Riverside Commons Rehab and Nursing Center, LLC

In the surveyor’s words

From the most serious findings on record at Riverside Commons Rehab and Nursing Center, LLC, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 24, 2026

  This citation pertains to intake 3034793.Based on observation, interview and record review, the facility failed to lock one resident's bed and failed to stop repositioning a resident at their request during a brief change for one (R504) of three residents reviewed for falls, resulting in R504 falling from the bed, injuring their head and knee with subsequent hospitalization related to a fracture.Findings include:A review of an intake submitted to the State Agency revealed the following: Complainant (Family Member A) states that (R504) fell about two weeks ago, maybe longer. (Family Member A) states the aide (Certified Nurse Aide), (CNA D) was changing (R504) brief, rolled (R504) over, the bed wasn't locked so (R504) rolled to the floor. […]

• Actual harm, isolatedF686Mar 27, 2026

  This citation pertains to intake 2961759.Based on interview and record review, the facility failed to implement interventions and skin treatments as prescribed to prevent the development or worsening of pressure ulcers for two (R703 and R708) of five residents reviewed for pressure ulcers resulting in R703 and R705 developing stage 3 pressure ulcers (total loss of skin, exposing fatty tissue) to the coccyx area while in the facility.Findings include:The State Agency received a complaint that R708 developed a pressure ulcer at the facility.R708:According to R708's closed Electronic Health Record (EHR), R708 re-admitted to the facility on [DATE] with multiple diagnoses that included surgical repair in the cervical region of C3-C6, diabetes, and metabolic encephalopathy. […]

• Actual harm, isolatedF689Feb 29, 2024

  Based on observation, interview, and record review the facility failed to ensure a safe wheelchair transport for one (R15) of seven residents reviewed for accident hazards, resulting in a fracture with subsequent wound, pain, and decreased activities of interest due to the inability to participate. Findings include: On 2/27/2024 at 9:58 AM R15 was observed in bed wearing a hospital gown. R15's heel boots were observed on R15's wheelchair. When R15 was asked the purpose of the heel boots, R15 stated, The boots are for my feet when I sit in my wheelchair, so my feet don't slip off the footrests. When asked have your feet slipped off the foot rests, R15 replied, Yes I broke a bone and now I can't get up. My ankle hurts. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2026

  Based on observation, interview, and record review, the facility failed to maintain best practices in the food service area and maintain cleanliness of ice machines resulting in the potential to spread food borne illness to all residents that consume food from the kitchen. Findings Include:On 04/07/2026 at 9:17 AM observed a container with unidentified food inside and no date or label in the main walk-in cooler. Dining Director (DD) A removed the bin to be labeled.According to the 2022 FDA Food Code section 3-501.17 Ready-to-Eat, Time/Temperature Control for Safety Food, Date Marking. […]

• No harm, potential for more than minimal, widespreadF812Mar 19, 2025

  Based on observation, interview, and record review, the facility failed to: 1. Properly clean and sanitize a thermometer stem prior to insertion into prepared food; 2. Ensure items stored in resident refrigerators were properly labeled with resident's name and expiration date; 3. Ensure pans were properly cleaned and allowed to air dry before stacking. These deficient practices had the potential to affect all the residents who consumed food from the kitchen, resulting in the increased likelihood for food borne illness. […]