River Garden Hebrew Home for the Aged

In the surveyor’s words

From the most serious findings on record at River Garden Hebrew Home for the Aged, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF812Jul 30, 2026

  Based on kitchen and nourishment room observations, staff interviews, and a review of the facility's policies and procedures, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect more than a few residents who consumed foods from the facility. The facility failed to properly store, label and date food items, remove expired food items, and clean/maintain essential kitchen equipment used to prepare meals in sanitary condition. […]

• No harm, potential for more than minimal, patternF812Apr 29, 2021

  Based on observations, staff interview, and facility policy and procedure review, the facility failed to follow proper sanitation, food distribution and service practices with the potential to affect all of the residents in the facility. The facility failed to ensure dietary staff implemented the policy for for hand hygiene, disposable glove use, and proper sanitation practices in the kitchen during the lunch meal service. Hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. […]

• No harm, potential for more than minimal, isolatedF656Jul 30, 2026

  Based on observations, interviews, record reviews, and a review of the facility's policies and procedures, the facility failed to implement the person-centered care plans for two (Residents #158 and #13) of three residents reviewed for seizure precautions out of eight residents on seizure precautions involving pool noodles. Failure to follow resident care plans can result in physical and mental decline, including injuries from striking limbs against bed rails during seizure activity.The findings include:1.On 7/28/2026 at 1:20 PM, an observation was made of Resident #158 in her room lying in bed. No padding was observed on the top two half-rails of her bed. On 7/29/2026 at 1:44 PM, an observation was made of Resident #158 in her room lying in bed with her eyes closed. […]

• No harm, potential for more than minimal, isolatedF695Apr 29, 2021

  Based on observations, interviews, record reviews and policy and procedure review for oxygen administration, the facility failed to ensure that two (Residents #56 and #32) of ten residents on oxygen therapy, received the correct number of liters of oxygen ordered by the physician, in a total sample of 39 residents. This could result in the resident not receiving appropriate care and/or clinical complications. The findings include: 1. On 4/27/21 at 10:36 AM, Resident #56 was observed lying in bed with oxygen via nasal cannula. […]