River Ridge Rehabilitation and Nursing LLC

In the surveyor’s words

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

• Actual harm, isolatedF600Aug 1, 2024

  Based on interviews and record review, the facility failed to keep residents free from neglect for 2 (#s 1 and 15) of 17 sampled residents. This deficient practice of neglect contributed to skin breakdown and psychosocial harm and pain for 1 (#15) and psychosocial harm to 1 (#1) of the 17 sampled. Findings include: 1. During an interview on 7/31/24 at 9:47 a.m., resident #15 stated staff member F refused to change his brief. Resident #15 stated NF4 came in during the evening and was very upset he had not been changed. Resident #15 stated he needed frequent brief changes due to medications he had been given for constipation. Resident #15 stated staff member F told him, I'm not changing your diaper again until shift change, when he asked to be changed for the second time after breakfast. […]

• Actual harm, isolatedF686Oct 26, 2023

  Based on observation, interview, and record review, the facility failed to prevent the development of an Unstageable pressure injury for 1 (#38) of 2 sampled residents with wounds Findings include: During an interview and observation on 10/23/23 at 2:40 p.m., resident #38 stated she had gotten a new bed because she had a blister on her heel. She stated it did hurt if she tried to walk. She had bed slippers on her feet, which were on the floor, with no pressure reduction in place for the left heel During an observation on 10/24/23 at 10:41 a.m., resident #38 was lying in bed with no pillow or pressure relieving boots for her left heel. During an observation and interview, on 10/24/23, at 2:43 p.m., staff member B removed the boot, and took the sock off resident #38's left foot. […]

• Actual harm, isolatedF692Oct 26, 2023

  Based on observation, interview, and record review, the facility failed to monitor and follow interventions for a severe weight loss for 1 (#6) of 1 sampled resident. Findings include: During an observation and interview on 10/24/23 at 9:08 a.m., resident #6 was sitting in bed, alone with the door to her room closed, and her breakfast tray in front of her. The plate was full of food she was pushing around with her fork. She stated today's breakfast was one of the better ones because the staff usually dropped her tray off while she was asleep, and it would be cold when she woke up to eat. During an observation on 10/25/23 at 8:37 a.m., resident #6 used her call light to notify the CNA that she was done with her tray. Her plate remained full of food. […]

• Actual harm, isolatedF686Jan 5, 2023

  Based on interview and record review, the facility failed to maintain the skin integrity of a resident resulting in a Stage II pressure ulcer for 1 (#43) of 1 sampled resident; and the facility failed to assess and document three newly identified pressure ulcers, failed to prevent an eight day delay in the implementation of appropriate wound care for each of the pressure ulcers identified, and failed to consistently perform wound care dressing changes as ordered for each of the three pressure ulcers for 1 (#31) of 1 sampled resident. Findings include: 1. During an interview on 1/4/23 at 2:33 p.m., NF2 stated resident #31 had an ace wrap on her broken left leg for 10 days after her surgical repair of the fracture. […]

• No harm, potential for more than minimal, widespreadF812Jan 15, 2026

  Based on observation, interview, and record review, the facility failed to ensure safe food labeling and storage in accordance with professional standards for food service safety, and failed to maintain sanitary and clean conditions including employee hygiene. These deficient practices affected all residents receiving food services from the facility kitchen and dietary staff. Findings include: 1. During an observation of the kitchen on 1/12/26 at 12:40 p.m., the following conditions were present:- The kitchen floor was soiled with white, brown, and black debris resembling crumbs and dirt. It did not appear to have been cleaned for some time. […]