Riverside Health & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Riverside Health & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Aug 1, 2023

  Based on clinical record reviews, review of facility documentation, review of the ambulance run sheet, review of facility policy and interviews, for one of three sampled residents (Resident #1) who had a diagnosis of difficulty swallowing and a recent history of aspiration, the facility failed to implement aspiration precautions and one (1) to one (1), supervision during meals, the resident experienced a choking episode, and required emergency intervention. As a result Immediate Jeopardy was identified. The finding includes: Resident #1's diagnoses included dysphagia (difficulty swallowing), cognitive communication deficit, mild cognitive impairment, acute respiratory failure with hypoxia, and cardiac arrest due to underlying cardiac condition. […]

• Actual harm, isolatedF684Aug 6, 2026

  Based on review of the clinical record, facility documentation/policy, and interviews for one (1) of three (3) sampled residents (Resident #1) reviewed for skin impairments, the facility failed to ensure changes in the resident's skin condition were identified, reported, and evaluated in accordance with facility policy. Multiple NAs observed bruising and swelling to the resident's right groin and upper inner thigh beginning on the day of admission and on multiple subsequent dates but failed to report the findings to licensed nursing staff. Additionally, the licensed nurse responsible for the weekly Skin Check on 7/9/26 signed the assessment as complete despite not visualizing the right inner thigh and groin area. […]

• Actual harm, isolatedF689Apr 16, 2025

  Based on review of the clinical record, facility documentation, facility policy and interviews for one (1) of three (3) residents (Resident #2) reviewed for accidents, the facility failed to ensure the resident received supervision assistance during mealtime in accordance with the plan of care which resulted in a choking incident. The findings include: Resident #2 's diagnoses included hemiplegia (severe or complete loss of strength or paralysis on one side of the body) and hemiparesis (muscle weakness or partial paralysis on one side of the body) following a cerebral infarction (death of brain tissue/stroke) affecting the right dominant side, dysphagia (difficulty swallowing), aphasia (language disorder), apraxia (motor disorder), epilepsy and dementia without behavioral disturbances. […]

• Actual harm, isolatedF686Jan 10, 2024

  Based on observations, clinical record review, facility documentation review, facility policy review, and interviews for two of four residents (Resident #177 & #69) who were at high risk for the development of pressure ulcers and who developed facility acquired pressure ulcers, the facility failed to ensure that resident specific comprehensive interventions were implemented, failed to assess the wound in a timely manner inclusive of description, measurements, and stage upon initial discovery of an opened area, and failed to provide consistent turning and repositioning to offload the sacrum contributing to the advanced worsening of the wound. The findings include: 1. […]

• Actual harm, isolatedF689Jan 10, 2024

  Based on clinical record review, facility documentation review, facility policy review, and interviews for one of two sampled residents (Resident #199) reviewed for falls, the facility failed to appropriately monitor the placement of a pelvic positioning belt on an adaptive wheelchair to ensure safety, leading to a subsequent fall that resulted in an injury. The findings include: Resident #199 's diagnoses included fifth lumbar vertebra fracture, left femur fracture, low back pain and abnormal posture. […]