Riverview Health Services

Inspectors wroteBased on record review and interview, the facility did not ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services to ensure resident safety for 3 of 30 residents (R1, R4, and R8). Licensed Practical Nurses (LPNs) assessed R1 after a fall, without contacting a Registered Nurse (RN), the Director of Nursing (DON), or R1's provider prior to moving R1 for 5 of 8 falls. No documentation to support that the LPN contacted an RN prior to moving R8 after a fall. LPN did not report a change of condition in R4 to an RN.Per the Wisconsin LPNs Standard of Practice (N 6.04), -LPNs must work under the general supervision of an RN or direction of a provider. -LPNs provide basic nursing care, including collecting data and recording it. -LPNs must report changes in a patient's condition to the appropriate person. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident has the right to a dignified existence, self-determination, and communication by ensuring the ability to communication interventions were in place for 1 of 4 residents (R8). Surveyor observed R8 sitting in lounge area without the jingle bell R8 uses to communicate with staff when R8 needs something. R8 was admitted to facility on 11/03/25 with diagnosis that include Parkinson's disease with dyskinesia fluctuation (difficulty in performing or controlling voluntary movements). R8's admission Minimum Data with target date of 11/09/25 and documented on 11/13/25 indicates:R8 has a BIMS of 7/15 (moderately impaired). R8 has no speech sometimes understood and sometimes understands. R8's care plan, I have difficulty communicating as evidenced by whispered/soft voice, initiated on 11/03/25. [...]

Inspectors wroteBased on interview and record review, the facility did not notify a physician and/or RN about a significant change in a resident's physical status for 1 resident (R4) of 13 residents reviewed in a sample of 13. Documentation in R4's medical record by Licensed Practical Nurse (LPN) I indicated a change in R4's physical condition during an evening shift. LPN I did not notify a physician or a Registered Nurse (RN) for further guidance, resulting in R4's prolonged discomfort resulting from a dislocated hip. R4's medical record did not include further documentation of assessment by licensed staff following LPN I's initial documentation of a physical change in R4's status, resulting in delayed intervention for a dislocated hip. This is evidenced by: The facility policy, titled Change in Condition: [...]

Inspectors wroteBased on record review and interviews, the facility did not ensure residents/representatives received written or verbal consent of Bed Hold reserved payment at time of transfer and the notice of transfer prior to discharge or transfer did not include written specific reason the specific for transfer for 2 of 3 residents (R4 and R14). R4 was sent to the hospital via ambulance on 09/19/25 for a change in condition. R4's representative was provided with a Bed Hold Request form that did not contain the written specific reason for transfer and was dated 09/22/25 of receiving verbal consent. R14 was sent to hospital via ambulance on 12/27/2025 for a change in condition. [...]

Inspectors wroteBased on record review and interview, the facility did not conduct a Level II Preadmission Screening and Resident Review (PASARR) for 1 of 4 residents reviewed (R33) within 30 days of admission to ensure individuals with a serious mental disorder received care and services in the most integrated setting possible. This is evidenced by:The facility policy, titled Resident Assessment - Coordination with PASARR Program, with a date implemented of 11/10/25, reads in part, The Level II resident review must be completed within 40 calendar days of admission. Surveyor reviewed R33's record and noted R33 was admitted on [DATE] with a diagnosis of major depressive order. R33's original order included Quetiapine Fumarate 25MG once daily and Duloxetine HCl 30 MG twice a day. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure pain management was provided to residents, consistent with the comprehensive person-centered care plan, and the resident's goals and preferences for 1 resident (R4) of 2 residents reviewed for pain management in a sample of 13. Facility did not develop and implement a care plan on pain management for R4 with a known diagnosis of dementia. R4 may not normally recognize and verbalize when having pain resulting in a prolonged status of discomfort while experiencing a hip dislocation. This is evidenced by:The facility policy, titled Pain Management, last revised 08/09/2022, states in part: [...]

Inspectors wroteBased on interview and record review, the facility did not ensure menus were followed to meet the nutritional needs of each resident. This practice had the potential to affect all 38 residents residing in the facility. Meals were not provided as listed on the menu. The facility did not consult with the Registered Dietitian when changes were made to the menu to ensure nutritional adequacy.

Inspectors wroteBased on observation, interview and record review, the facility did not ensure proper sanitization and food handling practices to prevent the outbreak of foodborne illness for all 38 residents (R). The facility did not measure the internal temperature of the dishwasher. Dietary staff did not wear appropriate hair restraints.

Inspectors wroteBased on observation and interview, the facility did not ensure staff followed procedures for the accurate administration of insulin. Staff did not complete a safety check by priming the needle on an insulin pen to ensure the injectable pens were dispensing insulin before administration for 1 of 2 residents (R), (R3).

Inspectors wroteBased on interview and record review, the facility did not ensure one of five residents (R15) reviewed for unnecessary medications had appropriate monitoring and indication for use of an antipsychotic medication. R15 was prescribed risperidone for a diagnosis of dementia with behaviors. Behavior monitoring did not include the behaviors the medication was being used to treat. This is evidenced by: The facility policy titled, Psychotropic Medications read in part, Residents should not receive psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinic record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the resident's response to the medication(s). Psychotropic medications can affect behavior, mood, thoughts, and perceptions. [...]

Inspectors wroteBased on observation, record review and interview, the facility did not perform hand hygiene when warranted during resident cares. The facility practice affected 1 of 3 residents observed for cares (R10). Certified Nursing Assistant (CNA) C did not perform hand hygiene after performing R10's peri care and before proceeding to touch presumably clean items. Findings Include: Surveyor requested and received the facility policy titled Hand Hygiene dated 11/02/22. The policy in part read: Policy: All staff will perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors. This applies to all staff working in all locations within the facility. Definitions: Hand Hygiene is a general term for cleaning your hands by handwashing with soap and water or the use of antiseptic hand rub, also known as alcohol-based hand rub (ABHR). [...]

Inspectors wroteBased on observation, interview and record review, the facility did not prepare and store foods in a sanitary manner. The facility practices had the potential to affect all 50 residents. The facility does not have a system in place to verify the internal hot water temperature of the hot water sanitizing dishwasher. During the initial tour of the kitchen, Dietary Manager (DM) G and Dietary Aide (DA) H were observed with facial hair at sides and below surgical mask that were being worn. DM G did not perform hand hygiene after contaminating his hands with dirt and grime. DM G proceeded to tour the kitchen with Surveyor, touching presumable clean surfaces and food items with his contaminated hands. Potentially hazardous food and drinks were stored in the kitchen refrigerator and were not dated with open by and use by dates. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not prepare foods in a manner that maintained the nutritional value and palatability of foods. The facility practice has the potential to affect 14 of 50 sampled and supplemental residents (R20, R14, R45, R22, R25, R9, R12, R26, R27, R31, R21, R35, R15 and R7). Dietary Manager (DM) G was observed preparing lunch items of altered consistency without using a recipe or instructions to ensure nutritional values were maintained. This has the potential to affect 11 residents of 50 who are served an altered consistency diet (R20, R14, R45, R22, R25, R9, R12, R26, R27, R31 and R21). R35 indicated the foods served are often bland in taste and the meats are too tough to chew. R15 expressed that the food was cold and indicated it was not good. R250 expressed that the food was cold and said it was hard to eat. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that 3 of 3 sampled residents (R7, R18, R35) did not receive care and services to maintain and/or improve their highest level of range of motion (ROM). R7 did not receive assistance to ambulate twice daily per his restorative program. R18 did not wear hand brace at night as recommended by occupational therapy (OT). R35's care plan was not updated to indicate independence with walker.