River Terrace Health Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, isolatedF725Aug 18, 2026

  Based on interview and record review, the facility failed to ensure adequate staffing levels were maintained to meet the personal care needs related to transfers for 2 of 6 residents reviewed (Resident B and Resident A).Findings include: In a confidential interview, on 7/27/26 at 8:20 AM, the interviewee indicated the facility was extremely short staffed on Saturday, 7/25/26 and Sunday, 7/26/26. The interviewee indicated residents who required the assistance of 2 staff members had to stay in bed all day. The interviewee indicated a resident fell trying to transfer themselves to the bathroom.1. In an interview, on 8/18/26 at 2:09 PM, Resident B indicated they had to wait for a long time on July 26th to get out of bed. […]

• No harm, potential for more than minimal, isolatedF684Jul 6, 2026

  Based on interview and record review the facility failed to ensure residents received bathing at least 2 times a week (Resident B, Resident C) and physician orders were followed for 2 of 3 residents reviewed (Resident C, Resident D).Findings include:Resident B's record was reviewed on 7/6/26 at 10:43 AM. Diagnoses included type 2 diabetes mellitus and chronic obstructive pulmonary disease.Point of Care charting, dated 5/29/25 - 6/15/26, indicated Resident B did not receive bathing from 5/29/26 to 6/15/26.Nursing notes, dated 5/29/26 - 6/15/26, did not show any bathing refusals from Resident B.2. Resident C's record was reviewed on 7/6/26 at 12:24 PM. […]

• No harm, potential for more than minimal, isolatedF628Dec 4, 2025

  Based on a record review and interview, the facility failed to ensure discharge paperwork related to the bed hold policy was completed, for 1 of 3 resident reviewed. (Resident 30) Findings include: On 12/3/25 at 8:57 AM, Resident 30's record was reviewed. Medical diagnosis included Displaced intertrochanteric fracture of left femur, subsequent encounter for closed fracture with routine healing. A review of Resident 30's census list, indicated the resident was transferred out to the hospital, effective date 8/5/25 at 2:30 PM. A review of the nurse progress notes indicated the following: On 8/5/25 at 2:16 PM, the physician sent a text and gave a new order to send Resident 30 to the emergency room for hemoglobin of 5.2, resident was aware and in agreement with the plan. […]

• No harm, potential for more than minimal, isolatedF761Jan 10, 2025

  Based on observation, interview, and record review the facility failed to ensure labeling of open date for 1 of 1 carts reviewed. (Resident 29). Findings include: During an observation, on 01/07/25 at 9:38 AM, in the medication room with Qualified Medical Assistant 3 (QMA) and Registered Nurse 2 (RN), Resident 29's insulins were observed in a compartment labeled with his last name. The half full bottle of Humalog in the compartment was not labeled with an open date or any identifying information. RN 2 indicated there was no way to determine when the medication was opened, who it belionged to, and it would be discarded. A Glargine pen was labeled with an open date of 12/3/24. RN 2 indicated insulin is only good for 28 days after being removed from the refrigerator. […]

• No harm, potential for more than minimal, isolatedF842Jan 10, 2025

  Based on interview and record review the facility failed to document catheter output for 1 of 1 resident reviewed. (Resident 12) Findings include: Resident 12's record review began on 1/6/25 at 11:35AM, diagnoses included Neurospasmatic bladder. Certified Nursing Assistant (CNA) task charting indicated Resident 12 only had one entry for urinary catheter output on the following dates, times and amounts: 12/14/24 at 9:28PM 1200ml 12/21/24 at 1:59PM 901ml 12/23/24 at 9:59PM 600ml 12/25/24 at 1:59PM 1000ml 12/27/24 at 9:59PM 2001ml 12/28/24 at 9:35PM 1100ml 12/31/24 at 1:59PM 701ml 1/4/25 at 1:59PM 1000ml 1/5/25 at 7:37PM 1500ml 1/6/25 at 1:59PM 1000ml No other entries for each shift was available for review by the time of exit. […]