River Hills Health and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at River Hills Health and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF684Feb 8, 2025

  Based on interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a residents, the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 10 residents (Resident #1) reviewed for quality of care, in that: The facility failed to transcribe Resident #1's hospital order for insulin glargine on admission according to discharge instructions, and failed to administer the medication for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/7/25. The IJ template was provided to the facility on [DATE] at 5:01 PM. […]

• Immediate jeopardy, isolatedF755Feb 8, 2025

  Based on interview and record review, the facility failed to provide pharmacological services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to acquire, receive, dispense, and administer Resident #1's scheduled insulin 17u Insulin Glargine daily as ordered for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on [DATE] at 5:01 PM. […]

• Immediate jeopardy, isolatedF760Feb 8, 2025

  Based on observation, interview and record review the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure Resident #1 was administered Insulin Glargine 17units daily for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on [DATE] at 5:01 PM. The IJ was removed on 2/08/2025. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective actions. […]

• Immediate jeopardy, isolatedF689Dec 21, 2024

  Based on observations, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 had adequate interventions and supervision in place to prevent accidents for Resident #1. Resident #1 had seven falls in 1 month (11/19/24, 11/25/24, 11/27/24 x2, 12/11/24 x2, and 12/13/24), the last of which resulted in injuries and hospitalization . An IJ was identified on 12/19/24. The IJ template was provided to the facility on [DATE] at 7:15 pm. […]

• Immediate jeopardy, isolatedF580Jan 10, 2024

  Based on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 (Resident #1) of 5 residents reviewed for a change of condition. The facility failed to notify the physician and follow up on a change in condition for Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on [DATE]. Resident #1 expired at the hospital on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 7:35 pm. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. […]