Inspection·April 11, 2024

F 0603 Protect each resident from separation (from other residents, his/her room, or confinement to his/her room). Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of facility policy, the facility failed to ensure a resident met criteria for admission to the facility's secure unit and was in the least restrictive environment available. This affected one (#6) of three residents reviewed who resided in the secure or locked unit. The census was 173. Residents Affected - Few Findings include: Review of Resident #6's closed medical record revealed an admission date of 02/09/24. Diagnoses listed include anxiety disorder, major depressive disorder, hypokalemia, and hypertension. Resident #6 was transferred to a local hospital on [DATE] for stroke like symptoms and had not returned to the facility. Review of an admission Minimum Data Set (MDS) dated [DATE] revealed Resident #6 was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of a possible 15. Resident #6 was not having hallucinations or delusions, was not verbally of physically aggressive towards others, and had not wandered. Review of behavioral hospital documentation revealed Resident #6 was admitted from a local hospital on [DATE] after being found laying face down on her floor by neighbors. Resident #6 was psychotic and having delusions. Resident #6 was treated for nontraumatic rhabdomyolysis, severe hypokalemia, and starvation ketosis while at the local hospital. Review of discharge instructions dated 02/09/24 revealed Resident #6 was at her baseline as evidenced by decrease in psychotic and delusional behaviors. Resident #6 had been cooperative with care and denies any paranoid ideation's or delusional thoughts and has been medication compliant. Further review of Resident #6's closed medical record revealed she was admitted to a secured unit of the facility on 02/09/24 and remained there during her stay until transfer 04/06/24. Resident #6 was documented as being her own representative. Review of physician orders revealed and order dated 02/13/24 for may be on secured unit related to poor safety awareness and impaired cognition. Further review of Resident #6's closed medical record revealed no documentation of any hallucinations, delusions, wandering, or exit seeking behavior while at the facility from 02/09/24 to 04/06/24. Resident #6 was documented as being pleasant and cooperative with care and medications. There was no documentation by a physician of Resident #6's benefit from a secured unit environment. No (continued on next page) 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. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 365877 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 365877 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/11/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Riverside Nursing and Rehabilitation Center 1390 King Tree Drive Dayton, OH 45405 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)