Riverview Care Center

In the surveyor’s words

From the most serious findings on record at Riverview Care Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF658Jun 18, 2025

  Based on record review and interviews the facility failed to provide services that met professional standards for 1 (#1) of 3 (#1, #2 and #3) sample residents reviewed for impaired cognition and at risk of elopement. S3LPN (licensed practical nurse) failed to implement elopement precautions for Resident #1 when the admission elopement screening completed by S3LPN indicated Resident #1 was at high risk of elopement. The deficient practice resulted in an Immediate Jeopardy on 06/06/2025 at approximately 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. […]

• Immediate jeopardy, isolatedF689Jun 18, 2025

  Based on record review and interviews the facility administration failed to have an adequate system in place to ensure adequate supervision for 1 (#1) of 3 (#1, #2, and #3) sampled residents reviewed for impaired cognition and at risk of elopement. The deficient practice resulted in an Immediate Jeopardy on 06/06/2025 at approximately 5:55 p.m. when Resident #1, a severely cognitively impaired resident who was ambulatory, was unsupervised and eloped from the facility. Resident #1 was found to be an elopement risk upon admission to the facility on [DATE] when S3LPN (licensed practical nurse) completed an elopement risk assessment. […]

• Actual harm, isolatedF689Apr 23, 2026

  Based on record reviews and interviews, the facility failed to ensure a resident received adequate assistance to prevent accidents for 1 (#1) of 3 residents reviewed for transfers by failing to follow Resident #1's plan of care. The deficient practice resulted in actual harm for Resident #1 on 04/08/2026 when Resident #1 was transferred from a wheelchair to a bed without utilization of a mechanical lift. Resident #1's care plan indicated she was totally dependent in transferring with the use of a mechanical lift and two person assist. S4CNA reported Resident #1, sitting in her wheelchair, wrapped her arms around CNA's waist area, S4CNA put her arms under Resident #1's arms, lifted Resident #1 and transferred Resident #1 to her bed. […]

• Actual harm, isolatedF689Sep 13, 2023

  Based on observations, record review and interviews the facility failed to ensure 1 (#28) of 5 (#21, #28, #43, #44, #103) residents reviewed for accidents received necessary care to prevent accidents/falls. The deficient practice resulted in actual harm for Resident #28 on 06/12/2023 at 10:30 a.m. when Resident #28 suffered a major injury during a transfer from the bed to the shower chair. S6 CNA (Certified Nursing Assistant) and S7 CNA transferred Resident #28 without using a lift. S6 CNA and S7 CNA lowered Resident #28 to the floor when the shower chair slid out from under Resident #28. S6 CNA noticed Resident #28 was sitting on the floor with her legs folded under her. Resident #28 was transported to the emergency room (ER) on 06/12/2023 at 10:58 p.m. […]

• No harm, potential for more than minimal, patternF644Dec 10, 2025

  Based on record review and interviews, the facility failed to refer a resident with newly evident or possible severe mental disorder, intellectual disability, or a related condition to the appropriate state agency for a Level II PASARR evaluation for 1 (#10) of 1 resident reviewed for PASARR. Findings: Review of Resident #10's medical record revealed a readmission date of 11/15/2023 with a diagnosis of dementia without behavioral disturbance. Further review of Resident #10's diagnoses revealed in part, a diagnosis of Bipolar Disorder with a diagnosis date of 02/04/2025. Review of Resident #10's Level I PASARR screen and determination record dated 03/27/2023 revealed Resident #10 was not suspected to have or had ever been diagnosed with a mental illness. […]