 revealed that under Assessment and Recognition .5. The staff will evaluate and document falls that occur while the individual is in the facility; for example, when and where they happen, any observations of the event, etc. [...]

Inspectors wroteBased on observations, staff interviews, and review of the policy Storage of Medications, the facility failed to ensure two of eight medication carts were secured for medication storage. In addition, seven of 14 medication rooms and carts contained reviewed for medication storage contained expired medications. The deficient practice increased the risk of unauthorized access and administration of outdated medications. Findings Include:Review of the facility's policy titled, Storage of Medication, reviewed 01/21/2026 revealed that the Policy Heading included, The facility stores all drugs and biologicals in safe, secure, and orderly manner. The Policy Interpretation and Implementation section included, 3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner. 4. [...]

Inspectors wroteBased on observations, resident and staff interviews and record review the facility failed to ensure that two of 56 sampled residents (R113 and R155) did not have unauthorized, unsecured medications at the bedside. This deficient practice had the potential to allow unauthorized access to medications by other residents and visitors in the facility.1. Review of R155's electronic health record (EHR) revealed the following diagnoses, including but not limited to acute kidney failure, hypertension, and sepsis. Review of the Physician Order Form and Medication Administration Record (MAR), both dated March 2026 for R155, revealed that the resident did not have an order in place for the prescription. [...]

Inspectors wroteBased on observation, staff interviews, record review, and review of the facility's policy titled Care Plans, Comprehensive Person-Centered, policy, the facility failed to develop or implement a comprehensive person-centered care plan for two of 32 sampled residents (R) (R56 and R6). This deficient practice had the potential to place R56 and R6 at risk of unmet needs, medical complications, and diminished quality of life. Findings Include:Review of the facility's policy titled Care Plans, Comprehensive Person-Centered, revealed that the facility's interdisciplinary team is responsible for the development of resident care plans. A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial, and functional needs is developed and implemented for each resident.1. [...]

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility document titled Central Venous and Midline Catheter Flushing, the facility failed to ensure professional standards were followed for one resident (R) (R103) of five residents receiving care for a peripherally inserted central catheter (PICC.) This deficient practice had the potential to place R87 at risk of adverse clinical outcomes.

Inspectors wroteBased on observations, interviews, record review, and the facility policy titled, Colostomy/Ileostomy Care, the facility failed to ensure care consistent with professional standards of practice for one of two sampled residents (R) (R78). This deficient practice placed R78 at risk for skin breakdown and discomfort. Findings Include:Review of the facility's policy titled Colostomy/Ileostomy Care, review date 01/21/2026, revealed that The purpose of this procedure is to provide guidelines that will aid in preventing exposure of the resident's skin to fecal matter. Review of the Quarterly Minimum Data Set (MDS) assessment for R78, dated 01/10/2026, revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 15, indicating little to no cognitive impairment. [...]

Inspectors wroteBased on observations, staff interviews, record review, and the facility's policies titled Oxygen Administration and CPAP/BIPAP, the facility failed to ensure that one of 40 sampled residents (R) R56 received oxygen as ordered by the physician. In addition, the facility failed to ensure that one(R)(R6) had their CPAP mask properly cleaned and stored. This deficient practice had the potential to place R56 and R6 at increased risk of respiratory complications. Findings Include:Review of the facility's policy titled Oxygen Administration policy, reviewed 1/21/2026, revealed that, The purpose of this procedure is to provide guidelines for safe oxygen administration. The Steps in the Procedure section included,. 7. Turn on the oxygen. Unless otherwise ordered, start the flow of oxygen at the rate of 2 to 3 liters per minute. [...]

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility policies titled Enhanced Barrier Precautions and Hand Washing/Hand Hygiene, the facility failed to ensure proper hand hygiene during wound care and colostomy care for two of thirty two sampled residents (R) (R78 and R97). In addition, the facility failed to ensure the correct use of required personal protective equipment during care provided to three residents (R103, R78, and R97) receiving intravenous therapy, wound care, and colostomy care under enhanced barrier precautions. These deficient practices had the potential to place residents at increased risk for infection.

Inspectors wroteBased on observations, interviews, and the facility policy titled Call System, Resident, the facility failed to ensure the call light was within reach for one of 32 sampled residents (R ) (R121). This deficient practice had the potential to place R121 at risk of not having their needs met when required. Findings Include:Review of the facility's policy titled Call System, Resident with a review date of 01/21/2026 revealed that Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation. Review of the Quarterly Minimum Data Set (MDS) assessment for R121, dated 03/03/2026, revealed in Section C (Cognitive Patterns) a Brief Interview for Mental Status (BIMS) score of 11, indicating moderate cognitive impairment. [...]

Inspectors wroteBased on record review, staff and resident interviews, and review of the facility policy titled Abuse Policy, the facility failed to protect residents from verbal, sexual and physical abuse. Specifically, the facility failed to protect three residents (R) (R30, R60, and R125) of four sampled residents safe from sexual abuse from R64. In addition, the facility to protect R30 from physical and verbal abuse from Certified Nursing Assistant (CNA) AA. The failure of the facility to keep residents safe had the potential to diminish their quality of life and likelihood of resident abuse to continue. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. [...]

Inspectors wroteBased on record review, staff interviews, review of the Administrator and Director of Nursing job descriptions, and review of the policy titled Abuse Policy, the facility administration failed to provide protective oversight to attain the highest practicable physical and psychosocial wellbeing of the residents. Specifically, Administration failed to take appropriate action on allegations of employee-to-resident physical and verbal abuse for resident (R) R60; and failed to protect R30, R60, and R125 from sexual abuse from R64. The failures of the Administration to take appropriate action has the likelihood to lead to future allegations of abuse, that are not identified, reported, or investigated. The facility census was 161. Specifically: 1. [...]

Inspectors wroteBased on record review, staff and family interviews, and review of the policy titled Abuse Policy, the facility failed to ensure that allegations of verbal, sexual, and physical abuse were reported to the State Survey Agency (SSA). Specifically, residents (R) R30 and R125 were sexually abused by R64; and R60 was verbally and physically abused by Certified Nursing Assistant (CNA AA). The sample size was 57 residents. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. [...]

Inspectors wroteBased on record review, staff interview, and review of the facility policy titled, Abuse Policy, the facility failed to ensure allegations of abuse were thoroughly investigated for two of four residents (R) R30 and R60 reviewed for abuse. Specifically, the facility failed to investigate allegations of resident-to-resident sexual abuse for R30 perpetrated by R64 and an allegation of employee to resident abuse for R60, perpetrated by Certified Nursing Assistant (CNA)AA. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. [...]

Inspectors wroteBased on record review, resident and staff interviews, and review of the facility policy titled Specialized Services the facility failed to ensure one resident (R) R64 received necessary behavioral health services to address repeated verbal abuse and hypersexuality behaviors towards other residents in the facility. The sample size was 57. On 2/5/2025, a determination was made that a situation in which the facility's noncompliance with one or more requirements of participation had caused, or had the likelihood to cause, serious injury, harm, impairment, or death to residents. The facility's Administrator and Director of Nursing (DON) were informed of the Immediate Jeopardy (IJ) on 2/5/2025 at 5:54 pm. The noncompliance related to Immediate Jeopardy (IJ) was identified to have existed on 10/28/2024. A Credible Allegation of Compliance was received on 2/10/2025. [...]

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled Staffing, Sufficient and Competent Nursing and [NAME] Payroll-Based Journal (PBJ) dated July 1, 2024, through September 30, 2024, the facility failed to ensure the required Registered Nurse (RN) coverage of at least eight consecutive hours per day, seven days per week. This had the potential to affect all residents residing in the facility. The facility census was 161 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Infection Prevention and Control Manual Dietary Department, the facility failed to ensure food stored in the main kitchen was labeled and dated, and failed to ensure staff wore proper hair restraints while in the food prep area. The deficient practice had the potential to affect 52 of 61 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, record reviews, and review of the facility's policy titled, Self -Administration of Medication, the facility failed to ensure two of 57 sampled residents (R) (R303) and (R136) did not have unauthorized and unsecured medicated treatment products at the bedside. This deficient practice had the potential to allow unauthorized access of unsecured medications to residents and visitors.

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADL) Supporting, the facility failed to provide a shower and/or bed bath for one of seven residents (R) R357.

Inspectors wroteBased on observations, staff interviews, and review of the policy titled, Food Safety Requirements Policy, the facility failed to ensure that food items were discarded after expiration date from the walk-in cooler in the main kitchen. The facility also failed to ensure that food stored in the residents' pantry on two of four pantries reviewed had resident food items that were dated and labeled properly, and expired foods were removed from refrigerator. The deficient practice had the potential to affect 160 of 166 residents receiving an oral diet.

Inspectors wroteBased on observation, record review, staff interviews and review of the facility policy titled Catheter Care, Urinary, the facility failed to secure the catheter tubing to prevent tension on the urethra for four residents ((R) R#20, R#42, R# 55, and R#127,); failed to have an appropriate diagnosis for two residents (R# 55 and R# 42); failed to ensure two residents (R# 55 and R# 128) had orders for utilizing a catheter; failed to ensure the catheter's drainage bag and tubing was maintained off the floor for two residents (R# 127 and R# 128), and failed to provide a urinary privacy bag for one resident (R# 128) . This deficient practice impacted five of 13 residents observed with indwelling urinary catheters.

Inspectors wroteBased on observation, record review, staff interviews, and review of policy titled Infection Prevention and Control Manual - Cleaning and Disinfecting Blood Glucose Meters and Administering Oral Medications, the facility failed to properly disinfectant the glucometer after use per the manufacturer's specifications by one of two nurses observed for getting a fingerstick blood sugar (FSBS), failed to properly disinfect and store glucometer, and the facility failed to maintain infection control by attempting to administer a medication that was dropped on the floor. The census was 172 residents.

Inspectors wroteBased on record review, staff interview, review of policy titled Infection Prevention and Control Manual the facility failed to provide evidence of a process for periodic review of antibiotic prescribing practices, and to document follow-up measures in response to the data for eight of eight months of 2022 infection control data reviewed (January 2022 through August 2022). This had the potential to affect any resident who was prescribed an antibiotic. The facility census was 166 residents.

Inspectors wroteBased on observation, record review, resident and staff interview, and review of policy titled Care Plans, the facility failed to implement the care plan related to caring for a tracheostomy as appropriated of one resident (R) R#49. In addition, the facility failed to implement the care plan related to bilateral knee contractures for one resident (R# 101). The sample size was 47 residents.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to revise the care plan after each fall with a new intervention and/or with an appropriate intervention to prevent further falls for one resident ((R) R# 101) of 47 residents sampled for care plans.

Inspectors wroteBased on observations, record review, staff interviews, and review of the facility policy titled Tracheostomy Care the facility failed to provide tracheostomy care for one of one resident with a tracheostomy (R# 49).

Inspectors wroteBased on observations, resident and staff interviews, and record review the facility failed to ensure that one of 46 residents, ((R) R# 97), received effective pain management by consistently monitoring resident pain level and adjusting medication as indicated. The deficient practice had the potential to affect 75 residents on facility pain management program according to resident census and condition collected during survey.

Inspectors wroteBased on record review record review and staff interviews, the facility failed to document the intended rationale and duration of therapy for one resident ((R) R#14), that had an as needed order (PRN) for a PRN antianxiety medication beyond 14 days, of five residents reviewed for unnecessary medications.