River Place Nursing Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF576Apr 20, 2023

  Based on resident interview, staff interviews, and facility policy review, the facility failed to promptly deliver postal mail to residents on Saturdays for 54 of 54 residents in the nursing facility that would possibly receive postal mail. Resident #25 Findings include: Review of a document on facility letterhead from the Administrator dated 4/20/23, revealed, The Policy of (Proper Name of the facility) is to pass mail daily. Activities passes on the weekdays and the Registered Nurse (RN) supervisor or charge nurse is responsible for mail collection on the weekends. Review of the Resident's Rights with a copyright date of 2018, revealed, .7. Information and communication . i. […]

• No harm, potential for more than minimal, isolatedF558Dec 18, 2025

  Based on observation, interview, record review and facility policy review the facility failed to ensure that a call light was within reach for one (1) of forty-nine residents observed. Resident #30. Findings Include: Review of the facility policy, Call Light Policy with revision date of 01/12/15, revealed Procedure .8.When providing care to residents be sure to position the call light conveniently for the resident to use An observation on 12/16/25 at 11:00 AM and on 12/17/25 at 8:30 AM, revealed Resident #30 lying in her bed and the call light was not within reach. The call light cord was draped over her nightstand to the right of her bed with the red call button approximately two (2) feet from the head of her bed. […]

• No harm, potential for more than minimal, isolatedF578Dec 18, 2025

  Based on resident and staff interview, record review, and facility policy review, the facility failed to ensure a resident's right for self-determination related to end-of-life care was respected as evidenced by resident not receiving the opportunity to sign her own code status directive for one (1) of 24 residents sampled. Resident #7Findings include: Record review of facility policy titled, Resident Rights, dated [DATE] revealed, The resident has the right to be informed of, and participate in, his or her treatment, including: . the right to request, refuse, and/or discontinue treatment . The resident has the right to, and the facility must promote and facilitate resident self-determination through support of resident choice. […]

• No harm, potential for more than minimal, isolatedF605Dec 18, 2025

  Based on record review, staff interview, and facility policy review, the facility failed to initiate and implement a physician's order obtained during a Gradual Dose Reduction (GDR) attempt for 1 (one) of five (5) residents reviewed for unnecessary medications. Resident #39.Findings Include: Review of the facility policy Gradual Dose Reduction of Psychotropic Drugs with revision date of 05/03/18 revealed Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Record review of Resident #39's Consultation Report revealed a pharmacy recommendation to change Trazodone to 50 milligrams (mg) at bedtime as needed (PRN) for insomnia for 90 days. […]

• No harm, potential for more than minimal, isolatedF688Dec 18, 2025

  Based on observation, staff and resident interviews, record review and facility policy review the facility failed to provide services to maintain or prevent worsening of contractures for one of three residents reviewed with contractures. Resident #38.Findings Include: Review of the facility policy Range of Motion revealed Policy: To safely move the resident's joints as full a range of motion as possible; To improve or maintain joint mobility and muscle strength; To prevent contractures; To increase strength and activity tolerance; To reduce pain; To prevent complications of mobility. An observation on 12/15/25 at 3:05 PM revealed Resident #38 sitting up in her wheelchair in her room. She had contractures to her left wrist and four fingers on the left hand. […]