River Valley Healthcare & Wellness Centre, LP

In the surveyor’s words

From the most serious findings on record at River Valley Healthcare & Wellness Centre, LP, in the surveyor’s own words.

• Actual harm, isolatedF686Dec 9, 2021

  Based on observation, interview, and record review, the facility failed to evaluate, assess, and provide wound care treatments to three of eight sampled resident's (Residents 37, 42, and 211). The facility also failed to use professionally recognized standards for documenting, and staging pressure injuries. These failed practices resulted in the developing of new, or worsening of existing pressure injuries (wounds caused by unrelieved pressure on the skin) for these residents, which could lead to negative clinical outcomes. […]

• Actual harm, isolatedF692Dec 9, 2021

  Based on interview, and record review, the facility failed to ensure that two of 22 sampled residents (Residents 37, and 47), whose weights were not within acceptable parameters of nutritional status, received adequate evaluations, interventions, and monitoring. These failures resulted in significant weight loss for these residents, and had the potential to lead to a decline in their overall health condition. Findings: The facility's policy titled, Evaluation of Weight and Nutritional Status, dated 1/19, was reviewed, and indicated that its purpose was to ensure that residents maintain acceptable parameters of nutritional status through evaluation of their weight and diet. […]

• Actual harm, isolatedF689Feb 23, 2021

  Based on interview, and record review, the facility failed to provide supervision and safety interventions for one of three residents (Resident 1) at high risk for wandering, and elopement (leaving the facility without permission). As a result of this failure, Resident 1 left the facility without staff being aware and fell out of his wheelchair, into the street where he was found by a passerby who alerted the staff. Resident 1 sustained facial, nasal (nose), and head injuries, and was taken to a nearby hospital where he died a few days later. Findings: Resident 1's record was reviewed, and indicated that he was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. […]

• No harm, potential for more than minimal, widespreadF851May 21, 2026

  Based on interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS).This failure has the potential for nursing homes to have inadequate staffing to care for residents and can lead to adverse clinical outcomes. Findings:During a concurrent interview and record review on 5/18/26 at 9:30 am, with the Administrator (ADM), the PBJ reporting data was reviewed, the PBJ indicated the CASPER report 1705D fiscal year Quarter 1, 2026 (October 1 - December 31), was not submitted for that quarter. ADM confirmed the report was not submitted due to their corporation having computer issues and they could not submit the PBJ report on time. […]

• No harm, potential for more than minimal, patternF577May 21, 2026

  Based on observation, interview, and policy review the facility did not protect the rights of all residents of the facility to access and review the results of the most recent recertification survey (a recertification survey is an evaluation of the facility to ensure they are compliant with federal regulations, clinical quality, and operational standards so they can continue to receive Medicare/Medicaid reimbursement) of the facility.This failure resulted in residents of the facility not knowing where to find the results to review.Findings:Review of a facility policy titled, Resident [NAME] of Rights, dated 5/2011, indicated (g) Examination of survey results. […]