Riverstreet Manor
RIVERSTREET MANOR in WILKES-BARRE, PA — inspection on May 28, 2026.
Found 2 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
Review of physician orders revealed an order dated May 24,
skin and typically presents as a shallow open wound or blister) of the sacrum with normal saline solution, pat dry, apply hydrogel, a moisture-retaining wound treatment used to promote healing, and cover the wound with bordered gauze.
Despite documentation from the hospital identifying the presence of a sacral pressure ulcer and physician orders directing wound treatment upon readmission, review of the clinical record failed to reveal documented evidence that licensed nursing staff completed a comprehensive skin assessment upon the resident's return to the facility on May 24, 2026. A review of the clinical record failed to reveal documentation identifying the wound's measurements, wound bed characteristics, presence or absence of drainage, condition of the surrounding tissue, pain assessment, or a comprehensive staging assessment upon readmission.
Additionally, the clinical record failed to reveal documentation that nursing staff completed and recorded the assessment components required by facility policy to evaluate and monitor an existing pressure injury. A review of nursing documentation revealed a skin and wound evaluation completed by the contracted wound care specialist on May 27, 2026, at 2:36 PM.
The wound care note documented that the coccyx/sacral wound contained 100 percent slough (a yellow or white nonviable tissue that can delay wound healing and increase the risk of infection).
The wound was reclassified as an unstageable pressure injury, meaning the true depth of the wound could not be determined because the wound bed was completely covered with dead tissue.
The wound measured 1.0 centimeters in length, 2.0 centimeters in width, and 0.5 centimeters in depth and contained exposed dermal tissue with a light amount of serous exudate a clear, thin, watery fluid produced by the body in response to tissue injury or inflammation).
The wound care specialist recommended new treatment interventions including cleansing the wound with normal saline solution, applying Santyl (an enzymatic debridement medication used to remove dead tissue from chronic wounds) covering the wound with a bordered dressing, and changing the dressing daily.
The wound characteristics documented by the contracted wound care specialist on May 27, 2026, had not been identified or documented by facility nursing staff upon the resident's readmission on [DATE].
During an interview with the Director of Nursing (DON) on May 28, 2026, at 2:15 PM, the above findings were reviewed.
The Director of Nursing stated that skin assessments were expected to be completed and documented by licensed nursing staff upon readmission to identify existing skin impairments and facilitate timely treatment.
The facility was unable to provide documentation demonstrating that licensed nursing staff completed the comprehensive skin assessment required by facility policy upon the resident's readmission on [DATE].
The facility failed to ensure a timely and comprehensive skin assessment was completed and documented upon readmission to identify existing skin impairment, evaluate wound characteristics, and guide appropriate interventions to promote healing in accordance with facility policy and accepted standards of practice. 8 Pa.
Code 211.10(d) Resident care policies. 28 Pa.
Code 211.12(c)(d)(1)(3)(5) Nursing services.
395691 05/28/2026
Riverstreet Manor 440 North River Street Wilkes-Barre, PA 18702
During an interview on May 28, 2026, at 2:00 p.m., the Director of Nursing reviewed the above findings and stated that Resident B2 was always incontinent of urine and bowel movements and should have been checked and changed every two hours.
The Director of Nursing was unable to provide documented evidence demonstrating that two-hour check-and-change interventions were consistently implemented or documented for Resident B2. 28 Pa.
Code 211.10(a)(d) Resident care policies. 28 Pa.
Code 211.12 (d)(1)(3)(5) Nursing services.
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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.