River Towne Center

Inspectors wroteBased on observations, record reviews, interviews, and review of the facility policy titled, Medication Therapy, the facility failed to ensure residents or resident representatives were informed in advance of the risks and benefits of a prescribed psychotropic medication or an alternative treatment for two of three residents (Resident (R) 46, and R61) reviewed. This failure had the potential for residents to receive the medication without informed consent or understanding of the treatment, and/or alternative treatment available.

Inspectors wroteBased on observations, interviews, and facility policy review titled Environment, the facility failed to ensure the kitchen was maintained in a clean and sanitary manner for one of one kitchen affecting 103 residents who consume food from the kitchen. This failure had the potential to contribute to contamination and infection control concerns. During a kitchen observation, alongside the Dietary Manager (DM), on 04/01/26 at 6:02 AM, a large section of non-slip flooring in front of the steam table was worn through to show the underneath tile, and some missing grout for the tile.-Two sections of non-slip flooring in front of the three-pan sink were worn through, showing the underneath tile and concrete. [...]

Inspectors wroteBased on record review, interviews, and review of the facility's policy titled, Administering Medications, the facility failed to administer medications timely for one of six residents (Resident (R) 141) reviewed for medications out of a total sample of 38 residents. This failure had the potential to alter the effectiveness of the medication with the potential for overdosing if medications were given too close together.

Inspectors wroteBased on observations, record reviews, and interviews, the facility pharmacy services failed to ensure medication irregularities were identified and addressed when ordered medications were not available for administration for one resident (Resident (R) 147) out of four newly admitted residents reviewed for medication irregularities. This failure had the potential to result in a decline of the resident's condition due to missed medication.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Food Receiving and Storage, the facility failed to ensure food items were discarded upon expiration. This deficient practice had the potential to promote foodborne illnesses in the 110 residents receiving an oral diet from the kitchen.

Inspectors wroteBased on record review, observations, staff and family interviews, and review of the facility policy titled Care Plans, Comprehensive Person-Centered, the facility failed to develop a comprehensive, person-centered care plan for two of 49 sampled residents (R) (R70 and R385). This deficient practice had the potential to place R70 and R385 at risk of unmet needs, medical complications, and a diminished quality of life.

Inspectors wroteBased on observations, resident interviews, staff interviews, record review, and review of the facility policy titled Activities of Daily Living (ADL), Supporting, the facility failed to ensure that two of 49 sampled residents (R) (R12 and R43) received activities of daily living (ADL) care related to receiving scheduled showers to maintain good personal hygiene. This deficient practice had the potential to place R12 and R43 at risk of being unclean and feeling insecure about their appearance.

Inspectors wroteBased on observations, resident interviews, and staff interviews, the facility failed to ensure an environment free from accident hazards on one of seven medication carts and in three of 49 sampled residents' (R) (R12, R87, and R36) rooms. This deficient practice had the potential to place the residents at risk of accident hazards.

Inspectors wroteBased on staff interviews, resident family interviews, record review, and review of the facility policy titled Pain Assessment and Management, the facility failed to provide pain management for one of 49 sampled residents (R) (R385).

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Medication Labeling and Storage, the facility failed to ensure expired medications were discarded after the expiration date in one of two medication rooms. This deficient practice had the potential to place residents at risk of receiving medications with altered effectiveness.

Inspectors wroteBased on record review, observations, staff interviews, and review of the facility's policy titled Departmental (Respiratory Therapy) -Prevention of Infection Level I the facility failed to ensure the safe handling, labeling, and storage of nebulizer equipment to prevent contamination for one Resident(R)(R1) of 23 sampled residents. This deficient practice had the potential to contribute to the spread of infection and respiratory illness.

Inspectors wroteBased on staff interview and record review, the facility failed to implement care plan interventions for pressure ulcer treatments as ordered and provide descriptive wound documentation for two of 12 sampled Residents (R) (R2 and R6). These failures increased the potential for the residents not to receive treatment and/or care according to their needs.

Inspectors wroteBased on staff interview and record review, the facility failed to provide treatment timely for one of 12 sampled Residents (R) (R10) with a venous stasis ulcer.

Inspectors wroteBased on staff interviews, record review and review of the facility's policy titled Pressure Ulcers/Skin Breakdown - Clinical Protocol, the facility failed to assess pressure ulcers and initiate pressure ulcer treatments timely for three of 12 sampled Residents (R) (R2, R6 and R10).

Inspectors wroteBased on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Healthcare Personnel (HCP) During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the job description for the Administrator, the facility Administration failed to ensure the health and safety of the residents by not maintaining an effective Infection Prevention Control Program (IPCP) that would identify and investigate an infection outbreak to prevent or reduce the spread of Covid-19 by not following current guidelines for resident and staff testing (contact tracing or broad based testing). This failure resulted in a total of five residents and two staff members who tested positive for COVID-19. The facility census was 131. [...]

Inspectors wroteBased on record review, staff interviews, review of the Centers for Disease Control and Prevention (CDC) Interim Infection Prevention and Control Recommendations for Health Care Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, and review of the facility's COVID -19 Response, the facility failed to implement initial and ongoing testing of residents and staff as recommended by the CDC to lessen the exposure of COVID-19 during an outbreak, failed to ensure source control was used during outbreak, ensure the safety of all residents in the facility by not following current guidelines related to COVID-19 for resident and staff testing, infection control, monitoring and documenting COVID-19 symptoms for residents, notification of staff and family of outbreak status during an outbreak and source control that resulted in five residents (R)(R15, R89, R94, R111, and R433) and two [...]

Inspectors wroteBased on observations, resident and staff interviews, record reviews, and the review of the facility policy titled Resident Rights, the facility failed to provide care in a manner that maintained or enhanced a resident's dignity for one resident (R) (R11) of 59 sampled residents.

Inspectors wroteBased on observation, resident and staff interviews, record reviews, and review of the policy titled Residents Rights, the facility failed to allow four residents (R) (75, 86, 105, and 125) of 59 sampled residents the choice to take showers instead of bed baths.

Inspectors wroteBased on record review, staff interviews, and review of facility policy titled Care Plans - Baseline revealed the facility failed to ensure the baseline care plan for one resident (R) (R98) of 59 sampled residents was completed to include goals and interventions for fall risk.

Inspectors wroteBased on observations, record reviews, resident and staff interviews, and review of facility policy titled Shower/Tub Bath, the facility failed to ensure Activities of Daily Living (ADL) was provided related to bathing for one resident, (R) (R80), of 59 sampled residents.

Inspectors wroteBased on observations, interviews, review of facility documentation, and review of facility policies titled Medication Administration,, the facility failed to administer medication as ordered by the Physician for two residents (R) (R105 and R86) of 59 sampled residents. Specifically, the facility failed to treat diabetes and weight management for resident R105 and failed to have neuropathy medication available for R86.

Inspectors wroteBased on observations, staff interviews, record review, the facility failed to provide oxygen therapy as ordered for one resident (R) (R27) of 14 residents who were on oxygen therapy and failed to contain BiPAP tubing in a clean plastic bag when not in use for one resident (R27) out of four residents.

Inspectors wroteBased on observations, staff interviews, and review of the policy titled Storage of Medications, the facility failed to discard discontinued and outdated supplements, tube feedings, and Covid-19 test stored in one of two medication storage areas.

Inspectors wroteBased on observations, interviews, review of facility documentation, failed to get labs administer treatment for infection in a timely manner for one resident (R) (R102) of 59 sampled residents. Review of the electronic medical record of resident R102, revealed that he was admitted to the facility on [DATE]. R102 admission diagnoses included but are not limited to cerebral infarction, gastrostomy status, tracheostomy status, obstructive and reflex uropathy with chronic use of indwelling catheter, and dependence on respirator status. Review of Section G of the quarterly minimum data set (MDS), dated [DATE], revealed that R102 is total dependence with all activities of daily living. Section H revealed that the resident was admitted with and still has a foley catheter. [...]