River Terrace Health Campus

In the surveyor’s words

From the most serious findings on record at River Terrace Health Campus, in the surveyor’s own words.

• Actual harm, isolatedF690Sep 27, 2023

  Based on observation, interview and record review, the facility failed to ensure staff irrigated a resident's (Resident B) Indwelling catheter with the correct dosage of acetic acid which resulted in burning pain and a transfer to the emergency department for 1 of 3 residents reviewed for Indwelling catheters. Findings include: During an interview on 9/27/23 at 2:40 p.m., Resident B was observed resting in bed with her eyes open. She indicated RN 2 came in her room and asked if the stuff for her catheter was in her room and Resident B told her no. A few minutes later, RN 2 came in her room with a big jug and said she had gotten some vinegar to irrigate her catheter. As soon as the vinegar hit up in there, she told RN 2 to stop because it was screaming burning. […]

• No harm, potential for more than minimal, widespreadF812Mar 6, 2026

  Based on observation, record review and interview, the facility failed to ensure the kitchen was clean and in good repair for 2 of 2 observations. This deficient practice had the potential to affect 44 of 44 residents who received meals from the kitchen.Findings include:During the initial tour of the kitchen on 3/2/26 at 10:20 a.m., the following concerns were observed:Under the right long rack and center rack, next to the wall in the walk-in freezer, there were a handful of frozen french fries on the floor.The outside of the six white bins holding sugar, oatmeal, thickener, bread flour, bread crumbs, and all purpose flour, had brown dirt and streaks going down the front, back and sides of the bins.The inside shelf of the deep fryer had a moderate amount of yellow crumbs on the inside… […]

• No harm, potential for more than minimal, widespreadF725Mar 28, 2025

  Based on observation, record review, and interview, the facility failed to ensure the facility was staffed to provide adequate care for the residents related to toileting and as needed pain medication. This deficient practice had the potential to affect 41 of 41 residents residing in the facility. Findings include: An observation of the 2nd floor 200 Hallways, on 3/26/25 at 7:08 p.m., indicated no staff were observed on the right-side Hallway of the 2nd floor. On the right-side Hallway of the 2nd floor five call lights were alarming, Resident H was lying on the floor in her room between her wheelchair and the bathroom doorway. The resident was yelling for help, and no staff were insight or within hearing distance. A staff member was located at 7:09 p.m. […]

• No harm, potential for more than minimal, patternF677Mar 28, 2025

  Based on interview and record review, the facility failed to provide activities of daily living (ADL) related to incontence care and personal assistance for 4 of 5 residents reviewed for ADL care. (Residents E, D, G, and C) Findings include: 1. During an interview, on 3/26/25 at 8:03 p.m., Resident E indicated she had turned her call light on for assistance to go to the bathroom and the Certified Nurse Aide (CNA) indicated she was the only one on the floor and could not help her. The resident was advised the facility did not have a walker or wheelchair for her to use at that time. After waiting over an hour the resident contacted her family member at home. The resident's family member indicated the resident called him and asked him to come and get her help. […]

• No harm, potential for more than minimal, patternF623Dec 4, 2023

  Based on record review and interview, the facility failed to ensure 2 of 5 residents or responsible parties were provided written notice of Transfer/Discharge upon transfer to an acute care facility. (Residents 10 and 14) Findings include: 1. The record for Resident 10 was reviewed on 12/1/23 at 9:37 a.m. The diagnoses included, but were not limited to, influenza due to identified novel influenza A virus with other manifestations; acute respiratory failure, unspecified whether with hypoxia or hypercapnia; chronic obstructive pulmonary disease, unspecified; and pulmonary fibrosis, unspecified. […]