Riverview Estates

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Mar 20, 2025

  The facility had a census of 23 residents. The sample size included 12 residents, with 12 residents reviewed for neglect. Based on record review and interview, the facility failed to prevent the neglect of Resident (R) 26, when staff failed to timely and competently assess and provide care for R26, who had a known history of sepsis (a life-threatening systemic reaction that developed due to infections which cause inflammation throughout the entire body). On 01/05/25 at 06:58 PM, R26 struggled to talk and drink liquids. Licensed Nurse (LN) H contacted the on-call physician and reported R26 acted similar to the last time R26 was septic. […]

• Actual harm, isolatedF600Jun 2, 2025

  The facility identified a census of 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 and R1 remained free from verbal and mental abuse. This placed R2 and R1 at risk for continued abuse, embarrassment, humiliation, and decreased quality of life due to impaired psychosocial well-being. Findings included: - R2 ' s Electronic Medical Record (EMR) documented R2 had diagnoses of multiple sclerosis (MS- progressive disease of the nerve fibers of the brain and spinal cord), anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear), depression (a mood disorder that causes a persistent feeling of sadness and loss of interest),… […]

• Actual harm, isolatedF689Feb 14, 2023

  The facility identified a census of 30 residents with three residents reviewed for falls. Based on record review and interview, the facility failed to follow Resident (R) 1's care plan and provide her with the correct supervision resulting in a fall with injury. On 01/05/23 at approximately 07:50 AM, Certified Nurse Aide (CNA) M assisted R1 to the toilet and placed all of R1's clothing in the bathroom with her, and then shut the curtain to the bathroom. R1 reached down to pick up a sock on the floor, fell to her left side, sustained skin tears to her left hand and elbow, a minimally displaced zygomatic arch (the bone that forms the prominent part of the cheek and the outer side of the eye socket) fracture (broken bone), and soft tissue swelling overlying the left orbit (the socket of the… […]

• No harm, potential for more than minimal, widespreadF812Mar 20, 2025

  The facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to properly date opened bags of food with the open date and the expiration date. This practice placed the 23 residents at risk for foodborne illness and poor-quality food. Findings included: - On 03/13/25 at 08:20 AM, an inspection of the facility kitchen cold storage revealed the #4 upright freezer had seven opened, undated bags of frozen vegetables and potato items. The #5 freezer contained an opened box of hamburger patties with the plastic bag open to the air and undated. On 03/13/25 at 08:20 AM, Dietary Staff BB verified the bags were undated or the date was not readable. […]

• No harm, potential for more than minimal, widespreadF880Mar 20, 2025

  The facility had a census of 23 residents. The sample size included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R) 13 who had Influenza A (a contagious viral infection of the nose, throat and lungs that is spread from person to person through respiratory droplets). This placed the residents at increased risk for infection. Findings included: - On 03/13/25 at 09:30 AM, observation revealed License Nurse (LN) I entered the room of R13, who was on Droplet Precautions EBP. […]