Riverwood Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF578Jan 24, 2023

  Based on a review of resident records, the facility's policy and procedures, and interviews with staff, the facility failed to act in accordance with a resident's Advance Directives as per her Do Not Resuscitate (DNR) status (the desire not to be resuscitated in the event her heart or breathing stopped) after finding her unresponsive with no respirations. This affected one (Resident #1) of three residents reviewed for Advance Directives. The facility's failure to review and honor Resident #1's DNR status, prolonged her dying process, and deprived her of the right to experience a natural death. Immediate Jeopardy at a scope of J (isolated) was identified at 12:00 p.m. […]

• Immediate jeopardy, isolatedF678Jan 24, 2023

  Based on a review of resident records, the facility's policy and procedure for Emergency Care/CPR (Cardio-pulmonary resuscitation), facility reports and staff interviews, the facility staff failed to withhold cardiopulmonary resuscitation (CPR) per the resident's Do Not Resuscitate Order (DNRO) and Advanced Directives, when she was discovered unresponsive and without a pulse or respirations. CPR was initiated by facility staff, and Emergency Medical Services (EMS) was called. This affected one (Resident #1) of three residents reviewed for Advance Directives. […]

• Actual harm, isolatedF676Jan 9, 2025

  Based on observations, interviews, and record review, the facility failed to provide restorative nursing therapy to ensure that a resident's abilities in activities of daily living did not diminish for two (Residents #193 and #56) of two residents reviewed for the dining restorative program, from a total of 11 residents participating in the dining restorative program, in a total survey sample of 56 residents. The 11 residents on the dining restorative program were at risk of further decline. Resident #193 suffered a significant weight loss. The findings include: 1. During the dining observation on 01/06/25 at 11:50 AM, Resident #193 was observed seated at the dining table in the Caring Way unit. She was served a mechanical soft meal on a regular plate. […]

• No harm, potential for more than minimal, widespreadF804Feb 2, 2023

  Based on interviews, record review, and policy and procedure review, the facility failed to ensure that resident meals were served at a safe and appetizing temperature, for five (Residents #478, #467, #104, #31, and #184) out of 55 sampled residents. Failure to provide palatable, attractive, and appetizing food in accordance with professional standards for food service, can decrease the amount of food all residents eat and drink. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline. […]

• No harm, potential for more than minimal, widespreadF882Apr 18, 2022

  Based on interviews and record review, the facility failed to employ a qualified Infection Control Preventionist (ICP) who worked at least part time and who completed specialized training in infection prevention and control. The findings include: On 4/18/22 at 11:00 AM, an interview was conducted with the Director of Nursing (DON) regarding infection control. The DON informed the survey team that the facility did not have an ICP. The Regional Nurse Consultant (RNC) was the interim ICP. When asked if she had completed the infection control training. The DON replied, No, I started the training but never finished it. During an interview with the RNC on 4/18/22 at 2:00 PM, she confirmed she was the current interim ICP and there were no other staff in the facility with IC training. […]