River Valley Health and Rehabilitation Center LLC

Inspectors wroteBased on interview and document review, the facility failed to notify the medical provider with a change in condition for 1 of 1 resident (R33) reviewed for notification of change.

Inspectors wroteBased on interview and document review, the facility failed to accurately code the presence of a pressure ulcer on the admission Minimum Data Set (MDS) assessment for 1 of 3 residents (R20) reviewed for pressure ulcers. Findings Include: R20's admission Minimum Data Set (MDS) dated [DATE], indicated R20 was admitted to the facility on [DATE], no cognitive impairment, required supervision with personal hygiene, and dependent with dressing, toileting, and transfers; diagnosis included pressure ulcer of sacral region unspecified stage, and Section M-Skin Conditions indicated R20 had no unhealed pressure ulcers/injuries. R20's Interim Payment Assessment MDS dated [DATE], indicated one or more unhealed pressure ulcers, and one stage 3 pressure ulcer. R20's care plan dated 1/19/26, indicated pressure injury to buttocks and interventions included; [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to follow ordered wound care treatments, failed to ensure availability and use of ordered supplies, and failed to notify the provider when treatments were not completed for a pressure-related wound for 1 of 3 residents (R10) reviewed for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to administer a physician-ordered medication for 1 of 1 resident (R37), when lorazepam (used to treat anxiety) was not administered. The facility did not notify the provider or leadership, or implement an alternative intervention, resulting in a medication omission for several days.

Inspectors wroteBased on interview and document review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of eight consecutive hours per day for four of 30 days reviewed for RN coverage. This had the potential to affect all 35 residents residing at the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. This had the potential to affect all 32 residents living in the facility.

Inspectors wroteBased on interview and document review, the facility failed to submit accurate staffing data based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 32 residents living in the facility.

Inspectors wroteBased on observation, interview and document review, the facility failed to timely notify the physician of new onset pressure ulcers for 1 of 1 resident (R7).

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure ventilator equipment supply water was not expired for 1 of 1 (R18).

Inspectors wroteBased on observation, interview, and document review, the facility failed to assess and meet the needs of 1 of 1 (R7) resident reviewed for the provision of medically related social services, who was grieving the death of a significant other.

Inspectors wroteBased on observation, interview and document review the facility failed to ensure appropriate personal protective equipment (PPE) was used during a sterile dressing change for 1 of 1 resident (R85).

Inspectors wroteBased on interview and document review the facility failed to ensure 2 of 5 residents (R21, R31) were offered and/or provided updated vaccinations for pneumococcal disease in accordance with the Centers for Disease Control (CDC) vaccinations.

Inspectors wroteBased on interview and document review the facility failed to comprehensively assess proper full body mechanical lift sling type and size according to manufacturer recommendations to ensure safety for 1 of 1 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a history of behaviors during lift transfers, fell from the lift and suffered a shoulder fracture. The immediate jeopardy began on 1/19/25, when staff used a hygiene (toileting) sling that was too large causing R1 to experience pain resulted in behaviors and fell through the lift sling to the floor. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 5:00 p.m. on 1/27/25. The facility implemented immediate corrective action on 1/19/25 to prevent recurrence, so the IJ was issued at past none compliance.

Inspectors wroteBased on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 35 residents. Interview on 2/7/24 at 1:56 p.m., with registered nurse (RN)-A identified she has heard of a PIP before, and thinks maybe some staff are watching for urinary tract infections, but was unsure what the PIP was or what her role in the PIP project could be. RN-A thought if there was a PIP there may be signage in the staff breakroom. RN-A received online general QAPI training but had not received training specific for the facilities QAPI plan. Observation on 2/7/24 at 1: 58 p.m. [...]

Inspectors wroteBased on interview and document review, the facility failed to provide mandatory training on the facility's specific QAPI Program to include goals and various elements of the program, how the facility intends to implement the program, staff's role in the facility's QAPI program, or how to communicate concerns, problems, or opportunities for improvement to the facility's QAPI program. This had the potential to affect all 35 residents.

Inspectors wroteBased on interview and document review the facility failed include with their Abuse Prohibition/Vulnerable Adult policy reporting of reasonable suspicions of a crime and coordination with the QAPI program to define how staff will communicate situations of abuse, neglect, misappropriation of resident property and exploitation for review and oversight.

Inspectors wroteBased on interview and document review the facility failed to ensure 1 of 1 resident (R2) was free from potential psychosocial abuse using the reasonable person concept when R2's family reported R2 would have been severely embarrassed and angry when R2 had a photograph taken of her by staff while being toileted.

Inspectors wroteBased on interview and document review the facility failed to follow or revise and/or update facility policies and ensure reports to the State Agency (SA) not later than 2 hours after alleged abuse, neglect, exploitation or mistreatment for 1 of 1 resident (R2) after the facility had knowledge of the incident. The facility further failed to revise and/or update their policy to include to report reasonable suspicion of a crimes against a resident receiving care at the facility to the local law enforcement, or what those may entail.

Inspectors wroteBased on interview and document review the facility failed to thoroughly investigate an allegation of abuse for 1 of 1 resident (R2).

Inspectors wroteBased on interview and document review, the facility failed to notify the county (designated State Mental Health Authority (SMHA)) for 1 of 1 resident (R2) with new onset mental illness.

Inspectors wroteBased on interview and document review the facility failed to develop a comprehensive care plan for 3 of 3 residents (R1, R2 and R3) reviewed who were diabetic (a condition preventing the body's ability to process food leading to dangerously high or low blood sugar levels) when the care plan did not identify potential diabetic complications and specific diabetic preventative health concerns related to diet, skin, vision, and foot care. R1's nursing home admission orders dated 12/11/19, indicated R1 received three different diabetic medications along with an order to check her blood glucose level two times a day. R1's medical order dated 1/14/21, indicated a new order to change her current regular diet to a diabetic diet. R1's care plan dated 1/12/22, indicated she had a risk for pain related to her diabetes. [...]