Riverside Manor NRSG & Rehab CTR

In the surveyor’s words

From the most serious findings on record at Riverside Manor NRSG & Rehab CTR, in the surveyor’s own words.

• Actual harm, isolatedF689Apr 24, 2026

  Based on record review, review of therapy records, review of the facility's investigation, review of employee conference reports, and interviews with resident(s), family, and staff, the facility failed to ensure a resident was transferred safely following physical therapy recommendations. This resulted in Actual harm on 04/12/26 when Resident #1 was improperly transferred resulting in a fractured arm. This affected one (#1) of three residents reviewed for accidents and injuries.Findings include:Medical record review revealed Resident #1 was originally admitted to the facility 05/06/25 and re-admitted on [DATE] with diagnoses that included displaced fracture of base of neck of right femur, nondisplaced fracture of surgical neck of right humerus, anemia, orthopedic aftercare, restless legs,… […]

• No harm, potential for more than minimal, widespreadF926Jan 30, 2025

  Based on observation, interview with staff, and review of the facility policy, the facility failed to maintain a safe and clean environment free from discarded cigarette butts in the resident smoking area. This had the potential to affect all residents residing in the facility. The facility census was 62. Findings include: Observation on 01/27/25 at 11:15 A.M. the resident smoking area with Housekeeper #201 revealed several cigarette butts on the concrete pad under the awning and in the stones by the building where the residents smoked. There were several leaves laying around the area which could catch on fire. Interview on 01/27/25 at 11:20 A.M. with Housekeeper #201 confirmed the cigarettes were not discarded properly in the fireproof container. […]

• No harm, potential for more than minimal, patternF761Aug 13, 2026

  Based on observation, policy review and interview, the facility failed to dispose of opened insulin pens in accordance with manufacturer instructions and failed to consistently monitor medication refrigerator temperatures. This affected 14 residents (#2, #3, #4, #7, #10, #24, #30, #31, #41, #46, #50, #54, #58, and #69) of 47 residents who resided on the 200, 300 and 400 hallways. The facility census was 63. Findings include:1.On 08/11/26 at 2:31 P.M., observations of the 400 hall medication cart with Registered Nurse (RN) #138 revealed an opened humalog insulin pen for Resident #58 which was opened on 07/02/26. On 08/11/26 at 2:31 P.M., RN #138 verified Resident #58's humalog insulin pen had been opened 07/02/26 per the label. […]

• No harm, potential for more than minimal, patternF641Jun 30, 2022

  Based on record review and interview the facility failed to ensure Minimum Data Set (MDS) assessments were accurate. This affected four residents (#40, #6, #37, and #4) of four reviewed for accuracy of MDS assessments. The facility census was 62. Findings include: 1. Review of the medical record for Resident #40 revealed an admitted [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the quarterly MDS assessment dated [DATE] revealed the resident had severe cognitive impairment. The assessment indicated a wander/elopement alarm was not used and wandering was not exhibited. Review of the progress notes 05/13/22 at 2:04 P.M., 05/16/22 at 3:58 P.M., 05/17/22 at 3:40 P.M., 05/17/22 at 4:09 P.M., 05/18/22 at 4:13 P.M., and 05/18/22 at 9:42 P.M. […]

• No harm, potential for more than minimal, patternF880Jan 13, 2021

  Based on Centers for Disease Control (CDC) guidance, facility policy and procedure for employee screening, facility employee screening records, employee time punches and staff interviews, the facility failed to ensure COVID-19 employee signs and symptoms screening protocols were properly implemented. This had the potential to affect seven residents (Resident #5, #12, #25, #39, #42, #44, and #50) residing on the memory care unit. The facility census was 58. Finding include: Review of the COVID-19 staff screening logs revealed State Testing Nursing Assistant #301 was screened on 01/07/21 and she answered no to all the screening questions and her temperature was 97.3 Fahrenheit (F). On 01/09/21, STNA #301 answered yes to cough and shortness of breath and her temperature was 97.5 F. […]