Ottawa Co Riverview Nursing Ho

In the surveyor’s words

From the most serious findings on record at Ottawa Co Riverview Nursing Ho, in the surveyor’s own words.

• Immediate jeopardy, isolatedF700Jun 10, 2025

  Based on medical record review, observation, staff interview, coroner interview, coroner's office investigator interview, review of the U.S. Food and Drug Administration Guide to Bed Safety Bed Rails in Hospitals, Nursing Homes and Home Healthcare, review of Zenith 9000 Bed Service Manual, review of the Panacea Air Ease Owner's Manual review of policy on Bed Safety and Bed Rails, review of the facility investigation timeline, and review of the county coroner's preliminary findings, the facility failed to thoroughly assess the residents for the risk of entrapment when utilizing bed rails, when the facility assessment did not include compressing the alternating pressure relieving mattress (APM) to measure the potential gap between the mattress and the side rail, the medical needs that will… […]

• No harm, potential for more than minimal, isolatedF550Feb 26, 2026

  Based on observation, staff interview, and policy review, the facility failed to ensure residents were treated in a dignified manner. This affected three (#31, #25, #67) of three residents reviewed for dignity. The facility census was 86.Findings include:1.Review of the medical record for Resident #31 revealed an admission date of 12/01/23. Diagnoses included Alzheimer's disease, dementia, muscle weakness, and dysphagia. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had severe cognitive impairment. The resident was dependent on staff for eating meals. Review of a physician order dated 02/10/24 revealed the resident was ordered a regular diet with mechanical soft texture and thin liquids. Observation on 02/24/26 at 8:45 A.M. […]

• No harm, potential for more than minimal, isolatedF552Feb 26, 2026

  Based on record review and staff interview, the facility failed to ensure residents were informed about treatment options and alternatives before beginning treatment with psychoactive medications. This affected one (#9) of five residents reviewed for psychoactive medications. The facility census was 86.Findings include:Review of the medical record for Resident #9 revealed an admission date of 10/15/25 with diagnoses of depression, restlessness, anxiety, and protein-calorie malnutrition. Resident #9 was admitted to hospice on 02/21/26. Review of the quarterly Minimum Data Set (MDS) assessment, dated 01/22/26, revealed Resident #9 had intact cognition and received an antianxiety medication, and an antidepressant. […]

• No harm, potential for more than minimal, isolatedF578Feb 26, 2026

  Based on review of the electronic and paper medical records, review of care conference meeting progress notes, review of a signed Do Not Resuscitate (DNR) order, review of physician orders, review of the plan of care, staff interview, and policy review, the facility failed to ensure a resident's code status was consistent throughout the medical record. This affected one (#8) of 29 residents reviewed for code status in the initial sample pool. The facility census was 86. Findings include:Review of the medical record revealed Resident #8 had an admission date of [DATE]. […]

• No harm, potential for more than minimal, isolatedF604Feb 26, 2026

  Based on review of the medical record, observation, staff interview, and policy review, the facility failed to ensure proper use and monitoring of a physical restraint. This affected one (#10) of one resident reviewed for restraints. The facility identified one resident with a restraint. The facility census was 86. Findings include:Review of the medical record for Resident #10 revealed an admission date of 05/03/24. Diagnoses included Parkinson's disease, progressive multiple sclerosis, dementia, type two diabetes mellitus, and dysphagia. Review of the annual Minimum Data Set (MDS) assessment dated [DATE] revealed the resident had impaired cognition and was never understood. […]