Riverside Health Services

In the surveyor’s words

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

• Immediate jeopardy, isolatedF686Mar 5, 2025

  On 03/03/25, an Immediate Jeopardy (IJ) situation was determined to exist related to the facility's failure to have a system in place to ensure dependent residents were repositioned every two hours to prevent new and worsening pressure ulcers. On 03/03/25 at 6:00 pm, the OSDH was notified and verified the existence of the IJ situation. On 03/03/25 at 6:15 p.m., the facility administrator and DON were notified of the IJ situation and provided a copy of the IJ template. On 03/05/25 at 10:06 a.m., an acceptable plan of removal was submitted to the OSDH. The plan of removal, read in part, 1. DON/Designee Completed 100% Care Plan Audit to ensure Interventions are in place to prevent further Skin Breakdown on 3/3/25 and 3/4/25. 2. […]

• Actual harm, isolatedF580Mar 13, 2026

  Based on observation, record review, and interview, the facility failed to immediately notify the physician of a pressure ulcer for 1 (#1) of 3 sampled residents reviewed for a physician notification of a resident change in condition. The administrator identified 48 residents resided in the facility. Findings: On 03/10/26 at 11:55 a.m., the ADON was observed to provide wound care for Resident #1. The resident had a pressure ulcer to the coccyx area. Resident #1 was observed to be lying on an air mattress. […]

• Actual harm, isolatedF686Mar 13, 2026

  Based on observation, record review, and interview, the facility failed to prevent the development/worsening of pressure ulcers for 1 (#1) of 3 sampled residents reviewed for pressure ulcers. The ADON identified eight residents who currently had pressure ulcers. Findings: On 03/10/26 at 11:55 a.m., the ADON was observed to provide wound care for Resident #1. The resident had a pressure ulcer to the coccyx area. Resident #1 was observed to be lying on an air mattress. An undated Wound Treatment Management policy, read in part, Wound treatment will be provided in accordance with physician orders, including the cleansing method, type of dressing, and frequency of dressing changes. The baseline care plan, dated 11/21/25, showed Resident #1 currently had skin integrity issues. […]

• No harm, potential for more than minimal, widespreadF640Dec 29, 2022

  Based on record review and interview, the facility failed to ensure resident assessments were submitted to CMS within 14 days of completion for 40 of 40 residents. The Resident Census and Conditions of Residents, dated 12/29/22, documented a census of 40 residents. Findings: The MDS Completion and Submission Timeframes policy, dated July 2017, read in parts, Our facility will conduct and submit resident assessments in accordance with current federal and state submission timeframes .The assessment coordinator .is responsible for ensuring that resident assessments are submitted to CMS' QIES Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines . […]

• No harm, potential for more than minimal, widespreadF888Dec 29, 2022

  Based on record review and interview, the facility failed to ensure vaccination records for contract staff were kept and facility staff were fully vaccinated, had been granted an exemption or were delayed from the COVID-19 vaccine for 16 of 61 facility staff members. This resulted in a facility staff vaccination rate of 57%. The COVID-19 Vaccination Status for Providers documented 61 facility staff members. The Administrator had no records of how many contracted staff worked in the facility. Findings: An undated Covid-19 Vaccine Policy read in parts, All employees of Riverside Health Services will have received at a minimum of one dose of the covid-19 vaccine (Moderna or Pfizer) or their one dose of [NAME] vaccine by February 14, 2022. […]