Riverdell Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF803May 29, 2026

  Based on observation, interview and record review, the facility staff failed to prepare and serve food in accordance with the nutritionally calculated recipes to all residents. The facility census was 47.1. Review of the facility's standardized recipe for spaghetti with meat sauce showed staff directed to use 12.5 pounds of ground beef for 50 servings of meat sauce. Observation on 05/27/26 during the lunch meal, showed [NAME] H served residents portions of spaghetti noodles and meat sauce combined. Observation showed the cook did not offer residents additional protein. During an interview on 05/27/26 at 12:31 P.M., [NAME] H said he/she prepared the spaghetti for the noon meal following the recipe for 50 servings. […]

• No harm, potential for more than minimal, widespreadF812Dec 13, 2024

  Based on observation, interview and record review, facility staff failed to ensure the dish washer machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. The facility census was 46. 1. Review of the facility's Sanitization policy, revised November 2022, showed dishwashing machines are operated according to manufacturer's instructions. General recommendations for low temperature dishwashers (chemical sanitization) are wash temperature of 120 degrees Fahrenheit (F) and final rinse with 50 parts per million (ppm) hypochlorite (chlorine). […]

• No harm, potential for more than minimal, widespreadF880Dec 13, 2024

  Based on observation, interview and record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to position an indwelling catheter of one resident (Resident #11) out of two sampled residents off the floor. The facility census was 46 1. […]

• No harm, potential for more than minimal, widespreadF656Aug 12, 2022

  Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for eleven residents (Resident #3, #25, #35, #37, #44, #45, #47, #23, #28, #31, #38) to ensure their medical and nursing needs were met. The facility census was 49. 1. Review of the facility's Care Planning - Interdisciplinary Team policy, dated September 2013, showed: -The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team; -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the residents care plan. […]

• No harm, potential for more than minimal, patternF656May 29, 2026

  Based on observation, interview and record review, facility staff failed to develop and implement a person-centered comprehensive care plan for five (Resident #2, #8, #14, #20 and #40) of twelve sampled residents. The facility census was 38. 1. Review of the facility's policy titled Comprehensive Care Plan dated May 2026, showed comprehensive, person-centered care plans are based on resident assessments and developed by an interdisciplinary team (IDT). 2. Review of Resident #2's admission Minimum Data Set (MDS), a federally mandated assessment tool, dated 04/22/26, showed staff assessed the resident as cognitively impaired. Review of the resident's care plan, dated 05/26/26, showed the care plan did not contain use of signage above the resident's bed. […]