Riverside Rest Home

In the surveyor’s words

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

• Actual harm, isolatedF760Aug 12, 2021

  Based on interview and record review, it was determined that the facility failed to ensure that a resident was free of significant medication error resulting in an actual harm that is not immediate where one resident became unresponsive requiring medical emergency intervention after administration of a wrong concentration of opioid infusion medication for 1 resident out of 3 residents reviewed for opioid infusion therapy. (Resident identifier is #1.) Findings include: Review on 8/12/21 of Resident #1 medical record revealed that Resident #1 was admitted on [DATE] at the facility's hospice house for continuation of hospice services related to end-stage [CONDITION(S)] ([CONDITION(S)]). […]

• No harm, potential for more than minimal, patternF726Aug 12, 2021

  Based on interview and record review, it was determined that the facility failed to ensure that licensed nurses have the specific competencies to care for resident related to opioid infusion therapy via the CADD (Continuous Ambulatory Delivery Device) pump on hospice residents for 8 out of 8 licensed nurses reviewed. (Staff identifiers are C, D, E, F,G,H,I and J.) (Resident identifier is #1.) Findings include: Review on 8/12/21 of Resident #1's physician note dated 7/25/21 revealed that that Resident #1 overdose about 27 mg of [MEDICATION(S)] per hours for almost 5 hours and that his/her clinical situation was the result of high dose of [MEDICATION(S)]. Interview on 8/12/21 at approximately 8:40 a.m. […]

• No harm, potential for more than minimal, isolatedF658Apr 8, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to follow manufacturers' instructions for medication administration in 1 of 2 insulin administration observations. (Resident identifier is #111). Findings include: Review on 4/8/2026 of the manufacturer's' instructions for Novolog solution, To avoid injecting air and to ensure proper dosing: Turn the dose selector to select 2 units. Hold your Novolog FlexPen with the needle pointing up. Tap the cartridge gently with your finger a few times to make any air bubbles collect at the top of the cartridge. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to 0 . Observation on 4/8/2026 at approximately 8:30 a.m. […]

• No harm, potential for more than minimal, isolatedF880Apr 8, 2026

  Based on interview and record review, it was determined that the facility failed to have an water management plan that included an assessment and control measures to identify and prevent the growth and spread of Legionella and other opportunistic waterborne pathogens in a facility with a census of 164 residents. Findings include: Interview on 4/8/2026 at approximately 9:50 a.m. with Staff C (Infection Preventionist) revealed that he/she monitors the facility for empty rooms and flushes them on a weekly basis. Staff C was not able to provide a water management plan. Interview on 4/8/2026 at approximately 10:30 a.m. […]

• No harm, potential for more than minimal, isolatedF658Feb 12, 2025

  Based on observation, interview, and record review, it was determined that the facility failed to follow professional standard for 1 of 7 residents observed for medication administration (Resident identifier is #84). 38218 Findings include: [NAME], [NAME] A., and [NAME]. Clinical Nursing Skills & Techniques. 10th ed. St. Louis, Missouri: Elsevier, 2022, page 602, .Medication Administration: .3. Stay with the patient until the medication is taken. Provide assistance as necessary. Do not leave medication at bedside without a health care provider's order . Observation on 2/12/25 at approximately 7:50 a.m. to 8:00 a.m. on Unit 5 (Dementia Unit) revealed Staff D (Licensed Practical Nurse) preparing Resident #84's morning medications and putting them in a boost drink at the medication cart. […]