River Ridge Rehabilitation and Care Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689May 18, 2023

  Based on record review and interview, the facility failed to ensure that adequate supervision was provided to prevent elopement for 1 (Resident #2) of 4 (Residents #1, #2, #3 and #4) case mix residents. This failed practice resulted in past non-compliance at the level of Immediate Jeopardy, which caused or could have caused serious harm, injury or death for Resident #2. The Administrator and Regional [NAME] President was informed of the past Immediate Jeopardy situation on 05/16/23 at 1:02pm. The findings are: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses of Diffuse Traumatic [NAME] Injury with Loss of Consciousness of Unspecified Duration. […]

• Actual harm, patternF686Jun 10, 2021

  Based on observation, record review and interview, the facility failed to consistently off load the resident heels, consult the physician with changes in the resident ' s condition, obtain a physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] #3) case mix residents who were at risk for the development of pressure ulcers. This failed practice resulted in actual harm to Resident #2 who developed Deep Tissue Injury (DTI) to both heels and had the potential to cause more than minimal harm to affect 12 residents who were at risk for development of pressure ulcers according to a list provided by the Administrator on 6/10/2021. The findings are: 1. Resident #2 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF725Jun 6, 2025

  Based on observations, interviews, record review, facility document review, facility policy review, it was determined that the facility failed to ensure sufficient staffing to meet the residents' needs as evidenced by not following the facility assessment staffing guidelines for 74 of 87 shifts reviewed from 03/01/2025 day shift through 03/31/2025 night shift. The findings include: A review of a facility policy titled, Facility Assessment, dated 12/13/2024, indicated the facility had an average daily census of 74. […]

• No harm, potential for more than minimal, widespreadF812May 31, 2024

  Based on observation and interview, the facility failed to ensure (1) that the kitchen floor, wall and ceiling tiles were cleaned and free of stains, chipped, grease and paint peeling to provide a sanitary environment for food preparation, (2) food items stored in the refrigerator, freezer, and storage area were covered or sealed, (3) expired dressing were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of 2 kitchen, (4) the ice machine was maintained in clean and sanitary condition, and (5) dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. […]

• No harm, potential for more than minimal, widespreadF812Jun 2, 2023

  Based on observation and interview, the facility failed to ensure that the kitchen vents were cleaned to provide a sanitary environment for food preparation, floors, dish washer and kitchen walls, the door frames and baseboards were free of rotten wood, chipped floor tiles, debris, dirt, grease, rust, stains, wall tiles were replaced, food item stored in the refrigerator were covered or sealed, expired food items were promptly removed from stock to prevent potential food borne illness for residents who received meal trays from I of I kitchen; ice machine and ice scoop holder were maintained in clean and sanitary condition and dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1… […]