Inspection Report Summary
The most recent inspection on April 2, 2025, found no deficiencies and confirmed correction of prior issues. Earlier inspections showed a pattern of deficiencies related primarily to resident abuse protections, medication management, behavioral health services, and staffing, including an Immediate Jeopardy finding in February 2025. Prior reports also noted fire safety system issues and care plan implementation problems, with some substantiated complaints mostly involving abuse and neglect concerns. Complaint investigations in recent years were largely unsubstantiated, with no enforcement actions or fines listed in the available reports. The facility appears to have made significant improvements following the February 2025 survey, as all cited deficiencies were corrected by the most recent revisit.
Deficiencies (last 8 years)
Deficiencies (over 8 years)
8.6 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
76% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
143 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Riverview Health & Rehab Center following a survey completed on April 2, 2025.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
A revisit survey was conducted on 4/2/2025 to verify correction of deficiencies cited in the 2/12/2025 Recertification Survey and to investigate complaints GA00254059 and GA00254262.
Complaint Details
Complaint Intake Numbers GA00254059 and GA00254262 were investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the 2/12/2025 Recertification Survey were found to be corrected. The complaint investigations for GA00254059 and GA00254262 were unsubstantiated with no deficiencies found.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Re-Inspection
Census: 143
Deficiencies: 0
Date: Apr 2, 2025
Visit Reason
A revisit survey was conducted on 4/2/2025 to verify correction of deficiencies cited in the 2/12/2025 Recertification Survey and to investigate two complaint intake numbers GA00254059 and GA00254262.
Complaint Details
Complaint Intake Numbers GA00254059 and GA00254262 were investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the 2/12/2025 Recertification Survey were found to be corrected. The complaint investigations for GA00254059 and GA00254262 were unsubstantiated with no deficiencies found.
Report Facts
Complaint Intake Numbers: 2
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 25, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Feb 12, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of noncompliance related to medication self-administration, resident abuse, and failure to provide necessary behavioral health services.
Complaint Details
The complaint investigation was triggered by allegations of unauthorized medication self-administration, resident-to-resident sexual abuse, employee-to-resident physical and verbal abuse, failure to investigate abuse allegations, failure to provide behavioral health services, failure to provide hygiene care, and food safety violations. Immediate Jeopardy was identified related to abuse and failure to investigate and provide behavioral health services. The facility implemented corrective actions including 1:1 supervision, notification of law enforcement and Ombudsman, reassessment and care plan updates, staff education, and policy revisions. Immediate Jeopardy was removed on 2025-02-10.
Findings
The facility failed to ensure residents did not have unauthorized medications at bedside, failed to protect residents from verbal, sexual, and physical abuse, failed to thoroughly investigate abuse allegations, failed to provide necessary behavioral health services to a resident with repeated verbal abuse and hypersexuality, failed to provide a shower or bed bath to a resident, and failed to ensure proper food labeling and staff hair restraints in the dietary department.
Deficiencies (6)
Failed to ensure two residents did not have unauthorized and unsecured medicated treatment products at the bedside.
Failed to protect residents from verbal, sexual and physical abuse, including failure to protect three residents from sexual abuse by another resident and one resident from abuse by a CNA.
Failed to thoroughly investigate allegations of abuse for two residents, including failure to report to law enforcement and complete assessments.
Failed to provide a shower and/or bed bath for one resident since admission.
Failed to ensure one resident received necessary behavioral health services to address repeated verbal abuse and hypersexuality behaviors.
Failed to ensure food stored in the main kitchen was labeled and dated, and staff wore proper hair restraints in the food prep area.
Report Facts
Residents sampled: 57
Residents affected: 2
Residents affected: 3
Residents affected: 1
Staff educated: 132
Staff educated: 18
Agency staff educated: 5
Contracted therapy staff educated: 16
Contracted therapy staff remaining: 6
Residents receiving oral diet: 52
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in physical and verbal abuse finding and investigation failure |
| LPN BB | Licensed Practical Nurse | Witnessed abuse by CNA AA and reported incident |
| LPN UM EE | Licensed Practical Nurse Unit Manager | Reported abuse incidents and communicated with DON |
| DON | Director of Nursing | Abuse Coordinator, involved in investigation and reporting failures |
| Administrator | Facility administrator involved in Immediate Jeopardy removal and policy revisions | |
| CNA UU | Certified Nursing Assistant | Confirmed medications should not be at bedside without orders |
| LPN EE | Licensed Practical Nurse | Confirmed medications should not be at bedside without orders |
| CNA PPPP | Certified Nursing Assistant | Interviewed about failure to provide bed bath |
| Dietary Manager | Confirmed food labeling and hair restraint deficiencies |
Inspection Report
Routine
Census: 161
Deficiencies: 7
Date: Feb 12, 2025
Visit Reason
A standard survey was conducted including complaint investigations related to allegations of abuse and medication self-administration concerns.
Complaint Details
Multiple complaint intake numbers were investigated. Some were substantiated with deficiencies related to abuse and neglect, including substantiated allegations of physical, verbal, and sexual abuse involving residents R30, R60, R64, and R125. Immediate Jeopardy was identified on 2/5/2025 related to these abuse incidents.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations due to multiple deficiencies including failure to protect residents from abuse, failure to investigate and report abuse allegations, failure to provide necessary behavioral health services, medication self-administration issues, and insufficient staffing. Immediate Jeopardy was identified related to abuse incidents involving residents R30, R60, R64, and R125. The facility implemented corrective actions including 1:1 supervision, staff education, policy revisions, and external consultation.
Deficiencies (7)
Failure to protect residents from physical, verbal, sexual abuse and failure to report and investigate allegations of abuse.
Failure to ensure two residents had physician orders for self-administration of medications and unsecured medications were found at bedside.
Failure to provide necessary behavioral health services to resident R64 with repeated verbal and hypersexual behaviors.
Failure to provide a shower or bed bath to resident R357 since admission.
Failure to ensure required RN coverage of at least eight consecutive hours per day, seven days per week.
Failure of administration to provide oversight and supervision to ensure residents were protected from abuse and to thoroughly investigate and report abuse allegations.
Failure to ensure food in the kitchen was labeled and dated and staff wore proper hair restraints.
Report Facts
Resident census: 161
Deficiency days without RN coverage: 7
Staff educated: 132
Staff not yet educated: 18
Agency staff educated: 5
Contracted therapy staff educated: 16
Contracted therapy staff not yet educated: 6
Resident census: 57
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Named in physical abuse incident throwing mechanical lift pad at resident R60 |
| LPN BB | Licensed Practical Nurse | Witnessed abuse incidents involving R64 and R30 |
| LPN CC | Licensed Practical Nurse | Reported sexual abuse allegations involving R64 and R30 |
| Administrator | Named in oversight failures and response to abuse allegations | |
| Director of Nursing | Named in oversight failures and response to abuse allegations |
Inspection Report
Complaint Investigation
Census: 161
Deficiencies: 9
Date: Feb 12, 2025
Visit Reason
The inspection was conducted due to complaints and allegations of abuse, neglect, and medication self-administration violations at Riverview Health & Rehab Center.
Complaint Details
The complaint investigation involved allegations of verbal, physical, and sexual abuse of residents by staff and other residents, failure to properly investigate and report abuse, failure to provide behavioral health services, and medication self-administration violations. Immediate jeopardy was identified related to these issues and was removed after corrective actions were implemented.
Findings
The facility failed to ensure residents were free from abuse including verbal, physical, and sexual abuse, failed to properly investigate and report abuse allegations, failed to provide necessary behavioral health services, failed to ensure proper medication self-administration procedures, and failed to maintain required RN coverage. Corrective actions were implemented and immediate jeopardy was removed on 2025-02-10.
Deficiencies (9)
Failed to ensure two residents had authorized and secured medications at bedside per physician orders and facility policy.
Failed to protect residents from verbal, sexual, and physical abuse, including failure to report and investigate incidents involving residents and staff.
Failed to timely report suspected abuse, neglect, or theft and report investigation results to proper authorities.
Failed to respond appropriately to all alleged violations, including thorough investigations of abuse allegations.
Failed to ensure residents did not lose the ability to perform activities of daily living unless medically indicated; one resident was not provided a shower or bed bath as required.
Failed to have a registered nurse on duty for at least eight consecutive hours per day, seven days per week, as required by policy and regulation.
Failed to ensure one resident received necessary behavioral health care and services to address repeated verbal abuse and hypersexuality behaviors.
Failed to administer the facility in a manner that enables it to use its resources effectively and efficiently, including failure of administration to provide protective oversight and take appropriate action on abuse allegations.
Failed to procure food from approved sources and ensure food was labeled and dated; failed to ensure staff wore proper hair restraints in food prep area.
Report Facts
Facility census: 161
RN coverage missing days: 7
Staff educated on abuse prevention: 132
Agency staff educated on abuse prevention: 5
Contracted therapy staff educated on abuse prevention: 16
Facility team members total: 150
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN CC | Licensed Practical Nurse | Witnessed CNA AA verbally and physically abuse resident R60 |
| CNA AA | Certified Nursing Assistant | Alleged to have verbally and physically abused resident R60 |
| LPN BB | Licensed Practical Nurse | Witnessed resident R64 kissing resident R30 and reported abuse |
| LPN UM EE | Licensed Practical Nurse Unit Manager | Reported abuse incidents involving resident R64 |
| DON | Director of Nursing | Abuse Coordinator; failed to follow up on abuse investigations and reporting |
| Administrator | Facility Administrator | Failed to provide oversight and take appropriate action on abuse allegations |
| Dietary Manager | Dietary Manager | Confirmed food labeling and hair restraint deficiencies in kitchen |
Inspection Report
Life Safety
Census: 160
Capacity: 190
Deficiencies: 2
Date: Feb 3, 2025
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, specifically related to the fire alarm system showing a ground fault trouble affecting 10 residents, and the sprinkler system having a yellow tag due to a non-working water alarm affecting five residents and staff in that area.
Deficiencies (2)
Fire alarm system was showing a ground fault trouble.
Sprinkler system had a yellow tag due to the water alarm not working.
Report Facts
Residents affected by fire alarm trouble: 10
Residents and staff affected by sprinkler system issue: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings of fire alarm ground fault trouble and sprinkler system water alarm issue during facility tour |
Inspection Report
Abbreviated Survey
Census: 161
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating three complaint allegations (GA00234566, GA00242234, and GA00231512).
Complaint Details
The complaint investigations GA00234566, GA00242234, and GA00231512 were unsubstantiated with no deficiencies cited.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations. The three complaint investigations were unsubstantiated with no deficiencies cited.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Feb 22, 2024
Visit Reason
The inspection was conducted as an annual survey of Riverview Health & Rehab Center to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met all required standards at the time of the survey.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Nov 10, 2022
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for Riverview Health & Rehab Center following a survey completed on 11/10/2022.
Findings
The document contains initial comments but does not provide detailed findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Census: 158
Deficiencies: 0
Date: Nov 10, 2022
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the September 8, 2022 Recertification Survey.
Findings
All deficiencies cited in the prior Recertification Survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 26, 2022
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited survey tags.
Findings
All previously cited survey tags have been corrected as noted by the surveyor.
Inspection Report
Routine
Deficiencies: 10
Date: Sep 8, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, catheter care, tracheostomy care, pain management, medication administration, food safety, infection prevention and control, and antibiotic stewardship at Riverview Health & Rehab Center.
Findings
The facility failed to develop and implement complete and updated care plans for residents with tracheostomy care, bilateral knee contractures, and fall interventions. Deficiencies were found in catheter care including securing catheters, appropriate orders, and maintaining privacy bags. The facility also failed to provide safe respiratory care for a resident with a tracheostomy, ensure effective pain management for a resident, properly document psychotropic medication use, maintain food safety standards, properly disinfect glucometers, and implement an effective antibiotic stewardship program.
Deficiencies (10)
Failed to implement care plan related to tracheostomy care for resident R#49.
Failed to implement care plan related to bilateral knee contractures for resident R#101.
Failed to revise care plan after falls for resident R#101.
Failed to secure catheter tubing, have appropriate diagnosis and orders, maintain catheter drainage bags off the floor, and provide urinary privacy bags for multiple residents.
Failed to provide safe and appropriate respiratory care for resident with tracheostomy (R#49).
Failed to ensure effective pain management for resident R#97 by inconsistent pain monitoring and medication adjustment.
Failed to document rationale and duration for PRN psychotropic medication beyond 14 days for resident R#14.
Failed to discard expired food items and ensure proper labeling and dating of food in kitchen and resident pantries.
Failed to properly disinfect glucometer after use and maintain infection control by administering medication dropped on the floor.
Failed to implement a program that monitors antibiotic use including periodic review and documentation of follow-up measures.
Report Facts
Residents sampled for care plans: 47
Residents affected with indwelling urinary catheters: 5
Resident census: 166
Residents receiving oral diet: 160
Residents on pain management program: 75
Residents reviewed for unnecessary medications: 5
Residents affected by infection prevention deficiencies: 172
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse AA | LPN | Verified lack of tracheostomy care plan and provided trach care without physician order |
| Resident Assessment Instrument Director FF | RAI Director | Verified lack of care plans for tracheostomy care, knee contractures, and fall interventions |
| Licensed Practical Nurse GG | LPN | Confirmed resident self-care with trach and lack of physician order for trach care |
| Certified Occupational Therapy Aide KK | COTA | Reported resident on skilled therapy caseload for limited range of motion |
| Director of Nursing | DON | Confirmed care plan deficiencies, catheter care issues, and oversight of infection control and antibiotic stewardship |
| Licensed Practical Nurse DD | LPN | Observed catheter care deficiencies and glucometer cleaning practices |
| Certified Nursing Assistant II | CNA | Reported awareness of missing catheter straps and informed nurses |
| Administrator | Confirmed suprapubic catheter issues and food pantry policies | |
| Licensed Practical Nurse BB | LPN | Discussed pain management practices and glucometer cleaning |
| Licensed Practical Nurse CC | LPN | Observed administering medication dropped on floor and lack of infection control education |
| Licensed Practical Nurse EE | LPN Infection Control Preventionist | New ICP, described infection control and antibiotic stewardship practices |
| Hospice RN JJ | RN | Reported hospice practices related to PRN lorazepam |
Inspection Report
Complaint Investigation
Census: 172
Deficiencies: 4
Date: Sep 8, 2022
Visit Reason
The inspection was a Licensure survey conducted from September 6 to September 8, 2022, to determine compliance with State Long Term Care Requirements. Complaint Intake Numbers GA00225380, GA00225470, and GA00227295 were investigated in conjunction with this licensure survey and found to be unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00225380, GA00225470, and GA00227295 were investigated and found to be unsubstantiated.
Findings
The facility failed to properly disinfect the glucometer after use, failed to maintain infection control by attempting to administer a medication dropped on the floor, and failed to implement or revise care plans appropriately for residents with tracheostomy care, bilateral knee contractures, and fall interventions. The complaints investigated were unsubstantiated.
Deficiencies (4)
Failure to properly disinfect the glucometer after use and improper storage, and failure to maintain infection control by attempting to administer a medication dropped on the floor.
Failure to implement the care plan related to tracheostomy care for one resident.
Failure to implement the care plan related to bilateral knee contractures for one resident.
Failure to revise the care plan after each fall with new or appropriate interventions for one resident.
Report Facts
Resident census: 172
Sample size: 47
Falls: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD | Licensed Practical Nurse (LPN) | Observed failing to properly disinfect glucometer and improper storage |
| BB | Licensed Practical Nurse (LPN) | Interviewed about glucometer cleaning education and practices |
| CC | Licensed Practical Nurse (LPN) | Observed attempting to administer medication dropped on floor |
| EE | Licensed Practical Nurse (LPN) Infection Control Preventionist (ICP) | Interviewed about infection control education and skill fair |
| FF | Resident Assessment Instrument (RAI) Director | Verified lack of care plans and care plan revisions for residents |
| KK | Certified Occupational Therapy Aide (COTA) | Interviewed about resident #101's therapy caseload |
| AA | Licensed Practical Nurse (LPN) | Verified absence of care plan addressing tracheostomy care |
| GG | Licensed Practical Nurse (LPN) | Reported resident #49 was self-care with trach care on admission |
| DON | Director of Nursing | Interviewed about nursing education, expectations, and care plan oversight |
Inspection Report
Annual Inspection
Census: 166
Deficiencies: 9
Date: Sep 8, 2022
Visit Reason
A standard recertification survey was conducted from September 6 through September 8, 2022, including investigation of three complaint intake numbers which were found unsubstantiated.
Complaint Details
Complaint Intake Numbers GA00225380, GA00225470, and GA00227295 were investigated and found to be unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to implement comprehensive care plans, inadequate care plan revisions after falls, improper catheter care, lack of tracheostomy care orders and documentation, ineffective pain management, improper psychotropic medication documentation, food safety violations, infection prevention and control deficiencies including glucometer disinfection and medication administration practices, and lack of an effective antibiotic stewardship program.
Deficiencies (9)
Failed to implement care plans related to tracheostomy care and bilateral knee contractures for two residents.
Failed to revise care plan after each fall with new or appropriate interventions for one resident.
Failed to secure catheter tubing, maintain appropriate catheter orders and diagnoses, and maintain catheter drainage bags off the floor for multiple residents.
Failed to provide tracheostomy care consistent with professional standards and failed to have physician orders for tracheostomy care, size, and type.
Failed to provide effective pain management by inconsistent pain monitoring and lack of medication adjustment for one resident.
Failed to document rationale and duration for PRN psychotropic medication beyond 14 days for one resident.
Failed to ensure food items were discarded after expiration and properly labeled in kitchen and resident pantries.
Failed to properly disinfect glucometer after use, improperly stored glucometer, and attempted to administer medication dropped on floor.
Failed to provide evidence of periodic review of antibiotic prescribing practices and follow-up measures for eight months of 2022.
Report Facts
Resident census: 166
Sample size: 47
Falls: 3
BIMS score: 12
BIMS score: 10
BIMS score: 1
BIMS score: 15
Missing pain assessments: 14
PRN lorazepam administrations: 14
Expired food items: 7
Months with no antibiotic stewardship data: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| FF | Resident Assessment Instrument (RAI) Director | Verified lack of care plans for tracheostomy and knee contractures |
| AA | Licensed Practical Nurse (LPN) | Verified no care plan for tracheostomy care |
| GG | Licensed Practical Nurse (LPN) Unit Manager | Confirmed catheter securing devices missing and lack of diagnosis/orders |
| DD | Licensed Practical Nurse (LPN) | Observed glucometer use without proper disinfection |
| EE | Licensed Practical Nurse (LPN) Infection Control Preventionist | New ICP, not fully utilizing infection assessment tools or antibiotic stewardship program |
| DON | Director of Nursing | Provided multiple confirmations on deficiencies and program status |
Inspection Report
Life Safety
Census: 162
Capacity: 190
Deficiencies: 4
Date: Sep 6, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.
Findings
The facility was found not in substantial compliance with fire safety requirements, including issues with combustible storage around sprinkler risers, missing or outdated sprinkler inspection tags, unsealed penetrations in fire walls, use of prohibited portable space heaters, and improper use of extension cords as permanent power sources.
Deficiencies (4)
Combustibles stored around sprinkler riser; sprinkler inspection tags missing or not current; multiple risers yellow tagged.
Unsealed penetrations in fire walls at Evergreen wing doorway and front hallway doorway.
Use of portable space heaters throughout the building without thermostatic documentation.
Extension cords used as permanent power in admin offices; small appliance plugged into household extension cord.
Report Facts
Census: 162
Total Capacity: 190
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings during facility tour and observations |
Inspection Report
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for Riverview Health & Rehab Center, indicating a regulatory inspection was conducted.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or details are provided in the document.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 4, 2022
Visit Reason
A revisit survey was conducted by desk review to verify correction of deficiencies cited during the 6/23/22 Complaint Survey.
Findings
All deficiencies cited as a result of the 6/23/22 Complaint Survey were found to be corrected.
Inspection Report
Abbreviated Survey
Census: 166
Deficiencies: 1
Date: Jun 23, 2022
Visit Reason
An abbreviated survey was conducted from June 16, 2022 to June 23, 2022 to investigate multiple complaints including GA00221769, GA00222110, GA00222685, GA00220460, and GA00224180. Complaint GA00221769 was substantiated with a deficiency, while the others were unsubstantiated.
Complaint Details
Complaint #GA00221769 was substantiated with a deficiency related to delayed therapy services. The remaining complaints were unsubstantiated.
Findings
The facility failed to start therapy services based on admission orders for one resident (#2), resulting in a 16-day delay before therapy began. The delay was unexplained due to lack of access to prior records and unclear communication between therapy providers.
Deficiencies (1)
Failure to start therapy services based on admission orders for one resident, resulting in a 16-day delay.
Report Facts
Facility census: 166
Delay in therapy start: 16
Employees mentioned
| Name | Title | Context |
|---|---|---|
| GG | Licensed Practical Nurse (LPN) | Mentioned in relation to discharging therapy order for resident #2 |
| EE | Therapy Coordinator | Interviewed regarding therapy services and delay for resident #2 |
Inspection Report
Renewal
Deficiencies: 0
Date: Jun 23, 2022
Visit Reason
The inspection was conducted as a Licensure Survey from 6/16/22 through 6/23/22 to assess compliance for facility licensure renewal.
Findings
No deficiencies were identified during the Licensure Survey conducted between 6/16/22 and 6/23/22.
Inspection Report
Renewal
Deficiencies: 1
Date: Aug 25, 2021
Visit Reason
A Licensure Survey was conducted from 8/24/2021 through 8/25/2021 to assess compliance with licensure requirements.
Findings
The facility failed to notify the responsible parties timely for two of eight sampled residents who tested positive for COVID-19 and were transferred to the COVID-19 isolation unit. Interviews revealed miscommunication between staff regarding notification responsibilities.
Deficiencies (1)
Failure to notify the responsible party timely for residents testing positive for COVID-19 and transferred to isolation.
Report Facts
Number of sampled residents with notification issues: 2
BIMS score: 9
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse | Stated she did not call families about COVID-19 positive residents because she was told the Unit Manager would call. |
| BB | LPN Unit Manager | Stated he never told LPN AA he would contact families and that she was supposed to notify responsible parties. |
Inspection Report
Complaint Investigation
Census: 152
Deficiencies: 1
Date: Aug 25, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a Complaint Survey investigating complaint intake GA00216903, which was substantiated.
Complaint Details
Complaint GA00216903 was substantiated. The facility failed to notify the responsible party timely for two of eight sampled residents (#1 and #5) who tested positive for COVID-19 and were transferred to the COVID-19 isolation unit.
Findings
The facility was found to be in compliance with infection control regulations but failed to timely notify the responsible parties of two residents who tested positive for COVID-19 and were transferred to the COVID-19 isolation unit.
Deficiencies (1)
Failure to notify the responsible party timely for two residents who tested positive for COVID-19 and were transferred to the COVID-19 isolation unit.
Report Facts
Total census: 152
BIMS score: 9
BIMS score: 10
Days delay in notification: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Did not notify families of residents' positive COVID-19 status as instructed |
| BB | LPN Unit Manager | Stated he never told LPN AA to notify families and expected her to do so after documentation |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Aug 18, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00216891.
Complaint Details
Complaint #GA00216891 was investigated and found to be unsubstantiated.
Findings
The complaint was unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 27, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints identified by their numbers.
Complaint Details
Complaint #GA00215142 was substantiated; complaints #GA00216058, #GA00215533, and #GA00215350 were unsubstantiated.
Findings
Complaints #GA00216058, #GA00215533, and #GA00215350 were unsubstantiated, while complaint #GA00215142 was substantiated. No regulatory violations were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Apr 7, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00213052.
Complaint Details
Complaint #GA00213052 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint #GA00213052 was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Abbreviated Survey
Census: 151
Deficiencies: 0
Date: Feb 16, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated Partial Extended Survey investigating complaints #GA00211597 and #GA00212101 was conducted.
Complaint Details
Complaints #GA00211597 and #GA00212101 were investigated and found to be unsubstantiated.
Findings
Complaints #GA00211597 and #GA00212101 were unsubstantiated and no regulatory violations were cited. The facility was found to be in compliance with 42 CFR 483.80 infection control regulations and has implemented CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00208354.
Complaint Details
Complaint #GA00208354 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the survey.
Inspection Report
Re-Inspection
Census: 133
Deficiencies: 0
Date: Oct 5, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited as a result of a complaint survey on 2020-08-06.
Complaint Details
The revisit survey was conducted following a complaint survey on 2020-08-06. All deficiencies from that complaint survey were corrected.
Findings
All deficiencies cited during the complaint survey on 2020-08-06 were found to be corrected during this revisit survey.
Inspection Report
Re-Inspection
Census: 133
Deficiencies: 0
Date: Oct 5, 2020
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a complaint survey on 2020-08-06.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 2020-08-06; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the complaint survey were found to be corrected.
Report Facts
Census: 133
Inspection Report
Routine
Census: 126
Deficiencies: 0
Date: Aug 28, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted on August 27 - August 28, 2020 by Ascellon on behalf of the Georgia Department of Community Health (DCH).
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to infection control. There were no deficiencies cited during this survey.
Report Facts
Total census: 126
Inspection Report
Original Licensing
Deficiencies: 1
Date: Aug 6, 2020
Visit Reason
A Licensure Survey was conducted from 8/3/2020 through 8/6/2020 to assess compliance with licensure requirements.
Findings
The facility failed to ensure that one resident (#2) received pain medication as ordered, missing multiple doses of hydromorphone. Nursing staff did not notify the physician to obtain an equivalent order when medication was unavailable, contrary to facility policy.
Deficiencies (1)
Failure to ensure one resident received pain medication as ordered, with multiple missed doses of hydromorphone and lack of physician notification for medication unavailability.
Report Facts
Missed medication doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OO | Licensed Practical Nurse | Interviewed regarding medication administration and failure to notify physician for order change. |
| Administrator | Interviewed about expectations for nursing staff to follow physician orders and notify physician of problems. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Aug 6, 2020
Visit Reason
An abbreviated/partial extended survey was conducted from 08/03/2020 to 08/06/2020 to investigate multiple complaints (#GA00207031, #GA00206592, #GA00206257, #GA00204188, and #GA00202712). Four complaints were unsubstantiated, and one complaint (#GA00202712) was substantiated with deficiencies.
Complaint Details
Complaint #GA00202712 was substantiated with deficiencies; other complaints investigated were unsubstantiated.
Findings
The facility failed to follow the care plan related to administering pain medication as ordered for one of three sampled residents (Resident #2). Specifically, multiple doses of hydromorphone were not administered as prescribed, and the facility did not notify the physician or obtain alternate orders in a timely manner as required by policy.
Deficiencies (2)
Failure to develop and implement a comprehensive care plan related to administering pain medication as ordered for Resident #2.
Failure to ensure that Resident #2 received pain medication as ordered, including multiple missed doses of hydromorphone.
Report Facts
Missed medication doses: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| OO | Licensed Practical Nurse | Interviewed regarding medication administration and failure to call physician for alternate orders. |
| Administrator | Interviewed on 8/10/2020 regarding expectations for following care plans and physician orders. |
Inspection Report
Routine
Census: 130
Deficiencies: 0
Date: Jul 31, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness Survey and a COVID-19 Focused Infection Control Survey were conducted to assess the facility's compliance with relevant CMS and CDC regulations related to COVID-19 preparedness and infection control.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 139
Deficiencies: 0
Date: Jun 1, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) to assess compliance with COVID-19 related regulations and preparedness.
Findings
The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 infection control regulations, implementing CMS and CDC recommended practices for COVID-19.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 4, 2019
Visit Reason
An abbreviated Complaint Survey was conducted at Riverview Health and Rehabilitation on December 4, 2019 to investigate Complaint Number GA00200242.
Complaint Details
Complaint Number GA00200242 was investigated and found to be unsubstantiated.
Findings
The complaint was investigated and found to be unsubstantiated. The facility was found to be in compliance and no deficiencies were cited related to this complaint.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 19, 2019
Visit Reason
The document is an annual inspection report for Riverview Health & Rehab Center conducted to assess compliance with health regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Census: 148
Deficiencies: 0
Date: Sep 19, 2019
Visit Reason
A standard survey was conducted at Riverview Health and Rehabilitation from September 16, 2019 through September 19, 2019 to assess compliance with Medicare/Medicaid regulations. Additionally, complaint intake number GA00198985 was investigated.
Complaint Details
Complaint intake number GA00198985 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in substantial compliance with the health portion of Medicare/Medicaid regulations. The complaint investigation was unsubstantiated. Some deficiencies related to the standard survey were noted.
Report Facts
Resident Census: 148
Inspection Report
Life Safety
Census: 147
Capacity: 190
Deficiencies: 0
Date: Sep 16, 2019
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 Edition.
Findings
The facility was found in substantial compliance with the Emergency Preparedness plan requirements and Life Safety Code standards.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Dec 13, 2018
Visit Reason
The inspection was conducted as a complaint survey to investigate complaint number GA00193331.
Complaint Details
Complaint number GA00193331 was investigated and found to have no health care deficiencies.
Findings
No health care deficiencies were cited during the complaint survey.
Inspection Report
Abbreviated Survey
Census: 127
Deficiencies: 0
Date: Aug 14, 2018
Visit Reason
An abbreviated survey was conducted to investigate complaint GA00189986 at Riverview Health and Rehabilitation on August 13 and 14, 2018.
Complaint Details
Investigation of complaint GA00189986; facility found in substantial compliance.
Findings
The facility was found to be in substantial compliance with Medicare/Medicaid regulations at 42 C.F.R. Part 483, Subpart B-Requirements for Long Term Care Facilities.
Report Facts
Facility census: 127
Inspection Report
Re-Inspection
Census: 127
Deficiencies: 0
Date: Aug 14, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the standard survey conducted June 11-15, 2018.
Findings
All deficiencies cited in the prior standard survey were found to be corrected during the revisit survey conducted on August 13-14, 2018.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 2, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Life Safety
Census: 140
Capacity: 145
Deficiencies: 3
Date: Jun 11, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and building codes.
Findings
The facility was found not in substantial compliance with NFPA 101 Life Safety Code and related standards due to deficiencies in sprinkler system maintenance, smoke barrier separations, and gas equipment storage signage, which could place residents at risk in the event of fire.
Deficiencies (3)
Fire sprinkler alarm line valve was in a closed position instead of open, and a sprinkler head in the Admissions Office closet was not within 12 inches of the point of heat collection as required.
Smoke barrier separations had penetrations that were not properly sealed in three smoke compartment separation walls (Magnolia 1, Magnolia 2, and Azalea Hall).
Oxygen cylinder storage closet door lacked the required warning sign stating 'Caution: Oxidizing Gas (es) stored within no smoking' as required by NFPA 99.
Report Facts
Census: 140
Total Capacity: 145
Number of smoke compartment walls with unsealed penetrations: 3
Number of residents at risk due to oxygen storage signage deficiency: 15
Inspection Report
Follow-Up
Deficiencies: 0
Date: Aug 1, 2017
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jul 31, 2017
Visit Reason
A follow-up to the Recertification survey of June 8, 2017, was conducted to verify correction of previously identified deficiencies.
Findings
The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of July 23, 2017.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jul 2, 2017
Visit Reason
The inspection was conducted as a Complaint Survey to investigate complaints #GA 00176334 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA 00176334 was investigated and found to have no deficiencies cited.
Findings
No deficiencies were cited during the complaint survey at Riverview Health and Rehab Center.
Inspection Report
Annual Inspection
Census: 170
Deficiencies: 8
Date: Jun 8, 2017
Visit Reason
A standard survey was conducted at Riverview Health and Rehabilitation Center from 6/5/2017 through 6/8/2017 to assess compliance with Medicare/Medicaid regulations.
Findings
The facility was found not in substantial compliance with multiple regulatory requirements including reasonable accommodation of resident needs, housekeeping and maintenance, assessment accuracy, comprehensive care planning, services by qualified persons, food procurement and sanitation, pharmaceutical services, and pain management. Specific deficiencies included failure to allow a resident to use her electric wheelchair, unsanitary kitchen conditions, inaccurate resident assessments, incomplete care plans, failure to implement physician orders, and improper medication storage practices.
Deficiencies (8)
Failure to allow resident #43 to use her electric wheelchair limiting her independence and causing pain.
Failure to maintain a safe and sanitary environment in 9 rooms on 4 halls/units, including broken furniture, unclean vents, rust, and inadequate maintenance logs.
Failure to ensure accuracy of Minimum Data Set (MDS) assessments for resident #148, specifically not identifying contractures to both legs.
Failure to develop and implement a comprehensive care plan addressing resident #148's contractures and pain associated with movement and dressing.
Failure to provide services by qualified persons per care plan, specifically failure to implement physician order for INR testing for resident #143.
Failure to provide pain management for resident #148 who experienced pain during dressing related to contractures, with inadequate pain assessment and documentation.
Failure to ensure food was prepared, stored, and served in a sanitary manner, including unsanitary kitchen floors, broken tiles, soiled shelves, unclean equipment, improper sanitizer solution, and temperature control issues.
Failure to ensure pharmaceutical services included proper dating of multiuse medications in medication storage rooms and treatment carts.
Report Facts
Resident census: 170
Maintenance log entries not maintained: 112
Days freezer temperature at 10 degrees: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nurse Assistant | Interviewed regarding resident #43's inability to use electric wheelchair and resident #148's pain during dressing |
| AA | Licensed Practical Nurse | Interviewed regarding resident #43's shoulder pain and limitations |
| AA | Social Services Assistant | Interviewed regarding resident #43's complaints about electric wheelchair use |
| EE | Licensed Practical Nurse | Interviewed regarding resident #148's contractures and inaccurate MDS assessments |
| GG | Licensed Practical Nurse | Completed inaccurate MDS assessments for resident #148 |
| BB | Registered Nurse | Observed medication cart with undated multiuse insulin pens |
| FSS | Food Service Supervisor | Interviewed and observed kitchen sanitation deficiencies |
| DON | Director of Nursing | Interviewed regarding resident #143 INR testing and resident #148 pain management |
| ADON | Assistant Director of Nursing | Interviewed regarding undated multiuse PPD vial |
Inspection Report
Life Safety
Census: 170
Capacity: 284
Deficiencies: 1
Date: Jun 6, 2017
Visit Reason
The Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and sprinkler system maintenance.
Findings
The facility was found not in substantial compliance due to failure to ensure the automatic sprinkler system was inspected, tested, and properly maintained, specifically the 5 year internal inspection of the sprinkler system had not been completed.
Deficiencies (1)
Failure to ensure the automatic sprinkler system was inspected, tested, and properly maintained; the 5 year internal inspection of the sprinkler system had not been completed.
Report Facts
Census: 170
Certified beds: 284
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding sprinkler system inspection during facility tour |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Mar 21, 2017
Visit Reason
A follow-up inspection was conducted to verify that the facility had corrected the deficiencies cited on 2017-01-16, as alleged in their Plan of Correction effective on 2017-03-02.
Findings
The facility had corrected the previously cited deficiencies as of the follow-up inspection date.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Mar 19, 2017
Visit Reason
The inspection was conducted to investigate complaint GA00171770 at Riverview Health & Rehab Center.
Complaint Details
Complaint GA00171770 was investigated and found to have no health deficiencies.
Findings
No health deficiencies were cited during the complaint investigation survey.
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