Riverside Nursing And Rehabilitation Center
RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH — inspection on September 2, 2025.
Found 12 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Federal health inspectors cited RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH for a deficiency under regulatory tag F-F0565 during a standard health inspection conducted on 2025-09-02.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: Honor the resident's right to organize and participate in resident/family groups in the facility.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of RIVERSIDE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-30.
Federal health inspectors cited RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH for a deficiency under regulatory tag F-F0574 during a standard health inspection conducted on 2025-09-02.
Category: Resident Rights Deficiencies
The facility was found deficient in the following area: The resident has the right to receive notices in a format and a language he or she understands.
Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of RIVERSIDE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-30.
Review of the medical record for Resident #112 revealed an admission date of 02/19/24.
Diagnoses included dementia, anxiety disorder, and cerebrovascular accident.
Review of the MDS assessment dated [DATE] revealed Resident #112 had moderate cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of nine.
This resident was assessed to require setup with eating, substantial assistance with toileting, bathing, and dressing, and supervision with transfers.
Observation on 08/04/25 at 1:38 P.M. revealed five gashes about 12 inches in length behind the headboard of Resident #112's bed.
Interview on 08/07/25 at 9:10 A.M. with Maintenance Director #499 verified the gashes behind the headboard of Resident #112's bed.
This deficiency represents non-compliance investigated under Complaint Numbers 1259570 and
- 365877 09/02/2025
Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405
represents non-compliance investigated under Complaint Numbers 1259568 and 1259561.
365877 09/02/2025
Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405
resident to resident sexual abuse.
This affected two (#49 and #160) residents of ten reviewed for
admission date of 06/01/22.
Diagnoses included chronic obstructive pulmonary disease (COPD), major depressive disorder, dementia, and anxiety disorder.
Review of the Quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed Resident #160 had severe cognitive impairment as evidenced by a Brief Interview for Mental Status (BIMS) score of four.
This resident was assessed to require setup with eating, supervision with toileting and transfers, and partial assistance with dressing.
Review of the care plan for Resident #160 revealed she was not care planned for sexually inappropriate behaviors.
Review of the progress note dated 04/28/25 at 4:25 P.M. revealed Licensed Practical Nurse (LPN) #491 knocked on Resident #160's room with no answer. LPN #491 entered the room and observed Resident #160 on her bed with her pants and underwear on the ground. Resident #49 was standing in front of her fully clothed. LPN #491 educated Resident #49 that he was not supposed to be in her room and walked him to the common area. A skin assessment was completed on Resident #160 with no negative findings noted. Resident #160 was assisted with getting dressed and taken to the common area.
Review of the progress note dated 05/01/25 at 9:58 A.M. revealed Social Services Director (SSD) #447 documented Resident #160 was allegedly attempting to solicit Resident #49 to physically engage.
Guardian was notified.
Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place.
Social services will continue to follow up as needed.
Review of the medical record for Resident #49 revealed an admission date of 03/21/23.
Diagnoses included dementia, mood disorder, post-traumatic stress disorder (PTSD), and major depressive disorder.
Review of the MDS assessment dated [DATE] revealed Resident #49 had severe cognitive impairment as evidenced by a BIMS score of seven.
This resident was assessed to require setup with eating, supervision with toileting, dressing, and transfers.
Review of the care plan dated 07/17/25 revealed Resident #49 was not care planned for inappropriate sexual behaviors.
Review of the progress note dated 05/01/25 at 10:05 A.M. revealed Social Services Director (SSD) #447 documented Resident #49 was allegedly attempting to solicit Resident #160 to physically engage.
Guardian was notified.
Due to cognition concerns, facility recognized resident rights to consensual contact, but due to resident cognition/memory concerns, interventions were put into place.Review of the facility investigation revealed the facility did not provide proof of completing an investigation for possible sexual abuse.Interview on 08/06/25 at 11:53 A.M. with the Director of Nursing (DON) reported Resident #49 was found in Resident #160's room on 04/28/25 after 3:00 P.M. by LPN #491 and Certified Nurse Aide (CNA) #436.
The DON stated Resident #160 was found on her bed with no pants or depends on, and Resident #49 was standing at the end of the bed.
The DON explained Resident #49 could not recall why he was in the room.
The DON stated the facility completed an investigation but failed to give it this surveyor.
The DON also stated both residents had very low cognition.
The DON reported the daughter of Resident #160 reported that she didn't see anything on the camera, so they did not report it to the Ohio Department of Health (ODH).Interview on 08/14/25 at 1:55 P.M. with Unit Manager (UM)/LPN #406 revealed LPN #491 reported Resident #49 was found in Resident #160's room. Resident #160 was found with no pants or depends on sitting on her bed. Resident #49 was fully clothed and asked to leave the room. UM/LPN #406 reported she reached out to Resident #160's daughter and informed her of the incident. UM/LPN #406 stated both residents had progressive dementia and appeared that they didn't know who each other were. UM/LPN #406 stated the previous Administrator at the time of the incident did not feel it was necessary to complete a SRI for the incident. UM/LPN #406 also stated an incident report was not completed.
This deficiency represents non-compliance investigated under Complaint Numbers 1259568 and 1259561.
365877 09/02/2025
Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405
Federal health inspectors cited RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH for a deficiency under regulatory tag F-F0645 during a standard health inspection conducted on 2025-09-02.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: PASARR screening for Mental disorders or Intellectual Disabilities
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of RIVERSIDE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-30.
Federal health inspectors cited RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH for a deficiency under regulatory tag F-F0656 during a standard health inspection conducted on 2025-09-02.
Category: Resident Assessment and Care Planning Deficiencies
The facility was found deficient in the following area: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of RIVERSIDE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-30.
Review of the facility policy titled, Unit Supervision, revealed the policy of the facility was to provide resident centered care that met the psychosocial, physical, and emotional needs and concerns of the residents.
Safety was a primary concern for the residents, staff, and visitors.
The Unit Supervisor was a licensed nurse with the skills and competency to safely and appropriately monitor and delegate tasks to others and perform duties consistent with safe and effective care and treatment of the assigned residents.
Supervision responsibilities were assigned by the DON or designee to provide for the care and treatment of the residents, direct services of on-duty staff, and assume responsibility for a safe environment during the time the nurse was working the shift for the specific unit the nurse was assigned.
This deficiency represents non-compliance investigated under Complaint Numbers 1259562 and 2585469.
365877 09/02/2025
Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405
Federal health inspectors cited RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH for a deficiency under regulatory tag F-F0692 during a standard health inspection conducted on 2025-09-02.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Provide enough food/fluids to maintain a resident's health.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of RIVERSIDE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-30.
Federal health inspectors cited RIVERSIDE NURSING AND REHABILITATION CENTER in DAYTON, OH for a deficiency under regulatory tag F-F0693 during a standard health inspection conducted on 2025-09-02.
Category: Quality of Life and Care Deficiencies
The facility was found deficient in the following area: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 12 deficiencies cited during this inspection of RIVERSIDE NURSING AND REHABILITATION CENTER.
Correction Status: Deficient, Provider has date of correction.
The facility reported correction as of 2025-09-30.
Review of the medical record for Resident #02 revealed a Minimum Data Set (MDS) assessment, dated 07/07/25, which indicated Resident #02 was cognitively intact and was dependent upon staff for toilet hygiene, showers/bathes, transfers and bed mobility.
Review of the medical record for Resident #02 revealed a physician order dated 11/30/24 for Midodrine (hypotension medication) oral tablet 2.5 milligram (mg) one tablet by mouth every eight hours as needed for hypotension.
Hold if systolic blood pressure (SBP) is greater than 110 and administer if SBP is less than 110.
Review of the medical record for Resident #02 revealed a blood pressure reading on 06/03/25 of 97 (SBP)/50 diastolic blood pressure (DPB) milliliters in mercury (mmHg).
Review of the medical record revealed pre-dialysis assessments on 07/24/25 with a documented blood pressure of 105/78 mmHg, on 07/31/25 with documented blood pressure of 106/64 mmHg, and on 08/05/25 with a documented blood pressure of 104/67 mmHg.
Review of the medical record for Resident #02 revealed the Medication Administration Records (MAR) for June, July and August 2025 did not have documentation to support Midodrine was administered on 06/03/25, 07/24/25, 07/31/25, and 08/05/25.
Interview on 08/07/25 at 10:23 A.M. with NP #800 stated the order was supposed to be entered to administer Midodrine 2.5 mg one tablet every eight hours for hypotension and to hold if SBP is greater than 110 and to administer if SBP less than 110.
NP #800 stated Resident #02 should have her blood pressure checked three times per day for the facility to monitor her for possible Midodrine administration. NP #800 also stated the facility staff should have administered Midodrine as ordered prior to dialysis. NP #800 confirmed the facility had not administered Midodrine as ordered on 06/03/25, 07/24/25, 07/31/25, and 08/05/25.
Review of the facility policy titled, Medication Administration, revealed the facility is to provide resident centered care the meets the psychosocial, physician, and emotional needs and concerns of the residents.
The policy continued to state staff are to administer medication only as prescribed by the provider.
This deficiency represents non-compliance investigated under Complaint Number 1259566.
365877 09/02/2025
Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405
Review of the documentation from the employment agency provided to the facility revealed interim NHA #630's date of birth was 10/23/73 and resided in Cincinnati.
Review of the documentation revealed interim NHA #630 had used NHA license number 7258.
Review of documentation from BELTSS revealed NHA #700 had an active license of number 7258, a date of birth of [DATE] and resided in Englewood.
Review of BELTSS documentation revealed interim NHA #630 was registered as an Administrator in Training and did not have an active NHA license.
This deficiency represents non-compliance investigated under Complaint Number 2578224.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.