Riverwood Health Care

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement appropriate infection prevention and control practices for 2 of 3 sampled residents (Resident 1 and Resident 2) when:1. Resident 1's urinal (a portable plastic container that male residents use to urinate when they cannot get to the bathroom) was full of urine and was hanging on the edge of the bed without a lid cover; and,2. Resident 2's urinal was not labeled. These failures had the potential to spread infection and cause adverse health outcomes for Resident 1, Resident 2, and other residents residing in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to notify the Responsible Party (RP) of a significant change in condition and the physician's intervention for one of three sampled residents (Resident 1), when Resident 1 was prescribed an antibiotic for a urinary tract infection (UTI - a urine infection) and Resident 1's RP was not notified. This deficient practice had the potential to deprive Resident 1's RP of the opportunity to participate in Resident 1's care, be informed of Resident 1's change in condition and treatment plan, ask questions, and make informed decisions regarding Resident 1's care and services.

Inspectors wroteBased on interview, and record review, the facility failed to ensure proper post-fall assessment or interventions were implemented for 1 of 4 sampled residents (Resident 1) when:1) The facility did not hold a post fall Interdisciplinary Team (IDT) meeting for Resident 1's fall on 6/17/26. 2) Resident 1's fall care plan was not updated with new specific interventions after Resident 1's fall on 6/17/26; and,3) Resident 1's neurological checks (focused assessment to monitor a resident's neurological (brain, spinal cord, and nerves) function) was not completed at the designated intervals after Resident 1's unwitnessed fall on 6/17/26. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide written notification to the State Agency (SA) at the time of the position change of the facility's Director of Nursing (DON) for a census of 87 residents, when the Assistant Director of Nursing (ADON) assumed the role of the Interim Director of Nursing (DON) on 6/29/26, and the facility did not report the change of the DON position as of 7/10/26. This failure delayed the SA from verifying that the DON was qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 87 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to exercise reasonable care to protect the personal property of one of three sampled residents (Resident 1) from potential loss when Resident 1's Inventory of Personal Effects (a list of a resident's personal belongings) had not been updated since 10/28/20, continued to list hearing aids that were no longer available for Resident 1's use, and did not accurately reflect Resident 1's current clothing. This failure had the potential for Resident 1's personal property to not be adequately safeguarded and accounted for, placing Resident 1's personal belongings at risk for loss or misplacement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure treatment and care in accordance with professional standards of practice was provided for one of three sampled residents (Resident 1) when:1. Resident 1's skin conditions during the nurse's required weekly long-term care evaluations (Weekly Summary - a weekly nursing assessment used to evaluate and document changes in a resident's condition based on a comprehensive assessment of the resident), completed on 2/13/26 and 2/20/26, were not identified and documented. Additionally, the facility failed to ensure Resident 1's weekly long-term care evaluation, due on 5/1/26, was completed; and,2. The facility staff failed to implement the communication care plan intervention to assist with hearing aid placement and maintenance for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical abuse (intentional act of causing injury or trauma to another person through bodily contact) for one of three sampled residents (Resident 2) when on 3/3/26 Resident 1 became upset, started yelling at Resident 2 and hit Resident 2 on the back of the head with a fist. This failure had the potential to cause physical injury and psychosocial distress (anxiety, depression, fear, social withdrawal, or behavioral changes) to Resident 2.

Inspectors wroteBased on interview and record review, the facility failed to thoroughly investigate an allegation of resident-to-resident abuse for two of two sampled residents when:1. The facility did not complete a thorough interview of a Certified Nursing Assistant (CNA) witness who had reported an argument between Resident 1 and Resident 2 to the Licensed Nurse (LN) on 3/3/26, prior to Resident 1 hitting Resident 2;2. The facility's investigation did not reveal information regarding Resident 1's behavior, and incidents that showed arguments between Resident 1 and Resident 2 or interviews from staff with knowledge of them; and,3. The Director of Nursing (DON) was tasked with the responsibility of completing the investigation by the previous Administrator, even though the DON had never completed an investigation before. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice at the time of the position change of the Director of Nursing (DON) to the State Agency (SA) for a census of 85 residents, when the current DON started the DON position on 12/10/25, and the facility did not report the change of the DON position to the SA until 1/7/26. This failure delayed the SA from verifying that the DON was qualified to lead clinical services at the skilled nursing facility, which had the potential to compromise resident safety and compliance with federal and state regulation for a census of 85 residents.

Inspectors wroteBased on interviews, and record reviews, the facility failed to provide adequate respiratory care services, immediate ongoing clinical assessment, treatment, and identified changes in condition as per professional standards of practice for one out of two sampled residents (Resident 1) when,1. LVN (Licensed Vocational Nurse) 1 did not notify the Physician of Resident 1's change in condition when he had shortness of breath and low oxygen saturation level on [DATE],2. LVN 1 increased Resident 1's oxygen therapy from 2 liters to 4 liters without a Physician's order, 3. LVN 1 adjusted Resident 1's oxygen liter flow and did not escalate Resident 1's care to a qualified healthcare professional, not following their scope of practice, and,4. Hospital discharge orders for Resident 1's weekly CBC were not transcribed over and were not followed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a baseline care plan including the interventions and instructions needed to provide effective and person-centered care as per professional standards of quality care was developed for one of three sampled residents (Resident 1), when Resident 1 was admitted to the facility with oxygen therapy and an oxygen care plan was not developed for Resident 1. This failure had the potential to receive inadequate respiratory care for Resident 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe food storage and preparation, as well as maintain kitchen equipment and food contact surfaces in accordance with professional standards for food safety for the 87 residents who ate facility prepared meals when:1. Over ripe and spoiled produce was available for use in the walk-in refrigerator; 2. Black small bugs were found crawling on the onions and flying within the container that encompassed the onions; 3. Cutting boards and tray line pans were found with food particles, black, and brown colored substances on them; and,4. Several pots, pans, bowls, and trays were found stacked wet (in ready-to-use areas). These failures had the potential to put residents who ate the facility prepared meals at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a clean, comfortable, and homelike environment for 5 out of 41 facility rooms when window blinds were broken in Residents rooms (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER] and room [ROOM NUMBER]). These failures removed residents' rights to a dignified homelike environment, with the potential to result in psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe handling of Hazardous drugs (or HD, drugs that have the potential to cause harm to healthcare workers or patients when not handled properly), safe use of resident care devices (small devices that measure blood pressure (or BP, the force exerted by the blood on the walls of the arteries as it flows through the body) or heart beat), and timely measurement of blood sugar levels, based on standards of practice with a resident census of 87, when:Hazardous medications were not consistently labeled as hazardous to alert nursing staff on safe handling as observed during Resident 56's medication administration, and during a medication cart inspection for Resident 42, Resident 16, and Resident 76. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure safe pharmaceutical services with a resident census of 87 when:Emergency medication Kits (Ekit, a supply of prescription medication reserved for emergency use when needed) use, opening, and its contents were not accounted for in the IV medication Ekit (Intravenous, into the vein) and refrigerator medication Ekit in the main medication room. Facility staff's personal purse was stored in the medication room counter-top where prescription and controlled drugs (drugs that required doctor's prescription and subject to abuse) were stored. Pharmaceutical delivery records for prescription and controlled drugs were not signed and reviewed by licensed staff upon delivery. These failed practices could contribute to lack of accountability and risk of drug diversion (diversion is unauthorized use of drugs).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure proper infection prevention practices were implemented and followed to provide a safe and sanitary environment and help prevent the spread of infection with a resident census of 87 when: 1. The facility stored a resident's kidney basin with clean dishes in the kitchen, creating a risk of cross-contamination; 2. Dietary staff failed to follow infection control practices of hand hygiene during tray line service; 3. Shared glucometer devices (a device used to measure blood sugar) were not cleaned and disinfected in-between resident care per manufacturer's specification for Resident 5 and Resident 105; and,4. A pill cutter was not cleaned before and after each use for Resident 108. [...]

Inspectors wroteBased on observation, and interview, and record review, the facility failed to ensure that staff treated residents with dignity and respect for 1 of 24 sampled residents (Resident 40) when staff referred to Resident 40 as a feeder during care, rather than addressing the resident by name or in a manner that upheld his dignity. This failure had the potential to demean Resident 40, negatively impact his self-esteem, and compromise Resident 40's right to be treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the safe storage and use of a resident's personal medication for 1 of 14 residents observed during a medication pass (Resident 102) when over the counter medications (OTC, a medication that can be obtained without prescription) and supplements (pills that provide nutrients like vitamins, minerals and herbs that may be missing from a person's daily food intake) were found at Resident 102's bedside without a physician's order. This failure had the potential to result in unsafe and/or unauthorized use of OTC medications and/or supplements that could have resulted in illness or injury to Resident 102 and/or other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the protection of residents' personal information for a census of 81 when licensed nurse (LN) 8 left residents personal medical information unattended on the computer screen visible to anyone who walked by in the facility's dining room. This failure had the potential for misuse of residents personal information including identity theft.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in two of four Medication carts (a mobile cart that holds patient medications and supplies), in one out one treatment carts (a mobile cart that holds medical and wound treatment supplies) and in one out of one medication rooms (a locked room used to store medications and supplies) with a resident census of 87 when:1. Medication cart in hallway #2 stored an undated Humalog insulin pen (drug used for blood sugar disease in a pen shape product) 2. Main medication room stored two opened vials of Aplisol (same as Tuberculin Purified Protein, use to test for TB, or tuberculosis, a serious lung infection) which was not dated when it was first opened. The medication room stored an opened and undated eye drop bottle called Timolol (or Timoptic, used to treat eye disease). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and secure communication among staff when resident personal health information (PHI) was communicated via a facility approved group messaging platform (GMP, a smart phone (a mobile phone that performs many of the functions of a computer) free messaging application that lets users call and exchange texts, photos audio, and video messages with others across) on facility staff's personal smart phones based on regulatory requirements (HIPAA-Health Insurance Portability and Accountability Act, a set of federal rules requiring appropriate safeguards to protect the privacy of protected health information from disclosure without patient's consent) for a census of 88 residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of four sampled residents (Resident 1 and Resident 3) who were at risk for elopement (the act of leaving a facility unsupervised and without prior authorization), had implemented elopement prevention measures in place when: 1. Resident 1 had exit seeking behaviors on [DATE] but orders for a wander guard device (an alarm that alerts the facility when a wandering resident tries to leave the facility unattended) and monitoring for wandering behavior were not initiated according to Resident 1's care plan , and an elopement risk assessment was not completed; and, 2. Resident 1 ' s wander guard was not working when the elopement happened on [DATE]; and, 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standards for safe injection practices were followed when: 1. The Infection Preventionist (IP) stored pre-drawn, unlabeled, and undated flu (influenza, a respiratory disease) vaccine syringes in the staff food refrigerator. 2. Pneumonia vaccines (a vaccine that helps prevent an elderly resident get pneumonia, a serious lung infection) for three residents (Resident 1, Resident 2, and Resident 3) were documented as given, when the actual products were found among medication stored for destruction in the staffs ' food refrigerator. These failures could contribute to unsafe and ineffective use of vaccines and subsequent adverse outcomes for residents and staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication use and destruction practices in the facility with a census of 86 when: 1. Prescription medication destruction and disposition logs (Refers to paperwork that outlines the process for permanently getting rid of medications, including when and how they were destroyed) were not dated, witnessed and/or cosigned by licensed staff. 2. A discontinued medication called semaglutide (injectable drug used to treat blood sugar disease and for weight loss) prescribed to Resident 4 was stored in an active storage area in the main medication room after Resident 4 was discharged and included two boxes (prescriptions) of semaglutide. (One prescription was brought in by the family, and the second was delivered by the facility ' s pharmacy (Pharmacy A). 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication storage practices in the facility with a census of 86 when: A dorm style refrigerator in an office shared by the Director of Staff Development (DSD), Infection Preventionist (IP) and the staffing coordinator, contained personal food items and a drawer full of prescription injectable (shot into skin or veins) medications including vaccines and unlabeled pre-drawn syringes of a flu (or influenza, a respiratory infection) vaccine. There was no temperature monitoring performed for this refrigerator. The refrigerator in the main medication room stored: 1. Opened vials of flu vaccine and Tuberculosis testing agent (or TB, a serious lung infection) without any marking for a beyond use date (the date after which the drug should not be used). 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide written notice of a facility-initiated discharge (notice given to resident to find another place to live in 30 days ' time) for one of one sampled residents (Resident 2) when, Resident 2 ' s Responsible Party (RP, a designated person to make decisions for another person) was verbally notified of Resident 2 ' s discharge from the facility on 9/5/24, however a written notice of discharge document was not sent/given to Resident 2's RP. This failure resulted in Resident 2's RP being uninformed of how to appeal the decision of a facility-initiated discharge and removed the opportunity for Resident 2's RP and/or the ombudsman (advocate for residents) to advocate on Resident 2's behalf.

Inspectors wroteBased on interview and record review, the facility failed to determine if one of one sampled resident (Resident 2) could return to the facility following a transfer to an acute care hospital from the facility when, Resident 2 was sent to an acute care hospital on 9/5/24 from the facility and not allowed to return; 1. There was no documented evidence that the facility communicated with the hospital (communication with the hospital and nursing home staff and/or via visits to the acute care hospital to assess the resident ' s condition) to determine an accurate status of Resident 2 ' s condition at the time the acute care hospital attempted to discharge Resident 2 back to the facility; and 2. [...]

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure a medication error rate less than 5%. There were two errors out of 26 opportunities, which resulted in a 7.69% medication error rate for 2 (Resident #23 and Resident #82) of 5 residents observed for medication administration.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure enhance barrier precautions (EBP) were implemented for 1 (Resident #196) of 18 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure services provided met professional standards of quality, when one of three sampled residents (Resident 1) physician order to reduce gabapentin (medication used to treat nerve pain) was not carried out on 4/6/24. This failure resulted in Resident 1 not receiving medication as per her physician's order and had the potential for ineffective treatment and unwanted side effects of the medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote and facilitate self-determination for five (Resident 1, Resident 76, Resident 331, Resident 335 and Resident 337) of 12 yellow zone (designated area where newly admitted or readmitted residents are kept under observation/quarantine for 14 days for possible COVID-19 infection) residents, when: 1. Resident 1, Resident 76, Resident 331 and Resident 337 were kept in the yellow zone for longer than the required 14-day quarantine period, and, 2. Fully vaccinated residents, Resident 335 and Resident 337 were unnecessarily placed on quarantine in the yellow zone. This failure had the potential to cause psychosocial harm to Resident 1, Resident 76, Resident 331, Resident 335 and Resident 337.

Inspectors wroteBased on interview and record review, the facility failed to honor residents' right to visitation, when unvaccinated or partially vaccinated (individuals not fully protected from COVID-19 infection) residents or families were denied indoor visitation. This failure had the potential to negatively impact physical and emotional well-being of residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored and labeled appropriately for six residents from a census of 76 residents (Resident 21, Resident 13, Resident 46, Resident 381, Resident 56, and Resident 27) when: 1. Resident 56's insulin (a medication used to lower blood sugar levels) and Resident 27's inhalers (a medication used to treat lung disease) were stored on medication cart number four after they were discharged from the facility; 2. Resident 21's eye drops were stored in the refrigerator at a temperature not recommended by the manufacturer; 3. Resident 13's insulin pen had been stored in the refrigerator after being opened, contrary to the pharmacy medication label; 4. Resident 46's probiotic was located in the medication cart, not in the refrigerator as recommended by the manufacturer; 5. [...]

Inspectors wroteBased on interview, record, and facility policy review, the facility failed to ensure the Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN- a form that provides information to the beneficiary so that he/she can decide whether or not to get the care that may not be paid for by Medicare and assume financial responsibility) notice was issued for one of three sampled residents (Resident 46) when Resident 46's payment status for services received while in the facility had changed. This failure placed Resident 46 and /or responsible party at risk of not understanding the potential liability for payment of services not covered under Medicare (a federal health insurance).

Inspectors wroteBased on interview and record review the facility failed to complete discharge documentation for one of three sampled residents (Resident 33) when the discharge instructions had multiple blank sections. Without complete discharge instructions Resident 33 could misunderstand needs after being discharged from the facility to home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 23 sampled residents (Resident 20, Resident 42) received proper treatment to maintain good foot health when: 1. Resident 20's toenails were long, discolored, and curved, and 2. Resident 42 had overlong toenails and had not received podiatry services in over a year. This failure had the potential to negatively affect Resident 20 and Resident 42's mobility and cause complications such as injury, pain, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comprehensive pain management, including assessment, for one out of 23 sampled residents (Resident 380) when, Resident 380 had not been evaluated for the presence of pain using a pain assessment scale (a tool used to assess the level of pain) for a total of 12 days . This failure resulted in Resident 380's pain not being effectively managed, with the possibility of pain not being treated when indicated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for two of four residents observed during medication pass when: 1. The facility's pharmacist did not recognize a discrepancy between the dosage form (such as a chewable form) of a medication and the order for a medication for Resident 45 and Resident 16 and; 2. The facility's pharmacist did not ensure controlled drugs (medications that may be abused or cause addiction) were destroyed in a manner where they were unrecognizable and irretrievable.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication administration error rate was less than five percent (%), when three medication errors occurred out of 27 opportunities during medication administration for 3 out of 4 residents (Resident 45, Resident 16, and Resident 60). As a result of these failures, the facility's medication administration error rate was 11%.

Inspectors wroteBased on observation, interview and the facility policy review, the facility failed to properly store and label food in accordance with professional standards for food service safety for residents who received deli meat or drink thickener from the kitchen, when: 1. Two packages of meat stored in the walk-in freezer were not labeled by the specific meat name, and, 2. Three cans of expired food and drink thickener were available for use in dry storage. These failures had the potential to expose residents to a food allergen and/or expired food products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure infection prevention practices were in place and adhered to by staff to prevent possible spread of COVID-19 in the facility, when: 1. Two (Resident 331 and Resident 332) of 12 yellow zone residents (designated area for newly admitted residents' quarantine to prevent or contain COVID-19) were not cohorted (people with the same infectious disease or potential exposure to the same infectious disease are roomed together) adequately when Resident 332 was readmitted into the same room with Resident 331 on the last day of Resident 331's quarantine, and, 2. The Laundry Supervisor did not put on proper Personal Protective Equipment (PPE) (special equipment that protects from infection) before entering a yellow zone room. [...]