Rivers Edge Rehabilitation and Care

In the surveyor’s words

From the most serious findings on record at Rivers Edge Rehabilitation and Care, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Feb 21, 2023

  Based on interview and record review it was determined the facility failed to ensure Resident 1 was free from non-consensual sexual contact for 1 of 1 sampled resident (#1) reviewed for sexual abuse. This failure was determined to be an immediate jeopardy situation because the facility failed to investigate and report allegations of sexual abuse and follow Resident 1's care plan to ensure Resident 1's safety which resulted in physical injury and mental distress. Findings include: Resident 1 admitted to the facility in 6/2022 with diagnoses including Huntington's disease (a condition that leads to progressive degeneration of nerve cells in the brain which affects movement, cognitive functions, and emotions) and anxiety. […]

• No harm, potential for more than minimal, widespreadF679Feb 21, 2023

  Based on observation, interview and record review it was determined the facility failed to implement an ongoing resident centered activities program for 1 of 1 activity programs reviewed for activities. This placed residents at risk for decreased mental health and well-being. Findings include: Observations on 2/1/23 and 2/8/23 revealed no resident activities occurring with the exception of the resident smoke breaks. A review of the Activity Calendars form November 2022 through January 2023 revealed the following: *November 2022: Days with no resident activities: 11 Days with one game type activity 12 Days with movie only: 6 Days with 2 activities: 1 (Resident council and movie) *December 2022: Days with No activities: 12 Days with one game type activity only: 10 Days with movie only:… […]

• No harm, potential for more than minimal, widespreadF680Feb 21, 2023

  Based on interview and record review it was determined the facility failed to ensure the activities program was directed by a qualified professional for 1 of 1 Activity Directors reviewed for Activities. This placed residents at risk for a decreased sense of well-being and an increase in mental health and behavioral concerns. Findings include: A review of the November 2022, December 2022 and January 2023 Activity Calendars revealed most days had none or one group activity scheduled. On 2/8/23 at 10:50 AM Staff 24 (CNA) stated there were a lack of activities offered at the facility which led to resident boredom and an increase in resident behaviors. […]

• No harm, potential for more than minimal, patternF584Jun 5, 2026

  Based on observation, interview, and record review it was determined the facility failed to provide a clean and well-maintained homelike environment for 3 of 7 sampled residents (#s 5, 27, and 28) and 2 of 5 resident hallways reviewed for environment. This placed residents at risk for lack of a homelike environment. Findings include: 1. Resident 28 was admitted to the facility in 11/2025. On 6/1/26 at 12:10 PM, Witness 2 (Family Member) stated she/he was dissatisfied with the cleanliness and condition of Resident 28's room: the blinds were broken, there was a hole in the window frame leading directly to the outside, the floor was frequently dirty, and the resident's fall mat was dirty and sticky. […]

• No harm, potential for more than minimal, patternF812Jun 5, 2026

  Based on observation, interview and record review it was determined the facility failed to ensure kitchen staff wore appropriate hair restraints during meal preparation, provide a sanitary kitchen environment and ensure proper hand hygiene practices were followed for 1 of 1 facility kitchen reviewed for sanitation. This placed residents at risk for unsanitary foods and food-borne illness. Findings include:The facility's undated Food Preparation and Service policy indicated:-Food preparation staff are to adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illnesses.-Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. […]