Riverside Health & Rehab Center

Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on clinical record review and interviews with staff, it was determined that the facility did not ensure that a physician wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).Findings include:

Review of the clinical record indicated Resident R1 was admitted to the facility on [DATE], with diagnoses that included Clostridium difficile (C. diff - highly contagious bacterium that causes diarrhea and colitis), diabetes, and high blood pressure.

Resident R1 was on respite (provides short-term relief for primary caregivers, giving them time to rest, travel, or spend time with other family and friends) stay for seven days.

Review of the clinical record indicated Resident R1 was seen by the wound doctor on 10/13/25, with the following orders:Wound #1 Left, Plantar Foot: Cleanse Wound.

Cleanse with 0.125% Dakin's Solution - and pat dry.

Pack undermining, areas and wound bed with kling, cutting only once and leaving tail end visible out of wound bed.

Cover with ABD and wrap with kerlix, and secure with tape.

Change daily and prn.Wound #2 Right Buttock gluteus maximus: Cleanse Wound.

Cleanse with warm soap and water (gentle scrub) - and pat dry.

Use house stock barrier cream.

Perform every shift and prn.Review of the progress notes reveal the wound note was entered as a late entry on October 17, 2025, at 4:08 p.m.

Review of the physician orders indicated wound care orders were entered on 10/17/25.

Resident R1 discharged from the facility on 10/17/25.

During an interview on 11/19/25, at 12:40 p.m. the Director of Nursing confirmed the facility failed to ensure that a physician timely wrote, signed, and dated progress notes at each visit for one of two residents reviewed (Resident R1).28 Pa.

Code: 211.12(d)(5) Nursing services.28 Pa.

Code: 211.2(a) Physician services.28 Pa.

Code: 211.5(f) Clinical records.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

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