SAVANNAH, GA - State health inspectors have documented serious violations at Riverview Health & Rehab Center after finding that facility administrators failed to properly investigate and report multiple incidents of resident-on-resident sexual abuse and staff-on-resident physical abuse, placing vulnerable nursing home residents at risk of harm.
Administration's Failure to Investigate Sexual Abuse Incidents
The most troubling findings centered on the facility's inadequate response to witnessed sexual abuse involving three residents. According to the inspection report from February 2025, a male resident identified as R64 was observed engaging in non-consensual sexual contact with two female residents on separate occasions.
In one incident on December 25, 2024, Licensed Practical Nurse CC witnessed R64 fondling the breast of R30, a female resident whose adult brief had been undone. Despite this nurse providing a written statement about what she observed, facility administration conducted no thorough investigation. The Director of Nursing, who served as the facility's Abuse Coordinator, admitted during the inspection that she "did not do a thorough investigation for the incident since R64 admitted that he did it."
A second incident involved Licensed Practical Nurse BB witnessing R64 "tongue kissing" R30 in the television common area without the female resident's consent. Again, despite having a direct witness account from a staff member, the facility failed to conduct proper follow-up interviews with other staff or residents who might have observed similar behavior.
The inspection revealed that R125 was also subjected to sexual abuse by R64, though specific details of those incidents were not fully documented in the available narrative. The facility was unable to provide any documentation showing that comprehensive investigations were conducted, that family members were notified, or that incidents were reported to local authorities as required by federal regulations.
Physical Abuse by Staff Member Goes Uninvestigated
The inspection also uncovered a disturbing incident of physical abuse by a Certified Nursing Assistant against a resident. On October 28, 2024, CNA AA threw a mechanical lift pad at R60, with the pad landing on the resident's face. Despite having a witnessed and handwritten account of this physical assault, the facility failed to conduct a proper investigation or report the incident to appropriate authorities.
When questioned about this incident, the Director of Nursing stated that CNA AA was immediately suspended following the allegation. However, no further investigative steps were taken to interview other residents or staff about potential additional incidents involving this employee. The Administrator later admitted that "the team discussed it and the ball got dropped because the follow up was not done for either incident."
Medical and Safety Implications of Inadequate Protection
The failure to protect residents from abuse represents a fundamental breakdown in nursing home safety protocols. Sexual abuse in nursing facilities poses significant risks to vulnerable elderly residents who often have cognitive impairments or physical limitations that prevent them from defending themselves or reporting abuse. These incidents can result in physical injuries, psychological trauma, increased confusion and agitation, depression, and withdrawal from social activities.
Physical abuse by staff members violates the most basic trust between caregivers and residents. When a mechanical lift pad is thrown at a resident's face, it can cause facial injuries, eye damage, psychological distress, and create an environment of fear that affects not just the victim but other residents who may witness or learn about such incidents. The use of equipment as a weapon represents a particularly egregious violation of professional standards.
The facility's inadequate response to these incidents compounds the harm. When abuse allegations are not properly investigated, perpetrators may continue their harmful behavior, potentially victimizing additional residents. The failure to notify families denies them the opportunity to advocate for their loved ones or seek additional protections. Not reporting to authorities prevents proper criminal investigation and allows dangerous individuals to remain in positions where they have access to vulnerable populations.
Systemic Failures in Oversight and Training
The inspection revealed multiple systemic failures that contributed to these violations. Despite having written policies requiring comprehensive investigation of all abuse allegations, the facility's leadership failed to follow their own procedures. The facility's abuse policy, dated December 2023, clearly stated requirements for training all staff on identifying, preventing, and reporting abuse. It also mandated thorough investigations of all allegations and immediate reporting to appropriate authorities.
The Administrator's job description specifically included responsibility for "procedural guidelines relative to the prevention and reporting of patient abuse" and maintaining compliance with federal, state, and local regulations. Similarly, the Director of Nursing's role included assuming "responsibility for procedural guidelines relative to the prevention and reporting of patient abuse." Both leaders failed to fulfill these fundamental responsibilities.
During interviews with inspectors, the Administrator revealed concerning attitudes about oversight, stating his expectation was "for staff to know how to do their jobs, since they have the tools to do their job." This hands-off approach to critical safety issues contributed to the systemic failures that left residents unprotected.
Additional Issues Identified
Beyond the primary abuse incidents, inspectors identified several related deficiencies in the facility's operations. Staff training on abuse prevention and reporting was incomplete, with numerous employees lacking proper education on recognizing and responding to abuse situations. Documentation practices were inadequate, with the facility unable to produce evidence of required investigations or reports.
The facility's quality assurance systems failed to identify or address these serious safety gaps before the state inspection. Internal audits and monitoring systems did not detect the pattern of unreported and uninvestigated abuse allegations. Communication protocols between departments broke down, allowing critical safety information to be lost or ignored.
Immediate Jeopardy Declaration and Corrective Actions
The severity of these violations led inspectors to declare an Immediate Jeopardy situation on February 5, 2025, indicating that the facility's noncompliance had caused or was likely to cause serious injury, harm, impairment, or death to residents. This designation represents one of the most serious findings in nursing home inspections.
Following the Immediate Jeopardy declaration, the facility implemented several corrective actions. R64 was placed on one-to-one supervision and subsequently discharged from the facility on February 9, 2025. CNA AA was suspended pending investigation. The facility conducted comprehensive retraining for staff on abuse prevention and reporting procedures, with 132 of 150 staff members receiving education by February 8, 2025.
External consultants were brought in to review policies and provide leadership training. The facility updated its orientation programs and implemented new monitoring systems. A Performance Improvement Plan was initiated to address the systemic issues that allowed these incidents to occur. By February 10, 2025, inspectors validated that the immediate threat to residents had been removed, though the facility remained out of compliance pending full implementation of corrective measures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Riverview Health & Rehab Ctr from 2025-02-12 including all violations, facility responses, and corrective action plans.
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