Inspection Reports for River Ridge Nursing and Rehabilitation

The complaint investigation found that Resident #1's call light was not within reach for about 10 minutes after being transferred from wheelchair to bed, despite staff training and facility policy. The deficiency was substantiated based on observation, interview, and record review.

The facility failed to ensure Resident #1's call light was within reach, placing the resident at risk for unmet needs and accommodations. Observations and interviews confirmed the call light was left out of reach for about 10 minutes despite staff training and facility policy requiring call lights to be accessible.

The complaint investigation found that CNA A failed to follow Resident #1's care plan requiring 2-person assist during transfers and incontinent care, resulting in fractures. Immediate Jeopardy was identified on 11/08/25 and removed on 11/10/25. The facility remained out of compliance with potential for more than minimal harm. For Resident #3, the facility failed to transcribe a paper care plan documenting a fall into the electronic system, risking errors in care.

The facility failed to ensure adequate supervision and proper assistance levels for Resident #1, resulting in acute fractures due to use of 1-person assist instead of 2-person assist as required by the care plan. An Immediate Jeopardy was identified and later removed. Additionally, the facility failed to maintain accurate and complete clinical records for Resident #3 by not transcribing a paper care plan into the electronic system, potentially risking errors in care.

The complaint investigation was substantiated with findings that LVN A did not report the abuse allegation to the responsible party as required. The CNA involved was suspended immediately and terminated on 10/29/24. The responsible party was not notified promptly, contrary to facility policy.

The facility failed to implement its policies and procedures to prevent abuse and neglect by not reporting the abuse allegation to the resident's responsible party as required. The alleged abuse incident involved CNA C and Resident #39, with the CNA suspended and terminated. The resident showed no injuries and was unable to recall the incident. The facility's investigation and interviews revealed failures in timely notification to the responsible party.

The facility was found deficient in multiple areas including failure to implement abuse reporting policies, incomplete PASRR screenings for residents, failure to revise care plans timely after significant changes, unlocked medication cart, unsafe food storage and sanitation practices in the kitchen, and failure to maintain infection prevention protocols including proper PPE use during wound care.

The complaint involved failure to notify the physician of a significant change in Resident #21's condition after a fall and delayed notification of x-ray results indicating a displaced femur fracture. Immediate Jeopardy was identified on 9/18/24 and removed on 9/20/24 after corrective actions.

The facility failed to immediately notify Resident #21's physician of a displaced left femur neck fracture identified by x-ray three days after a fall. The delay in notification led to an Immediate Jeopardy situation, which was later removed. The facility also failed to develop and update a comprehensive care plan timely and accurately for Resident #21, including failure to retain DNR status and update fall-related care plans.

The complaint investigation focused on Resident #1's wound care after a fall and emergency room treatment. The facility was found to have failed in care planning, wound care documentation, pain assessment, and communication with the physician. Resident #1 was resistant to wound care but there was no documentation of resistance or physician notification.

The facility failed to develop a care plan within 48 hours addressing Resident #1's wound care needs, failed to document, monitor, and assess sutures for 5 days, and did not assess Resident #1 for pain prior to wound care. Staff lacked knowledge of the number of sutures and there was no documentation of resistance to care or notification of the physician.

The complaint investigation focused on allegations that the facility failed to provide care according to physician orders and resident preferences, specifically wound care and skin condition treatment. The investigation substantiated these concerns with findings of non-compliance in wound care procedures and skin assessments.

The facility failed to ensure wound care nurse followed doctor's orders for wound treatment for Resident #54 and failed to assess and provide treatment for redness/rash on Resident #59's forehead and scalp. Additional deficiencies included improper medication storage and labeling, incomplete temperature logs for medication and nutrition rooms, expired food items, and inadequate infection prevention practices including insufficient hand hygiene by wound care nurse.

The facility was found deficient in multiple areas including failure to ensure resident dignity regarding privacy of urinary drainage bags, improper positioning of a resident's head during enteral feeding, inaccurate meal portioning and substitutions without documentation, unsafe food temperatures, unsanitary kitchen conditions, and incomplete medical record documentation for a resident's feeding formula.