8 CMS Surveys
Inspection Report — Mar 27, 2025
Renewal
Date: Mar 27, 2025
Visit Reason
The survey was a renewal inspection to assess compliance with licensing requirements and professional standards.
Findings
The facility failed to ensure safe medication administration, proper use of lifts, dietary staff hygiene, and infection control practices. These deficiencies caused temporary harm to residents and posed risks to resident safety and sanitation.
Deficiencies (6)
F 0554 Allow residents to self-administer drugs if determined clinically appropriate: the facility failed to ensure an interdisciplinary team assessed resident #6's ability to self-administer medication and failed to secure as-needed medication in the resident's room.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: staff member K failed to safely administer a scheduled topical medication by leaving it unsupervised on resident #6's bedside table, causing a burning sensation.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: staff member J transferred resident #6 alone using a Hoyer lift, contrary to facility policy requiring two staff members.
F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist: the facility failed to ensure safe administration of topical medication for resident #6, resulting in a burning sensation due to application of the wrong cream.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: dietary staff member I failed to wear required hair coverings and beard nets while preparing food, risking contamination.
F 0880 Provide and implement an infection prevention and control program: staff members N and L failed to wear gowns during a high-contact transfer of resident #5 who required enhanced barrier precautions.
Report Facts
Medication cup size (cc): 30
Residents sampled: 9
Residents affected by dietary issue: Many
Inspection Report — Nov 7, 2024
Renewal
Date: Nov 7, 2024
Visit Reason
Routine renewal inspection of River Ridge Rehabilitation and Nursing LLC to assess compliance with health and safety regulations.
Findings
The facility had multiple deficiencies including failure to maintain a safe and clean environment, incomplete resident assessments and care plans, inadequate infection control practices, medication management issues, insufficient staffing in dietary services, and failure to provide timely dental and immunization services.
Deficiencies (20)
F 0584 Honor the resident's right to a safe, clean, comfortable and homelike environment: the facility failed to maintain a clean environment near resident #14's bed with dried crusty brown substances on walls, floor, and privacy curtains, and housekeeping documentation was not provided.
F 0623 Provide timely notification to the resident and representatives before transfer or discharge: the facility failed to provide written notice of transfer to residents #18, #64, and #78 or their representatives.
F 0623 A facility request was made for notification of transfer discharge for resident #64 and the facility did not provide one by the end of the survey period.
F 0625 Notify the resident or representative in writing how long the nursing home will hold the resident's bed in cases of transfer: the facility failed to provide required bed hold notices to residents #18, #64, and #78 or their representatives.
F 0636 Assess the resident completely in a timely manner: the facility failed to complete the comprehensive admission MDS assessment within 14 days for resident #233, which was 76 days late.
F 0641 Ensure each resident receives an accurate assessment: the facility failed to accurately complete the admission MDS assessment for resident #8's oral status, incorrectly documenting no broken or missing teeth despite resident having no natural teeth and no dentures.
F 0656 Develop and implement a complete care plan that meets all resident needs: the facility failed to implement a comprehensive care plan addressing resident #8's dental, eating, and hearing needs.
F 0657 Develop the complete care plan within 7 days of comprehensive assessment: the facility failed to revise resident #233's care plan to reflect a mental health diagnosis of bipolar depression.
F 0680 Ensure the activities program is directed by a qualified professional: the facility employed an activity professional who did not meet minimum qualifications and was not enrolled in training.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers: the facility failed to sufficiently document and care for pressure ulcers for residents #11, #57, and #76, including missed wound assessments and missed wound care sessions.
F 0689 Ensure nursing home area is free from accident hazards and provides adequate supervision: the facility failed to secure a housekeeping closet on the Rosebud unit hallway, leaving chemicals accessible to residents.
F 0693 Ensure feeding tubes are not used unless medically necessary and provide appropriate care: the facility failed to follow physician orders for PEG tube medication administration for residents #3 and #20, including improper flushing, failure to measure total fluid volume, and failure to follow enhanced barrier precautions.
F 0699 Provide care or services that are trauma informed and culturally competent: the facility failed to complete a trauma-informed assessment for resident #8 with PTSD.
F 0727 Have a registered nurse on duty 8 hours a day and a full-time director of nurses: the facility failed to assure the Director of Nursing did not work as charge nurse when census exceeded 60 residents.
F 0761 Ensure drugs and biologicals are labeled and stored properly: the facility failed to properly label and store medications, dispose of expired medications, lock medication carts when unattended, and monitor medication refrigerator and freezer temperatures.
F 0791 Provide or obtain dental services for each resident: the facility failed to provide dental services for resident #17, including failure to schedule or track dental appointments.
F 0802 Provide sufficient support personnel for food and nutrition services: the dietary department was understaffed, resulting in late and cold meals.
F 0812 Procure food from approved sources and store, prepare, distribute, and serve food according to professional standards: the facility failed to label and date food in walk-in cooler and nutrition room refrigerators, failed to clean dirty surfaces, and failed to maintain or monitor refrigerator/freezer temperatures on Rosebud Hall.
F 0880 Provide and implement an infection prevention and control program: the facility failed to follow proper hand hygiene, isolation mask use, equipment sanitization, enhanced barrier precautions, dietary infection control, and environmental cleanliness, including a heavily soiled medication room sink and unresolved maintenance issues.
F 0921 Make sure nursing home area is safe, easy to use, clean and comfortable: the facility failed to timely repair broken curtains and windowsills in resident rooms #17 and #44, and failed to maintain a clean and functional medication room sink with multiple sanitation issues.
Inspection Report — Nov 7, 2024
Date: Nov 7, 2024
Visit Reason
The survey was conducted to assess compliance with infection prevention and immunization policies.
Findings
The facility failed to ensure the infection preventionist had the required certification and did not provide pneumococcal and Covid-19 vaccines for one resident despite documented consent.
Deficiencies (2)
F 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home: the facility failed to ensure the infection preventionist had the necessary certification for oversight of the infection control program.
F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations: the facility failed to provide pneumococcal and Covid-19 vaccines for one resident despite documented consent.
Report Facts
Residents sampled: 7
Residents missing vaccines: 1
Inspection Report — Aug 1, 2024
Complaint Investigation
Date: Aug 1, 2024
Visit Reason
The complaint investigation was prompted by multiple grievances from residents regarding neglect, abuse, failure to respond to call lights, and inadequate grievance handling.
Complaint Details
The complaint investigation revealed multiple grievances from residents about neglect, abuse, failure to respond to call lights, inadequate grievance handling, and failure to protect residents from harm. The facility also failed to timely report incidents and investigations to the State Survey Agency.
Findings
The facility failed to refund a resident representative timely, did not promptly resolve grievances, failed to protect residents from neglect and abuse, and did not timely report incidents to the State Survey Agency. Additionally, the facility failed to ensure residents were appropriately assessed for independent outside privileges, resulting in a resident leaving the facility unsupervised at night.
Deficiencies (5)
F 0582 Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered: the facility failed to refund a resident representative within 30 days of discharge.
F 0585 Honor the resident's right to voice grievances without discrimination or reprisal and establish a grievance policy: the facility failed to act promptly to resolve grievances, provide anonymous filing access, protect residents from potential abuse, and conduct thorough investigations for 6 of 17 sampled residents.
F 0600 Protect each resident from all types of abuse including neglect: the facility failed to keep residents free from neglect for 2 of 17 sampled residents, contributing to skin breakdown, psychosocial harm, and pain.
F 0609 Timely report suspected abuse, neglect, or theft and report investigation results: the facility failed to protect residents who voiced concerns, failed to report neglect allegations within 24 hours, and failed to report investigative findings within five days for multiple residents.
F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents: the facility failed to ensure residents were appropriately assessed for independent outside privileges and failed to ensure residents were inside the facility at night for 1 of 17 sampled residents.
Report Facts
Residents sampled: 17
Residents affected by neglect: 2
Residents affected by grievance failures: 6
Call light durations (minutes): 32
Call light durations (minutes): 93
Call light durations (minutes): 38
Hours resident #15 left in soiled brief: 13
Date of resident #13 elopement: 7
Inspection Report — Apr 25, 2024
Renewal
Date: Apr 25, 2024
Visit Reason
Routine renewal inspection of River Ridge Rehabilitation and Nursing LLC to assess compliance with care and staffing regulations.
Findings
The facility failed to provide necessary care and restorative services consistently due to staffing shortages and inadequate documentation. Additionally, the facility did not post required nurse staffing information daily as mandated.
Deficiencies (4)
F 0677 Administrator: the facility failed to provide care and assistance for a dependent resident, causing discomfort and distress due to staff refusal to assist with mobility and catheter care.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: the facility failed to ensure residents with limited mobility received restorative services as required, with documentation showing missed or insufficient services for four sampled residents.
F 0725 Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift: the facility failed to maintain sufficient staffing to consistently provide restorative nursing services, with the restorative aide frequently pulled to floor duties and no backup plan in place.
F 0732 Post nurse staffing information every day: the facility failed to post required daily nurse staffing information consistently, with 45 of 90 days missing postings and incomplete data on posted days.
Report Facts
Residents sampled: 19
Residents sampled for restorative services: 4
Residents receiving restorative services: 16
Admissions: 74
Days missing staff posting: 45
Restorative services frequency: 3
Inspection Report — Oct 26, 2023
Renewal
Date: Oct 26, 2023
Visit Reason
The survey was a routine renewal inspection of River Ridge Rehabilitation and Nursing LLC.
Findings
The facility had multiple deficiencies including failure to complete baseline care plans timely, inadequate bathing and personal care for residents, failure to follow physician orders for medications and feeding tubes, insufficient infection control practices, and failure to maintain required nurse staffing levels.
Deficiencies (16)
F 0578 Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive: the facility failed to formulate an advanced directive for one resident.
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident: the facility failed to notify a resident representative of significant weight loss for one resident.
F 0583 Keep residents' personal and medical records private and confidential: the nursing staff failed to provide privacy by leaving window blinds open during perineal care for one resident.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to report and investigate a bruise alleged to be caused by another individual for one resident.
F 0637 Assess the resident when there is a significant change in condition: the facility failed to complete a Significant Change MDS within 14 days of a resident's change in condition for one resident receiving hospice services.
F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted: the facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents.
F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured: the facility failed to follow care plan interventions to protect a resident's room from being entered by other residents for one resident.
F 0658 Ensure services provided by the nursing facility meet professional standards of quality: the facility failed to follow a physician's order to hold insulin for a blood glucose value less than 100 mg/dL for one resident.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide routine bathing for dependent residents for four residents.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to prevent the development of an unstageable pressure injury for one resident with wounds.
F 0692 Provide enough food/fluids to maintain a resident's health: the facility failed to monitor and follow interventions for severe weight loss for one resident.
F 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube: the nursing staff failed to follow a physician's order for continuous tube feeding administration, failed to label enteral and free water bags, and failed to consistently document intake for one resident.
F 0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis: the facility failed to have an RN scheduled for eight hours per day on multiple dates.
F 0732 Post nurse staffing information every day: the facility failed to post daily staffing numbers for the current date, leaving family and visitors uninformed.
F 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards: the facility failed to prepare food in sanitary conditions, including dirty kitchen equipment and floors.
F 0880 Provide and implement an infection prevention and control program: the facility failed to keep a foley catheter and tubing from dragging on the floor for one resident and failed to follow infection control standards by placing urine-soaked bed linens on the floor during a bed linen change for another resident.
Report Facts
Weight loss (%): 15.9
Weight (lbs): 122
Weight (lbs): 102.6
Baths: 1
Baths: 1
Insulin units: 7
Blood sugar (mg/dL): 88
Enteral formula intake (ml): 1220
Water intake (ml): 374
Inspection Report — Oct 26, 2023
Date: Oct 26, 2023
Visit Reason
The survey was conducted to assess compliance with care and notification requirements for residents.
Findings
The facility failed to notify a resident representative of significant weight loss for one resident and failed to provide routine bathing for four dependent residents as required.
Deficiencies (2)
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident: the facility failed to notify a resident representative of significant weight loss for one resident.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide routine bathing for four dependent residents, with extended intervals between showers and no documentation of bed baths during those times.
Report Facts
Weight loss percentage: 8.32
Residents sampled: 23
Residents affected: 1
Residents affected: 4
Days between showers: 25
Days between showers: 21
Days between showers: 17
Days between showers: 15
Inspection Report — Jan 5, 2023
Renewal
Date: Jan 5, 2023
Visit Reason
The survey was a renewal inspection assessing compliance with health and safety regulations.
Findings
The facility had multiple deficiencies including failure to notify representatives of health changes, incomplete restraint assessments, delayed reporting of abuse investigations, incomplete care planning, inadequate personal hygiene and bathing assistance, pressure ulcer care deficiencies, failure to provide restorative range of motion services, medication administration errors, and infection control program deficiencies.
Deficiencies (11)
F 0580 Immediately tell the resident, the resident's doctor, and a family member of situations that affect the resident: the facility failed to notify a resident's representative of changes in health status including positive COVID-19 test and severe weight loss.
F 0604 Ensure that each resident is free from the use of physical restraints unless needed for medical treatment: the facility failed to perform ongoing monitoring and documentation of the continued need for a restraint for one resident.
F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities: the facility failed to submit findings of a reportable incident to the State Survey Agency within five days.
F 0610 Respond appropriately to all alleged violations: the facility failed to provide investigation documentation for a resident-to-resident altercation.
F 0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals: the facility failed to invite a resident representative to care plan meetings.
F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable: the facility failed to provide showers or baths for six residents and failed to provide personal hygiene care for one resident as required.
F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing: the facility failed to maintain skin integrity resulting in a Stage II pressure ulcer and failed to assess, document, and provide timely wound care for multiple pressure ulcers for one resident.
F 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason: the facility failed to provide restorative ROM services as per care plan for one resident.
F 0726 Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being: the facility failed to follow physician orders for medication changes for one resident and failed to update insulin sliding scale orders for another resident, resulting in incorrect medication administration.
F 0880 Provide and implement an infection prevention and control program: the facility failed to implement transmission based precautions for one resident with C-Diff and Norovirus.
F 0882 Designate a qualified infection preventionist to be responsible for the infection prevention and control program in the nursing home: the facility failed to ensure there was a designated infection preventionist meeting regulatory requirements for a period of time.
Report Facts
Weight loss (pounds): 27.2
Shower count: 7
Shower count: 8
Shower count: 5
Personal hygiene missed days: 21
Shower count: 3
Bath count: 3
Wound dressing missed: 10
Wound dressing missed: 8
Wound dressing missed: 9
Restorative ROM sessions: 13
Medication dosage: 150
Medication dosage: 50
Sliding scale insulin duration (weeks): 6
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