Riverstreet Manor

In the surveyor’s words

From the most serious findings on record at Riverstreet Manor, in the surveyor’s own words.

• Actual harm, isolatedF600Oct 21, 2025

  Based on a review of clinical records, the facility's abuse prohibition policy, facility investigative documentation, and staff interviews, it was determined the facility failed to ensure that a resident was free from neglect by not providing care with the required assistance of two staff members as planned to ensure safety and prevent major injuries. As a result, one resident (Resident 1) sustained multiple subdural hematomas and closed nasal fracture requiring hospital evaluation, representing actual harm for one resident out of one sampled for abuse prohibition.Findings include: A review of the facility's policy entitled Abuse and Neglect Clinical Protocol, last reviewed by the facility on May 2, 2025, defined neglect as the failure of the facility, its employees, or service providers… […]

• No harm, potential for more than minimal, widespreadF812Apr 17, 2026

  Based on observation, review of select facility policy, and staff interviews, the facility failed to maintain sanitary conditions in the dietary department, including the main kitchen and a nursing unit pantry (Station 2), to ensure food was stored, prepared, and served in a manner that prevented contamination and microbial growth in food, which increased the risk of food-borne illness. Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF812Jan 18, 2024

  Based on observation and staff interview, it was determined that the facility failed to maintain acceptable practices for the storage and service of food to prevent the potential for contamination and microbial growth in food, which increased the risk of food-borne illness in two of two resident pantries. (Station 1 and Station 2) Findings include: Food safety and inspection standards for safe food handling indicate that everything that comes in contact with food must be kept clean and food that is mishandled can lead to foodborne illness. Safe steps in food handling, cooking, and storage are essential in preventing foodborne illness. […]

• No harm, potential for more than minimal, widespreadF800Aug 26, 2021

  Based on a review of grievances lodged with the facility, observations, staff, and resident interviews, it was determined the facility failed to ensure effective management and execution of the facility's food and nutrition department to provide consistent planned meals and professional services to meet the nutritional needs of each resident. Findings include: A review of a grievance dated June 3, 2021, indicated that Resident 1 voiced complaints to the facility about meal service. The resident relayed in her grievance that she receives hard boiled eggs for breakfast, no toast, and her hot cereal is served cold. […]

• No harm, potential for more than minimal, patternF809Apr 17, 2026

  Based on review of scheduled mealtimes, resident council meeting minutes, resident interviews, and staff interviews, the facility failed to ensure residents were consistently offered a nutritious evening snack when more than 14 hours elapsed between the substantial evening meal and breakfast the following day, for 5 of 5 residents reviewed who expressed a desire for a bedtime snack (Residents 10, 53, 9, 65, and 105).Findings include: A review of scheduled facility mealtimes revealed the interval between the substantial evening meal and breakfast exceeded 14 hours across multiple resident care areas. […]