River Valley Care Center

In the surveyor’s words

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

• Actual harm, patternF684Jan 2, 2024

  Based on interview and record review, the facility failed to provide the necessary care and services to one of three sampled residents (Resident 1) to attain or maintain Resident 1's highest practicable physical, mental, and psychosocial wellbeing in accordance with Resident 1's comprehensive assessment and plan of care when: 1. Resident 1's urinalysis (UA, a urine specimen that determines if there is a bacterial infection in the urine) was not obtained when the physician placed the order on 11/9/2023. 2. The facility failed to notify the physician that the above order was not completed. 3. […]

• Actual harm, isolatedF692Dec 7, 2021

  Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status when staff did not identify insidious weight loss (gradual, unintended, progressive weight loss over time), implement or modify a plan of care that was individualized and consistent with the resident's needs or preferences for one of four sampled residents. (Resident 19) These failures resulted in severe weight loss and put Resident 19 at risk for further health decline. Findings: Review of the policy and procedure titled, Weight Assessment and Intervention, dated 2001 and revised April 2012, indicated the Dietician will review the resident's weights, following trends over time. Negative weight trends will be evaluated by the treatment team. […]

• No harm, potential for more than minimal, widespreadF812Jun 20, 2025

  Based on observation, interview, and record review, the facility failed to ensure the kitchen was sanitary and food was stored, prepared, and distributed in accordance with food safety when: 1. The low temp dishwasher sanitizing solution did not meet manufacturer guidelines. 2. Primary handwashing skink for dietary staff was low flow and not warm. 3. Tortillas were not dated once received and were expired. 4. Dirty dishes were found placed under kitchen preparation area. 5. The lid for the dry powder thickener was kept open when not in use. 6. Thickened milk in the fridge was not dated when created. These failures had the potential to result in cross contamination and place residents at risk for developing a foodborne illness. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF841Apr 17, 2025

  Based on interview and record review, the facility failed to ensure that the Medical Director (MD) supervised the development and implementation of mitigating a scabies outbreak that effected 31 residents. This failure resulted in a six-month scabies outbreak in the facility. Findings: A review of Medical Directorship Agreement, dated 01/01/2019 indicates the MD is involved at all levels of individualized patient care and supervision, and for all persons served by the facility. The MD services as the clinician who oversees and guides the care that is provided'. […]

• No harm, potential for more than minimal, widespreadF865Apr 17, 2025

  Based on interview and record review, the facility failed to have an effective Quality Assurance Performance Improvement (QAPI - a quality management program which takes a systematic, interdisciplinary, comprehensive, and data-driven approach to maintaining and improving safety and quality) when the committee did not develop, implement, and identify performance improvement activities related to a scabies outbreak. Refer to F 880 and F 658. This resulted in 31 residents and all staff, vendors, and visitors being at risk for exposure to scabies. […]