Riverwood Healthcare & Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, isolatedF600Jul 26, 2023

  Based on staff interviews, resident record review, hospital record review, and review of the facility's policies and procedures, the facility failed to ensure residents were free from medical neglect when the facility staff failed to provide adequate supervision when Resident #1 was left outside, inadequately supervised on the facility patio during weather conditions with outside temperatures of 93 degrees Fahrenheit for 3 hours and 31 minutes. The facility's failure to provide supervision for Resident #1 resulted in Resident #1 being found by another resident and brought inside the facility. Resident #1 was found unresponsive, CPR (Cardiac Pulmonary Resuscitation) was initiated, and the resident was transported to the hospital. […]

• Immediate jeopardy, isolatedF689Jul 26, 2023

  Based on staff interviews, resident record review, hospital record review, and review of the facility's policies and procedures, the facility failed to ensure residents were provided adequate supervision when Resident #1 was left outside, inadequately supervised on the facility patio during weather conditions with outside temperatures of 93 degrees Fahrenheit for 3 hours and 31 minutes. The facility's failure to provide supervision for Resident #1 resulted in Resident #1 being found by another resident and brought inside the facility. Resident #1 was found unresponsive, CPR (Cardiac Pulmonary Resuscitation) was initiated, and the resident was transported to the hospital. Resident #1 suffered from cardiac arrest, hyperthermia, 2nd degree burns and had a body temperature of 108.5 Fahrenheit. […]

• Immediate jeopardy, isolatedF835Jul 26, 2023

  Based on staff interviews, resident record review, hospital record review, and review of the facility's policies and procedures, the facility administration failed to use its resources effectively and efficiently to attain and maintain the highest practicable wellbeing of each resident by failing to ensure residents were provided adequate supervision when Resident #1 was left outside, inadequately supervised on the facility patio during weather conditions with outside temperatures of 93 degrees Fahrenheit for 3 hours and 31 minutes. The facility's failure to implement systemic interventions to protect residents from extreme weather conditions resulted in Resident #1 being found by another resident and brought inside the facility. […]

• No harm, potential for more than minimal, widespreadF761Jul 28, 2021

  Based on observation, interview, and record review, the facility failed to ensure the drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles in 4 of 4 medication carts. Findings: Observation of Medication Cart #1 on [DATE] at 9:10 AM with Staff C, Licensed Practical Nurse (LPN), showed one plastic cup with 67 white tablets that were labeled as NaCl (Sodium Chloride), one opened multidose vial of [MEDICATION(S)] 1% with no pharmacy packaging, resident identifier or opened date, two vials of [MEDICATION(S)] 1 gram with no pharmacy packaging or resident identifier, one opened [MEDICATION(S)] flex pen with no opened or expiration dates, one opened [MEDICATION(S)] flex pen and one opened Regular insulin with no opened or… […]

• No harm, potential for more than minimal, widespreadF812Jul 28, 2021

  Based on observation, record review, and interview, the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for food service safety. Findings: An observation during an initial tour of the facility on 7/25/2021 beginning at 9:20 AM with the Cook/Designee, and a second tour with the Administrator on 7/25/2021 at 10:30 AM, showed the following: Food preparatory area: two uncovered 50-gallon trash barrels in the food preparation area with trash in them; two cardboard boxes approximately 36 inches tall, against the side of the lit gas stove; a bag of thawed pancakes sitting on the table; after breakfast service, spice tray with lids not on containers, spilled spices on the tray, dirty utensils, Styrofoam container of breakfast food… […]