Riverview Village

In the surveyor’s words

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

• Actual harm, isolatedF744Mar 4, 2025

  Based on interview and record review, the facility failed to ensure the safety of a resident (Resident C), upon return from the hospital, from a resident (Resident D) with escalating behaviors, which resulted in Resident C's head injury/concussion without loss of consciousness for 2 of 4 residents reviewed for dementia care. Findings include: 1. The clinical record for Resident D was reviewed on 3/3/25 at 11:15 a.m. The resident's diagnoses included, but were not limited to, dementia with other behavioral disturbance, anxiety, depression, and vascular dementia with agitation. The Behavior Note, dated 10/7/24 at 9:08 p.m., indicated the resident repeatedly attempted to enter the nurse's station. The resident kicked the doors, tried to hit the nurse and asked staff to fight. […]

• No harm, potential for more than minimal, isolatedF656Jul 7, 2026

  Based on interview and record review, the facility failed to ensure a resident's (Resident E) plan of care was followed for 1 of 3 residents reviewed for implementation of care plans. Findings include:The clinical record for Resident E was reviewed on 7/6/22 at 10:22 a.m. The resident's diagnoses included, but were not limited to, dementia (cognitive decline) with mood disturbance, epilepsy (chronic brain disorder characterized by recurring, unprovoked seizures) and osteoarthritis. The care plan, dated 7/15/22, indicated the resident was at risk for falls and required two staff member assistance with transfers using a full body mechanical lift. […]

• No harm, potential for more than minimal, isolatedF689Jul 7, 2026

  Based on observation, interview and record review, the facility failed to ensure a resident (Resident E) was properly placed in bed to prevent a fall for 1 of 3 residents reviewed for accidents. Findings include:The clinical record for Resident E was reviewed on 7/6/26 at 10:22 a.m. The resident's diagnoses included, but were not limited to, dementia (decline in cognitive abilities, such as memory, thinking and reasoning) and osteoarthritis (degenerative joint disease that results from breakdown of joint cartilage and underlying bone). During an observation, on 7/6/26 at 3:00 p.m., the resident was observed resting in her bed with her eyes open and the call light was in reach. The resident was lying towards the left side with both knees drawn up towards her abdomen. […]

• No harm, potential for more than minimal, isolatedF842Jul 7, 2026

  Based on interview and record review, the facility failed to ensure a resident's (Resident E) fall was accurately documented for 1 of 3 residents reviewed for medical records. Findings include:The clinical record for Resident E was reviewed on 7/6/26 at 10:22 a.m. The resident's diagnosis included, but was not limited to, dementia (cognitive decline). A progress note, dated 6/27/26 at 11:53 p.m., indicated CNA 5 called LPN 4 into the resident's room to assess the resident due to a fall. CNA 5 stated that she sat the resident up onto the side of the bed. CNA 5 turned to grab something. When CNA 5 turned back around, the resident rolled off the bed and onto the floor before CNA 5 could stop her. […]

• No harm, potential for more than minimal, isolatedF842Nov 20, 2025

  Based on interview and record review, the facility failed to ensure residents' (Resident C and Resident F) medication administration accurately reflected the administration of narcotic pain medication for 2 of 3 residents reviewed for medical records. Findings include:1.The clinical record for Resident C was reviewed on 11/20/25 at 11:40 a.m. The resident's diagnoses included, but were not limited to, restless leg syndrome, depression and osteoarthritis. The physician's order, dated 5/19/25, indicated the resident was to receive Tramadol (narcotic pain medication) 50 mg (milligrams) every 6 hours for pain at 8:00 a.m., 2:00 p.m., 8:00 p.m. and 2:00 a.m. […]