River Heights Healthcare Center

In the surveyor’s words

From the most serious findings on record at River Heights Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF656Apr 17, 2024

  Based on resident and staff interview, record review and facility policy review the facility failed follow the person centered care plan to use a full body lift as indicated, causing a dislocated shoulder for Resident #1. This was for one (1) of four (4) resident care plans reviewed. Findings Include Record review of the facility policy titled, Care Plans, Comprehensive, Person Centered with no revision dated revealed Policy Statement: 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 . […]

• Actual harm, isolatedF689Apr 17, 2024

  Based on observation, resident and staff interview, record review and facility policy review the facility failed to prevent an accident that resulted in an injury, as evidenced by a staff member using a lift the physician had not ordered for one (1) of four (4) residents reviewed that required a lift. Resident #1 Findings Include Review of the facility policy titled, Modified Lifting Policy with no revision dated revealed .Policy Interpretation and Implementation .3. Staff will follow the documented lifting protocol deemed appropriate for each resident. This information is documented in the resident's chart and on the Resident Care Sheet. […]

• No harm, potential for more than minimal, patternF550May 7, 2026

  Based on interview, record review and facility policy review, the facility failed to ensure residents were treated with respect and dignity from a staff member for six (6) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20, #19, #29, #18, #47.Findings include:A review of the facility policy, Resident Rights, revised October 2025, revealed, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .A record review of the grievance logs for 2026 revealed no documented concerns related to staff conduct or resident dignity.A record review of the Resident Council meeting minutes for 2026 revealed no documented concerns related to staff conduct or resident dignity.During a Resident Council meeting on 5/5/26 at 2:00 PM,… […]

• No harm, potential for more than minimal, patternF561May 7, 2026

  Based on interview, record review, and facility policy review, the facility failed to promote and facilitate resident self-determination by restricting residents' right to freely congregate in the activity room during evening hours for three (3) of eleven (11) residents who attended the Resident Council meeting on 5/5/26. Residents #2, #20 and #40.Findings include:A review of the facility policy, Resident Rights, revised October 2025, revealed, Policy Statement .Employees shall treat all residents with kindness, respect, and dignity .Policy Interpretation and Implementation. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. […]

• No harm, potential for more than minimal, patternF656May 7, 2026

  Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for two (2) of (16) sampled residents reviewed (Resident #7 and Resident #9).Findings include:A record review of the facility's Care Plans, Comprehensive Person-Centered with a revision date of March 2022 revealed, A comprehensive person-centered care plan that includes measurable, objective and timetables to meet the residents physical, psychosocial and functional needs is developed and implemented for each resident.Resident #7A record review of Resident #7's Care Plan Report revealed an intervention to maintain Enhanced Barrier Precautions (EBP) including washing hands, wearing a gown, wearing gloves, and other precautions when performing close… […]