River Valley Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview, record review, and policy review, the facility did not ensure that two of seven residents sampled (Residents 1 and 2) were treated with dignity when:1. Resident 1 was left in his bed wet after bathing.2. Resident 2 reported that his pants were missing and the facility did not address the issue for more than a month. These failures caused Resident 1 to be frustrated and caused Resident 2 to be angry.

Inspectors wroteBased on interview, and record review, the facility failed to submit the required Payroll Based Journaling (PBJ), staffing information to the Centers for Medicare and Medicaid Services (CMS). This failure has the potential for nursing homes to have inadequate staffing to care for residents and can lead to adverse clinical outcomes.

Inspectors wroteBased on observation, interview, and policy review the facility did not protect the rights of all residents of the facility to access and review the results of the most recent recertification survey (a recertification survey is an evaluation of the facility to ensure they are compliant with federal regulations, clinical quality, and operational standards so they can continue to receive Medicare/Medicaid reimbursement) of the facility. This failure resulted in residents of the facility not knowing where to find the results to review.

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean homelike environment affecting two out of 21 resident bathrooms housing up to three residents in each room, when the shared bathroom between rooms [ROOM NUMBERS] was highly malodorous smelling of a high concentration of urine, with brown staining in the linoleum (vinyl flooring) and surrounding the front of the toilet, and what appeared to be fecal matter (poop) adhered to the toilet tank, seat, and rim of the toilet. The bathroom between rooms 19 ad 20 smelled of urine, had brown staining to the linoleum flooring in front of the toilet, and black staining spreading out behind the toilet within the linoleum. This failure had the potential to result in disease transmission, with increasing health complications and overall well-being issues to those residents utilizing the common space. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that one of five sampled residents (Resident 33) was administered an inhaler (hand held device that delivers medication directly into the lungs), in accordance with manufacturer's instructions. This failure had the potential for the medication to be ineffective and have a negative impact on the resident's respiratory health.

Inspectors wroteBased on interview, record review, and policy review, the facility failed to manage urinary retention (the inability to empty the bladder of urine) for one of four residents sampled (Resident 1) when Resident 1 did not urinate for over 14 hours, which can be a life-threatening medical emergency. This failure resulted in delayed treatment of Resident 1's urinary retention.

Inspectors wroteBased on interview and record review, the facility failed to report an outbreak of gastroenteritis (symptoms could include vomiting and diarrhea, which could be caused by an infection) to the California Department of Public Health (CDPH, responsible to protect the health of the public) in a timely manner. This failure had the potential for infection to spread to all residents, facility staff, and the community.

Inspectors wroteBased on interview and record review, the facility failed to monitor output of foley catheters (FC - a thin, flexible tube that drains urine from the bladder into a bag) per facility policy and physician orders for three of three sampled residents (Resident 1, 2, 3). This failure had the potential to endanger the residents and cause complications due to inaccuracies in fluid balance monitoring.

Inspectors wroteBased on interview and record review, the facility failed to inform one of three sampled resident's (Resident 1) representative (RP), of a change in Resident 1's condition which required the resident to have oxygen administered. This failure violated Resident 1 and her RP's right to be fully informed of a need to alter treatment before the treatment was initiated, and make choices that were consistent with Resident 1's wishes.

Inspectors wroteBased on interview and record review, the facility administered oxygen (02) without a physician's order to one of three sampled residents (Resident 1). This failure had the potential to lead to negative resident clinical outcomes when nurses choose to administer medications without an order to do so by a physician.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician when a medication was not available for administration for 1 (Resident #58) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on observation, record review, interview, and review of the Centers for Medicare & Medicaid (CMS) Resident Assessment Instrument (RAI) 3.0 User's Manual, the facility failed to ensure staff accurately coded a Minimum Data Set (MDS) for 4 (Residents #8, #25, #44, and #52) of 22 sampled residents.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to accurately complete a Level I Pre-admission Screening and Resident Review (PASRR) for 2 (Resident #6 and Resident #18) of 6 residents reviewed for PASRR.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to have a person-centered comprehensive care plan for 2 (Resident #44 and Resident #52) of 22 sampled residents. Specifically, the facility failed to include the use of a non-invasive mechanical ventilator for Resident #44 and Level II Preadmission Screening and Resident Review (PASRR) results for Resident #52 on the comprehensive care plan.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure non-invasive mechanical ventilation equipment was cleaned and stored properly for 1 (Resident #44) of 3 residents reviewed for respiratory care.

Inspectors wroteBased on interview, record review, facility document review, and facility policy review, the facility failed to ensure medications were received from the pharmacy in a timely manner for 1 (Resident #58) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview, record review, and facility policy review, the facility failed to notify the physician of pharmacy consultant recommendations for 1 (Resident #56) of 6 residents reviewed for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to update care plans (a plan that outlined resident goals, care needed, and support the facility staff would provide) for two out of three sampled residents (Residents 2 and 7) when Licensed Nurses (LN) did not update the care plan after Residents 2 and 7 had a fall. This had the potential for an increase in falls and injuries.

Inspectors wroteBased on observation and interview, the facility failed to ensure proper infection control procedures were followed when two staff members were observed not wearing proper personal protective equipment (PPE-equipment worn to create a barrier between infectious material and a person including, gloves, gown, N95 (specialized mask), and eye shields) in COVID-19 (a highly contagious respiratory disease caused by the coronavirus) positive resident rooms. This failure had the potential to spread infection among residents, visitors, and staff.

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy and procedure (P&P) for an abuse allegation that involved two out of four sampled residents (Residents 1 and 2) when the facility did not provide the State Survey Agency (SA) with results of the facility ' s investigation of the alleged abuse within five (5) working days. The lack of facility oversight placed residents at risk for further potential abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify specific risk factors (root cause, the reason why), reevaluate interventions (written instructions that described care provided), monitor interventions for effectiveness, and follow their policies and procedures (P&P) for one out of three sampled residents (Resident 1) that were identified as an elopement (leave without supervision) risk. This failure resulted in Resident 1 ' s second elopement on 9/7/24 and placed Resident 1 at an increased risk for continued elopement and injury.

Inspectors wroteBased on interview, record review, and policy review the facility failed to report the results of the facility investigation with corrective actions related to abuse, per state law and the facility policy, to the State Survey Agency within five (5) working days of the incident, when one of two sampled resident ' s abuse incidents (Resident 1 and 2) was not reported to the California Department of Public Health (CDPH) within 5 working days of the alleged abuse incidents occurring and presumptively being investigated with result determination and corrective action taken. This failure to report that an abuse incident was investigated resulting in a determination with corrective action taken by the facility had the potential to subject residents to continued abuse situations with no oversight.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two sampled residents (Resident 1) mail was delivered unopened and within 24 hours, per facility policy. This failure resulted in violating Resident 1's right to forms of communication with privacy and the potential for mental anguish.

Inspectors wroteBased on interview and record review, the facility failed to effectively assess and obtain a wound care treatment order for a surgical wound for two weeks after admission, for one of three sampled residents (Resident 1), when Resident 1 was admitted with a surgical wound that Resident 1 refused to have assessed by staff, and the facility waited two weeks for the Orthopedic (Ortho, medical branch concerned with conditions involving the musculoskeletal system), follow-up appointment to obtain an order for Resident 1's wound care and treatment. This failure had the potential to result in increased health and healing deterioration including worsening of the wound, heightened infection issues, including sepsis, loss of limb, and death, and aggravated mental and psychosocial decline.

Inspectors wroteBased on observation and interview, the facility failed to ensure that one of four sampled residents (Resident 1) got an activities schedule and a newletter (a written document about facility news and upcoming activities), for the months of June and July 2024. These failures caused Resident 1 to not know when activities were scheduled, what activities were being offered, or what the current news of the facility was, which violated his right to be informed and make decisions regarding his activities.

Inspectors wroteBased on interview and record review, the facility failed to ensure one or four sampled residents (Resident 2's) dignity was honored and that Resident 2 was respected when Certified Nursing Assistant (CNA) X did not stop when Resident 2 asked CNA X to stop trying to move her without the help of another person. This failure resulted in Resident 2 feeling afraid because the lack of respect shown by CNA X triggered Resident 2's Post Traumatic Stress Disorder (PTSD - anxiety and flashbacks triggered by a traumatic event).

Inspectors wroteBased on interview and record review, the facility failed to ensure Certified Nursing Assistant (CNA) X had knowledge about how much assistance was needed for one of four sampled residents (Resident 2), when CNA X provided cleaning for incontinence (inability to control the flow of urine from the bladder or the escape of feces from the rectum), without the help of a second person to roll Resident 2 in bed. This failure resulted in Resident 2 experiencing unnecessary discomfort during incontinent care.

Inspectors wroteBased on interview and record review, the facility failed to follow their dialysis policy and procedure (P&P) for four out of four sampled residents (Residents 1, 3, 4, and 5) when: 1. Resident 1 was not provided lunch before leaving the facility for a dialysis (a procedure to remove waste products and excess fluid from the blood when the kidneys stopped working) appointment, was not provided a meal to take to dialysis, and was not provided a meal upon return to the facility after her dialysis appointment. 2. Pre (before), during, and post (after) dialysis assessments (the assessment included information regarding the residents before, during, and after dialysis, such as, vital signs, lung sounds, skin condition, dialysis access site, weight, and if a meal was sent) were not completed consistently for Residents 1, 3, 4, and 5). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the resident ' s rights of being treated in a dignified manner for one of three sampled residents (Resident 2), when Certified Nursing Assistant (CNA) 1, rolled Resident 2 from side to side during changing her brief, and Resident 2 thought she smacked her on the hip which made her feel violated and indignant. This failure had the potential to cause harm both physically and emotionally leading to a decline in health status due to possible withdrawal and desolation from care providers and the care being provided.

Inspectors wroteBased on interview and record review, the facility failed to maintain a safe infection control program when unlicensed staff performed COVID-19 (COVID, a respiratory illness that caused many elderly people to be hospitalized ) testing on residents of the facility and COVID testing in-service (education and training provided to staff) documentation was not available. This failure had the potential to result in harm to residents and for COVID specimen samples to be collected incorrectly which could cause a false negative or false positive test result.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate, assess, and provide wound care treatments to three of eight sampled resident's (Residents 37, 42, and 211). The facility also failed to use professionally recognized standards for documenting, and staging pressure injuries. These failed practices resulted in the developing of new, or worsening of existing pressure injuries (wounds caused by unrelieved pressure on the skin) for these residents, which could lead to negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that two of 22 sampled residents (Residents 37, and 47), whose weights were not within acceptable parameters of nutritional status, received adequate evaluations, interventions, and monitoring. These failures resulted in significant weight loss for these residents, and had the potential to lead to a decline in their overall health condition.

Inspectors wroteBased on interview, and record review, the facility did not have sufficient Certified Nursing Assistant staffing to provide timely care of residents, answering of call lights and prevention of incontinence. This failure has the potential to cause mental distress, anguish and adverse clinical outcomes.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure food safety and resident nutrition care processes were adequately in place when: 1. There was no facility Registered Dietitian (RD) from mid-September 2021 through 12/3/2021. 2. Regular monthly food safety and sanitation inspections were not consistently performed by the RD to monitor food safety, sanitation and resident nutrition care processes, and identified deficiencies in the Dietary Department, that would then be addressed or resolved timely. 3. There was not an effective or consistent system in place to ensure timely communication between nursing services, and dietary services related to resident nutrition care. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was flavorful and prepared by methods that conserved nutritive value. This failure has the potential to negatively impact resident's nutrition intake, health, and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to create and implement a menu system that met resident food preferences into the facility menu cycle. This failure has the potential to result in resident dissatisfaction with the meal service, decrease meal intakes, and increase the risk for weight loss, malnutrition, and overall health decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that food was stored, prepared and distributed in accordance with professional food safety standards when: 1. Staff failed to wash hands, change gloves between tasks, and use gloves as personal protective equipment, increasing the potential for cross contamination to occur. 2. Staff did not consistently wear aprons, potentially resulting in cross-contamination between staff clothing, food, and equipment during food preparation meal service, and dish washing processes. 3. The kitchen was not sanitary. 4. Fixed equipment (equipment that cannot be cleaned in the dish washer or in the three-compartment sink) was not washed and rinsed prior to sanitizing, and air dry. 5. Food was not stored, labeled, dated or discarded appropriately. 6. Produce was not washed according to professional standards of practice. [...]

Inspectors wroteBased on interview, and record review, the facility's Quality Assessment and Assurance and Performance Improvement (QAPI) committee failed to identify, develop, and implement a plan of action to correct deficiencies related to residents receiving adequate nutrition to prevent significant weight loss, and facility acquired pressure ulcers. As a result of this failure deficiencies were present regarding severe weight loss for two residents, and facility acquired pressure ulcers for two residents. (Refer to F 686 and 692)

Inspectors wroteBased on interview, and record review, the facility failed to ensure its policies regarding pneumococcal immunizations (vaccines to prevent pneumonia) were followed when three of five randomly sampled residents (Residents 26, 28, and 49) had not received both pneumococcal immunizations. This failure had the potential to result in these residents, and other residents residing in the facility becoming ill with pneumonia.

Inspectors wroteBased on interview, and record review, the facility failed to develop an initial baseline care plan within 48-hours of admission, for one of four newly admitted residents (Resident 112). Resident 112 was admitted with known skin issues, and the baseline care plan did not include this problem. This failure had the potential to result in the worsening of the skin problems, which could lead to negative clinical outcomes.

Inspectors wrote2. The facility's policy titled, Fall Management Program, revised 3/13/21, was reviewed, and indicated that following every resident fall, the licensed nurse will perform a post-fall evaluation and update, initiate or revise the resident's care plan as necessary. For an unwitnessed fall, or a witnessed fall with suspected or known head injury, the licensed nurse will complete neurological checks for 72-hours following the fall incident. Resident 63's medical record was reviewed. Resident 63 was admitted to the facility on [DATE], with diagnoses that included; a pubic rami fracture (fracture of the ring of bones near the tailbone), a right femur (upper leg bone) fracture, diabetes (high blood sugar), dementia, anxiety, and high blood pressure. Resident 63's record indicated that on 9/17/21, Resident 63 had an unwitnessed fall. [...]

Inspectors wroteBased on observation, interview, and record review, for two of 22 residents (Residents 36 and 42), the facility failed to provide activities as indicated in their comprehensive care plans. This failure had the potential to result in a decline in their mental and psychosocial well-being, which could lead to negative clinical outcomes.

Inspectors wroteBased on interview, and record review, the facility failed to implement their fall management policy for one of five sampled residents (Resident 63) when they failed to initiate appropriate assessments and monitoring following multiple falls. This had the potential for post fall injuries and changes in condition to go unrecognized, and therefore untreated which could lead to negative clinical outcomes.

Inspectors wroteBased on observation, and interview, the facility failed to make sure that there was a secure, and safe method for disposal of medications and narcotics (strong pain medications). This failure had the potential to lead to drug diversion (the illegal distribution, or abuse of prescription drugs, or their use for purposes not intended by the prescriber) and possible exposure of the residents to potentially hazardous substances.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure a safe, functional and sanitary environment when: 1. The floors, walls, ceiling, cabinets and shelving in the Food and Nutrition Services kitchen were not maintained clean and in good repair. 2. The walk-in refrigerator fans and light were not maintained sanitary and it good repair. These failures have the potential to negatively impact the food safety and sanitation of food service areas and can be a safety issue for staff.