Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Bluff Nursing Home during CMS and state inspections, most recent first.
Failure to Offer Maintenance Ambulation Assistance: A resident with limited mobility and a goal to maintain walking ability was not offered his daily maintenance ambulation plan. Staff assumed he would ask to be walked, even though he did not use his call light and would not ask for assistance. Documentation showed the ambulation task as completed, but the restorative nurse said that was incorrect and the resident did not walk that day.
A resident’s quetiapine was used for another resident when her own supply had not yet arrived from the pharmacy. An RN removed a card from the return bin and directed staff to use it for the other resident, even though staff stated this was not allowed and the medication should have come from stock cubex until the resident’s own card arrived. The DON confirmed medication cards are only to be used for the resident they are prescribed for, and the facility policy required the 6 rights of med admin.
A resident with lower extremity weakness and recurring wounds, who was on a restorative ambulation program to walk 50 feet with a wheeled walker and standby assist twice daily, did not consistently receive the ordered walking sessions after the restorative aide who had been walking with him left employment. The resident reported missed and reduced walks and filed a grievance that his walking rehab schedule was not being followed. Nursing and restorative staff stated that floor CNAs were responsible for providing the twice-daily walks without set times, but CNAs assigned to the resident over a weekend did not walk him and were unsure who was responsible for restorative ambulation. Review of the medical record showed no documentation of walk refusals for the dates the resident reported not being walked, despite care plan instructions to document refusals and notify the nurse.
A cognitively impaired, obese resident with impaired balance was transferred from bed to wheelchair using a sit-to-stand mechanical lift by two CNAs. After the resident was seated, one CNA left the room while the resident was still attached to the lift by a back strap. As the remaining CNA unhooked the strap, no one was holding the resident or stabilizing the wheelchair, and the resident leaned back, causing the wheelchair to flip backwards and the resident to fall onto the floor. This occurred despite facility policy and leadership expectations that two CNAs remain present and that one staff member stabilize the resident and wheelchair until fully disconnected from the lift. The resident later required hospital evaluation, where imaging showed an acute, unstable thoracic vertebral fracture related to the fall.
A cognitively impaired resident fell backwards from a wheelchair onto his back and was started on Tramadol for pain after a NP was notified by phone. Over the next two days, the resident’s back pain worsened, with documented yelling during movement, staying in bed, and refusing cares due to pain, yet nursing staff did not notify a physician or NP or obtain an in‑person assessment. The resident continued to experience severe pain and refusal of care until a NP and the resident’s POA were finally contacted, leading to transfer to the hospital, where imaging showed an acute, unstable thoracic vertebral fracture. The facility’s pain management policy requiring reassessment and revision of the pain regimen when pain is not adequately controlled was not followed.
A resident fell backwards from a wheelchair, developed lower back pain, and had a lumbar X-ray ordered by an NP. When the X-ray tech attempted the study, it could not be completed due to weight concerns, and the tech did not return with additional support as stated. Staff did not notify the physician, NPs, or the resident’s POA that the ordered X-ray was not completed, and there was no documentation of such notification. The resident’s back pain worsened and the resident was later sent to a hospital, where a thoracic vertebral fracture was diagnosed, revealing that the ordered lumbar X-ray had never been performed despite facility policy requiring appropriate diagnostic services.
A resident with severe cognitive impairment and total dependence for ADLs was found in bed with saturated linens, incontinence brief, and mattress due to delayed incontinence care. Staff were unaware of the last time the resident was checked or changed, and the resident expressed discomfort. The care plan and facility policy required frequent checks and changes, but these were not followed, resulting in the resident being left in a soiled state.
A resident with significant medical needs and a stage III pressure ulcer did not have the required physician-ordered dressing in place during a survey observation, despite documentation indicating the treatment was completed. Staff confirmed the absence of the dressing, representing a failure to follow wound care orders and facility policy.
Multiple residents at risk for falls did not have required safety interventions in place, including a bed alarm that was not properly positioned and call lights that were not within reach. These lapses occurred despite care plans and facility policies mandating such interventions, and resulted in at least one unwitnessed fall and residents being unable to call for assistance.
A resident with an indwelling urinary catheter was found with the catheter bag positioned above bladder level during wound care, causing urine to flow back toward the resident. Staff failed to reposition the bag and tubing below the bladder as required by the care plan and facility policy, resulting in a deficiency.
A resident with significant medical needs received medications and feeding through a gastric tube without proper verification of tube placement using an approved method. Nursing staff relied on outdated practices and were unable to locate a clear facility policy, while the DON acknowledged the policy was vague and under revision.
Two residents did not receive medications as ordered: one was left with medications at bedside without a documented self-administration assessment or care plan, and another did not receive a scheduled dose of lisinopril due to a change in administration time and lack of MAR verification by nursing staff.
Staff did not wear gowns, as required by enhanced barrier precautions, while providing incontinent care and performing a dressing change for a resident with a stage III pressure ulcer. Although gloves were used, the omission of gowns occurred despite clear signage, care plan instructions, and facility policy mandating both gloves and gowns for high-contact care activities.
A resident with Alzheimer's and severe dementia was involved in an abuse incident when a housekeeper attempted to restrain him by grabbing his wrists and walking him backwards, causing the resident to fall. Staff members confirmed that the appropriate response should have been to walk away and allow the resident to calm down. The facility's policy defines such actions as abuse, leading to the housekeeper's termination.
The facility failed to report and investigate an incident where a resident hit another resident, despite multiple staff witnessing the event. Statements were taken by a former ADON, but no formal investigation or report was completed. The administrator and current DON were unaware of the incident, indicating a failure in communication and adherence to the facility's abuse policy.
A resident with multiple health conditions filed grievances but only received verbal responses, contrary to the facility's policy requiring written decisions. The resident requested written responses, particularly for a grievance involving disrespectful staff interaction, but was informed that written resolutions were not provided.
A resident with severe cognitive impairment and a history of falls fell and fractured her hip due to the absence of a required chair alarm in her wheelchair. The chair alarm, intended to alert staff when the resident attempted to get up, was left in a recliner, leading to a delayed response from staff. The resident's care plan included the use of a chair alarm due to her risk factors, but it was not in place at the time of the incident.
A resident with a history of dementia and a left femur fracture experienced a fall and complained of hip pain. An X-ray was ordered but conducted nearly 36 hours later, revealing fractures. Staff indicated delays with the contracted X-ray company, and the resident's family was not informed of the delay or given the option for immediate evaluation. The facility's policy allowed for up to 24-hour delays, but this was not communicated to the family.
Failure to Offer Maintenance Ambulation Assistance
Penalty
Summary
The facility failed to ensure a resident with limited mobility was offered a maintenance ambulation plan to maintain the ability to walk. The resident stated that staff did not assist him to walk in the hallway and said he tries to walk daily to maintain his ability to walk. His care plan, initiated on 4/23/26, identified limited mobility and included a goal for a maintenance ambulation plan, with floor staff to offer ambulation assistance in the hallway once a day for 5-7 days a week. The care plan also noted that the resident refused to use his call light to request walking assistance. On 5/17/26, the resident did not receive the expected offer to walk. The restorative nurse stated that staff did not offer the resident his maintenance ambulation plan that day and that the CNA caring for him assumed the resident would ask to be walked, even though the resident would not ask. The resident’s task documentation for that day showed the ambulation task as completed, but the restorative nurse said that documentation was not correct. The resident’s mobility maintenance audit indicated he did not walk on 5/17/26, and the progress note stated the resident did not ask to be walked, so the CNA assumed he did not want to walk.
Medication given from another resident’s card
Penalty
Summary
The facility failed to ensure medications were given as ordered for 1 of 3 residents reviewed for medication administration. One resident had quetiapine 12.5 mg ordered in the morning, but the medication was ordered and discontinued on 11/19/25 after the power of attorney did not consent to it. Another resident was admitted with diagnoses including generalized anxiety disorder and had quetiapine 12.5 mg ordered at bedtime on 4/17/26. Her MAR showed she began receiving the medication on 4/17/26, but the pharmacy proof of delivery showed the quetiapine tablets were not delivered until 4/26/26, and the facility stock supply receipt showed only one dose was taken on 4/22/26. On 5/13/26, an LPN found a card of quetiapine for one resident in the medication cart with a note from an RN directing that the card be used for the other resident until her supply arrived from the pharmacy. The LPN stated nurses are not allowed to use another resident’s medications for someone else and that the medication should have been obtained from stock cubex until the resident’s card arrived. The RN acknowledged she had taken the card from the return bin and used it for the other resident, stating she knew it was not the protocol and did not check the cubex for stock. The DON confirmed medication cards should only be used for the residents they are prescribed for, and the facility policy required the six rights of medication administration and comparison of the bubble pack with the MAR.
Failure to Provide Ordered Restorative Walking Program
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered restorative ambulation services to a resident with limited mobility and a documented restorative walking program. The resident, who has lower extremity weakness and recurring wounds, reported that he is supposed to be walked twice daily, historically at set times in the morning and afternoon by a restorative aide who was recently terminated. He stated that on two specific weekend days he was not walked at all and was not offered walking, and on a subsequent day he was not walked twice as planned. He filed a grievance stating that his walking rehabilitation schedule was not being followed and questioned whether his walking rehab would be continued. Staff interviews and record review confirmed that the resident had an active restorative ambulation program requiring walking 50 feet in the hallway with a wheeled walker and standby assist twice daily, with a preference for morning and afternoon walks, and that refusals were to be reported to the nurse and documented. Nursing leadership and the restorative nurse stated that, after the restorative aide left, floor CNAs were responsible for providing the twice-daily walks, but there would no longer be a set time. The unit coordinator indicated the resident was not scheduled for restorative services every other weekend and did not follow up with CNAs on the days the resident alleged he was not walked. CNAs assigned to the resident over that weekend reported they did not walk him and were unsure who was responsible for walking residents on restorative programs. Progress notes for the dates in question did not contain any documentation of the resident refusing walks, despite the care plan requirement to document refusals and notify the nurse.
Failure to Safely Use Mechanical Lift During Transfer Resulting in Resident Fall and Spinal Fracture
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe transfer and adequate supervision during the use of a sit-to-stand mechanical lift, resulting in a resident fall and injury. The resident involved was cognitively impaired and care planned as being at risk for falls due to impaired cognition, obesity, and impaired balance. According to the incident report and staff interviews, two CNAs used a sit-to-stand lift to transfer the resident from bed to wheelchair. After the resident was placed in the wheelchair, one CNA left the room, even though the resident remained attached to the lift via a strap around his back. As the remaining CNA began to unhook the back strap from the lift, the resident leaned or laid back in the wheelchair, causing the wheelchair to flip backwards and the resident to land directly on his back. The facility’s Assistant DON stated that facility practice requires two staff members to remain with the resident until the resident is completely unhooked from the sit-to-stand lift and securely seated, with one staff operating the lift and the second stabilizing the resident and wheelchair. The facility’s written policy on “Safe Lifting and Movement of Residents, Including Mechanical Lifts” requires at least two CNAs for mechanical and stand lift transfers to safely move residents. In this incident, no one was holding the resident or the wheelchair while the strap was being disengaged, and one CNA had already left the room, contrary to facility expectations and policy. Following the fall, the resident complained of back pain over the next two days and was subsequently sent to the hospital, where a CT scan showed an acute, unstable hyperextension fracture of the eighth thoracic vertebra, attributed to the fall.
Failure to Notify Providers and Manage Worsening Pain After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to effectively manage and treat a cognitively impaired resident’s pain following a fall from a wheelchair. On 2/1/26, the resident fell backwards onto the floor while seated in a wheelchair during care, landing directly on his back. A nurse practitioner was notified by phone of the fall and ordered Tramadol 50 mg every four hours as needed for pain, in addition to the resident’s scheduled Tramadol three times daily. Progress notes for that day documented the fall and the new pain medication order but did not show that the resident was seen or assessed in person by a physician or nurse practitioner on 2/1/26. On 2/2/26, progress notes documented that the resident began complaining of increased back pain with movement, yelling when the head of bed was elevated or lowered or when staff assisted with repositioning. Nursing staff interviews confirmed that the resident stayed in bed, yelled with movement due to back pain, and refused cares because movement worsened his pain. Despite these observations of worsening pain and refusal of care, there was no documentation that the physician or nurse practitioner was notified on 2/2/26, and no evidence that the resident was seen or assessed by a provider that day. The nurse practitioner later stated she had been in the facility seeing other residents on that date but was not informed of the resident’s worsening pain. By 2/3/26, progress notes showed the resident continued to have back pain from the fall, was yelling out when staff attempted to provide care, and refused a shower, stating he hurt too badly. Nursing staff notified a nurse practitioner that morning regarding the resident’s condition and that he was yelling out in pain even when not being touched. The resident’s POA was also notified and requested that he be sent to the hospital. The resident was transferred by ambulance, and a hospital CT scan on 2/3/26 revealed an acute, unstable fracture of the eighth thoracic vertebra consistent with a hyperextension injury from the fall. The facility’s own pain management policy required reassessment and revision of the pain management regimen and plan of care when pain was not adequately controlled, but the record showed no timely provider notification or adjustment of treatment in response to the resident’s worsening pain on 2/1/26 and 2/2/26.
Failure to Complete Ordered Lumbar X-Ray and Notify Providers After Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure that ordered radiology services were completed or alternative arrangements made after a resident sustained a fall with resulting back pain. The resident fell backwards from a wheelchair onto the floor, landing on his back, and subsequently complained of lower back pain. A nurse practitioner ordered a lumbar X-ray to be completed in the facility, with a physician order specifying 2–3 views of the lower lumbar area related to trauma and pain. When the X-ray technician arrived, the study could not be completed due to weight concerns and the technician stated that an additional tech and a special board would be needed to hold the resident. The X-ray staff did not return to complete the ordered study, and the lumbar X-ray was never performed in the facility. The resident continued to complain of back pain and was later transferred to a local hospital due to worsening pain, where he was diagnosed with a thoracic vertebral fracture. Facility progress notes for the day the X-ray attempt failed contained no documentation that the physician, nurse practitioners, or the resident’s POA were notified that the ordered X-ray was not completed. An LPN confirmed she did not notify the POA or either nurse practitioner that the X-ray was not done. The POA and both nurse practitioners reported they were not informed until the following day, shortly before or on the day the resident was sent to the hospital, that the X-ray had not been completed as ordered. This failure occurred despite a facility policy stating it will provide appropriate diagnostic services, including radiology, in accordance with state and federal guidelines.
Failure to Provide Timely Incontinence Care
Penalty
Summary
A resident with severe cognitive impairment, chronic kidney disease, malnutrition, and other significant diagnoses was found to have not received timely incontinence care. The resident required total to substantial staff assistance for activities of daily living and was always incontinent of urine and bowel, with a documented risk for skin breakdown. During an observation, a certified nurse aide responded to the resident's request to be changed and discovered that the resident's bed linens, incontinence brief, blue pad, bed sheet, bed alarm safety pad, and mattress were all saturated with urine. The resident expressed discomfort, stating she was cold and uncomfortable, and could not recall when she was last changed. The aide was unaware of the last time the resident was checked or changed and noted that the situation was inappropriate, attributing it to possible inexperience among newer staff. The resident's care plan required staff to check and change her incontinence products upon waking, before and after meals, before bed, during nighttime checks, per request, and as needed. The Director of Nurses confirmed that residents should be checked at least every two hours and that being left in urine is a dignity issue and increases the risk for skin breakdown and infection. The facility's policy also stated that residents unable to perform activities of daily living should receive necessary services to maintain hygiene. Despite these protocols, the resident was left in a saturated state, indicating a failure to provide timely and adequate incontinence care.
Failure to Maintain Physician-Ordered Pressure Ulcer Dressing
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including cerebral palsy, chronic obstructive pulmonary disease, polyneuropathy, obesity, osteoarthritis, seizures, peripheral vascular disease, and heart failure, did not have a physician-ordered pressure ulcer dressing in place. The resident had a stage III pressure ulcer on the sacrum, with specific orders for wound care to be performed three times a week and as needed. Documentation indicated that the dressing change was signed off as completed, but during an observation by surveyors, no dressing was found on the resident's pressure wound, nor was it present in the brief. Certified Nursing Assistants confirmed that no dressing was in place during the provision of incontinent care. The resident's care plan and facility policy required adherence to physician orders for wound care and communication of interventions to all relevant staff. The resident was dependent on staff for activities of daily living, including repositioning and incontinence care, and was at high risk for pressure ulcers. Despite these documented needs and orders, the required dressing was not applied or maintained as ordered, resulting in a failure to provide appropriate pressure ulcer care.
Failure to Implement Fall Prevention Interventions and Ensure Call Light Accessibility
Penalty
Summary
The facility failed to ensure that fall prevention interventions were consistently implemented for multiple residents identified as being at risk for falls. One resident with a history of stroke, hemiplegia, dementia, and other significant medical conditions was care planned to have a bed alarm in place due to her high fall risk. However, during observation, the bed alarm was found on top of the blankets and not under the resident, rendering it ineffective. This same resident had a recent unwitnessed fall in her room, and documentation indicated that the bed alarm was not activated at the time of the incident. Two additional residents, both with dementia and a history of falls, were observed in their rooms without their call lights within reach. One resident's call light was on an empty bed next to him, and he was unable to locate it, stating he had previously fallen while trying to get up. The other resident's call light was found on the floor, out of reach, and he was unaware of its location. Staff interviews confirmed that call lights should be accessible to residents at all times, and care plans for both residents specified that call lights should be within reach and that residents should be encouraged to use them for assistance. The facility's own policies on fall prevention and call light accessibility require that interventions such as bed alarms and accessible call lights be in place for residents at risk of falls. Despite these policies and individualized care plans, staff failed to ensure that these safety measures were consistently implemented, resulting in residents being left without necessary fall prevention interventions.
Catheter Bag Improperly Positioned Above Bladder Level
Penalty
Summary
A deficiency was identified when a resident with a history of stroke, dementia, and a stage IV pressure injury was observed with an indwelling urinary catheter bag positioned above the level of her bladder. During wound care provided by an LPN and a Unit Manager/RN, the resident was in bed with her feet elevated, and the catheter drainage bag was attached to the footboard, even with her feet and above her bladder. The drainage tubing was on the bed, and during repositioning, urine was seen flowing back toward the resident and away from the bag. After the wound care was completed, the staff exited the room without repositioning the catheter bag and tubing below the bladder level. Interview with the LPN confirmed that the catheter bag was incorrectly placed and acknowledged that it should have been hanging lower, off the bed frame, to prevent backflow. The resident's care plan specifically directed that the catheter bag and tubing be positioned below the level of the bladder, and the facility's catheter care policy also required this practice to discourage backflow of urine. The failure to follow these protocols resulted in the identified deficiency.
Failure to Verify Feeding Tube Placement Using Approved Method
Penalty
Summary
A deficiency occurred when staff failed to verify the placement of a gastric feeding tube using an approved method prior to administering medications and a bolus feeding to a resident. The resident in question had multiple diagnoses, including colon cancer, stroke, high blood pressure, and hemiplegia, and was dependent on staff for all care, including tube feeding. During observation, a registered nurse checked tube placement by injecting air into the tube and listening with a stethoscope, a method that is no longer considered best practice. The nurse then proceeded to administer medications and feeding through the tube. Interviews with nursing staff revealed uncertainty regarding the facility's policy for verifying tube placement, with both the nurse involved and another RN unable to locate a clear policy. The Director of Nursing acknowledged that the current policy was vague and in the process of being updated, and confirmed that air insufflation is not the best practice. Facility guidelines and care plans required verification of tube placement before administering feedings or medications but did not specify the method to be used.
Failure to Administer Medications as Ordered and Lacking Self-Administration Assessment
Penalty
Summary
The facility failed to ensure that physician-prescribed medications were administered as ordered for two residents. In the first case, a resident with multiple diagnoses including dementia, diabetes, and chronic kidney disease was found with four assorted pills left on her bedside table, which she identified as her morning medications. She reported that the nurse leaves her medications for her to take at her convenience, but she was unable to identify the pills or their purpose. Review of her records showed no assessment or documentation indicating she was capable of self-administering her medications, nor was there any care plan reflecting self-administration, contrary to facility policy. In the second case, a resident with colon cancer, stroke, and hemiplegia, who is dependent on staff for all care, did not receive a prescribed dose of lisinopril as ordered. The nurse prepared and administered several medications but omitted the lisinopril, which was scheduled for the morning medication pass. The MAR showed the time for lisinopril administration had recently changed, and the nurse was unsure if it had been given. The MAR was not signed for the administration of lisinopril, and the DON confirmed that the MAR should be referenced to ensure all medications are given as ordered. Facility policy requires verification of medications against the MAR prior to administration.
Failure to Use Required PPE During High-Contact Care Under Enhanced Barrier Precautions
Penalty
Summary
Staff failed to follow enhanced barrier precautions while providing care to a resident with multiple complex medical conditions, including a stage III pressure ulcer. During observed episodes of incontinent care and a dressing change, certified nursing assistants and a licensed practical nurse wore gloves but did not don gowns, despite clear signage and care plan instructions requiring both gloves and gowns for high-contact activities under enhanced barrier precautions. The care plan and posted signage specified that gowns and gloves were necessary for activities such as changing briefs, providing hygiene, and wound care for residents on these precautions. The facility's policies, as well as statements from the unit manager, confirmed that staff are required to wear gowns and gloves when providing high-contact care to residents on enhanced barrier precautions. Documentation showed that the resident had an active order for wound care and was assessed with a stage III pressure ulcer. Despite these requirements and the presence of clear instructions, staff did not comply with the expected infection control protocols during the observed care events.
Resident Abuse Incident Involving Physical Restraint
Penalty
Summary
The facility failed to ensure a resident was free from physical abuse, as evidenced by an incident involving a resident with Alzheimer's disease, severe dementia with agitation, and other conditions. The resident, who has a history of becoming physically aggressive due to anger, dementia, and poor impulse control, was involved in an incident where a housekeeper, V9, attempted to physically restrain him. The resident was walking around the facility when V9 tried to direct him to a chair by grabbing his wrists and walking him backwards, resulting in the resident falling. Multiple staff members, including a CNA, LPN, and unit attendant, witnessed the incident and confirmed that V9 held the resident's wrists and forcefully walked him backwards, which led to the fall. The LPN and other staff members indicated that the appropriate response to the resident's agitation should have been to walk away and allow the resident to calm down, rather than physically restraining him. The incident was considered abuse by the staff, as it involved the willful infliction of physical harm and mental anguish on the resident. The facility's policy on abuse, neglect, and exploitation emphasizes the protection of residents from abuse by anyone, including staff. The policy defines abuse as the willful infliction of injury or unreasonable confinement, which aligns with the actions taken by V9 during the incident. The Director of Nursing and the Administrator both acknowledged that V9's actions were inappropriate and constituted abuse, leading to V9's termination.
Failure to Report and Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure that allegations of resident-to-resident abuse were immediately reported and investigated. Specifically, an incident occurred where one resident (R2) hit another resident (R3) in the dining room, which was witnessed by several staff members, including a Unit Attendant (V5) and a CNA (V7). Despite these observations, the incident was not reported to the facility's administrator or documented as required by the facility's abuse policy. The policy mandates that any incident, allegation, or suspicion of abuse must be reported immediately to the administrator or a supervisor, who must then inform the administrator. However, the administrator (V1) and the current Director of Nursing (V2) were unaware of the incident, indicating a breakdown in communication and reporting procedures. Interviews with staff revealed that statements were taken by the former Assistant Director of Nursing (V18), but no formal investigation or report was completed or submitted to the proper authorities. The facility's administrator confirmed that no abuse allegations or investigations had been reported in the past two months, despite the incident occurring in September. This lack of documentation and failure to follow the established abuse reporting protocol resulted in a deficiency, as the facility could not provide any reports or documentation of an investigation regarding the incident between R2 and R3.
Failure to Provide Written Grievance Decision
Penalty
Summary
The facility failed to ensure that a resident received a written grievance decision, as required by their grievance policy. The resident, who is diagnosed with peripheral neuropathy, Type 2 diabetes, obesity, heart failure, chronic kidney disease stage 3, and peripheral vascular disease, had filed grievances but only received verbal responses. During an interview, the resident expressed that he did not receive written responses to his grievances, despite requesting them. The facility's policy mandates that a written decision be provided to the resident at the conclusion of the grievance investigation. The resident's grievance dated 6/9/24 involved an incident of rude and disrespectful conversation with a staff member. The grievance specifically requested both a verbal and written response. However, the Director of Nursing informed the resident that written grievance resolutions were not provided, contradicting the facility's policy. The policy clearly outlines that the grievance official is responsible for issuing a written decision, including details such as the date received, investigation steps, findings, and any corrective actions taken.
Failure to Implement Fall Prevention Measures
Penalty
Summary
The facility failed to ensure fall prevention interventions were in place for a resident with a history of falls, resulting in the resident falling and fracturing her left hip. The resident, who had severe cognitive impairment and was dependent on staff for transfers, was supposed to have a chair alarm in her wheelchair as part of her care plan. However, on the morning of the incident, the chair alarm was not in place, as it had been left in a recliner the previous night. The incident occurred when a CNA transferred the resident to her wheelchair and left her at the nurses' station without realizing the chair alarm was missing. Shortly after, the resident was found sitting on the floor with her back against another resident's wheelchair. The CNA and LPN on duty confirmed that the chair alarm was not in the wheelchair at the time of the fall, which was supposed to alert staff when the resident attempted to get up. The Director of Nursing and other staff members acknowledged the importance of chair alarms in preventing falls, especially during shifts with fewer staff. The resident's care plan clearly indicated the need for a chair alarm due to her risk factors, including confusion, weakness, and a history of falls. The lack of the chair alarm contributed to the delay in staff response, ultimately leading to the resident's fall and subsequent hip fracture.
Delay in Radiology Services for Resident Post-Fall
Penalty
Summary
The facility failed to provide timely radiology services for a resident who fell and was experiencing pain in her hip. The resident, who had a history of dementia, depression, and a left femur fracture, was found sitting on the floor with complaints of discomfort to her left hip. An X-ray was ordered after the fall, but it was not conducted until nearly 36 hours later, revealing acute fractures. Interviews with staff indicated that the contracted X-ray company typically takes 24 to 48 hours to perform X-rays, and the family was not informed of the potential delay or given the option to send the resident out for a quicker evaluation. The resident's Power of Attorney was not made aware of the delay in obtaining the X-ray and was not offered the option to have the resident sent out for immediate evaluation. The Director of Nursing acknowledged that ideally, X-rays should be done within 24 hours, but the facility had no control over the contracted imaging company's timeline. The facility's change in condition policy indicated that X-rays and labs might take up to 24 hours, but this was not communicated effectively to the resident's family, leading to a delay in diagnosis and treatment.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Rockford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| East Bank Center, Llc | 0.6 mi | ★★★★★ | 1 | 0 |
| Rock River Health Care | 0.6 mi | ★★★★★ | 14 | 1 |
| Willows Health Center | 0.9 mi | ★★★★★ | 13 | 0 |
| Mercyhealth Javon Bea Hospital -snf | 2.1 mi | ★★★★★ | 0 | 0 |
| Amberwood Care Centre | 2.1 mi | ★★★★★ | 2 | 0 |
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