River Walk Care Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the physicians orders were followed for one of three sampled residents (Resident 1) when the diet order was not updated correctly during an order update for Resident 1. This failure resulted in Resident 1 not receiving a controlled carbohydrate diet (CCHO- commonly used for diabetics) for approximately three months.

Inspectors wroteBased on interview and record review, the facility failed to ensure their policy and procedure was followed when one of three sampled residents (Resident 1) did not have a discharge care plan developed. This failure had the potential for Resident 1 to have unmet discharge needs.

Inspectors wroteBased interview and record review, the facility failed to follow its own policy and procedure (P&P) for one of three sampled (Resident 1) when written request for Resident 1's clinical records was not provided in a timely manner. This failure resulted in violation of Resident 1's rights and not providing Resident 1's clinical records approximately 29 days after the request date.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Ensure one of 25 sampled residents' (Resident 92) medical record contained accurate documentation. This failure resulted in inaccurate medical documentation and had the potential to result in inaccurate monitoring of wound progression, inappropriate treatment, and wound treatment complications. 2. Ensure one of 6 sampled residents (Resident 92) had a physician order prior to changing a wound treatment. This failure had the potential to result in inappropriate treatment and wound treatment complications.3. Ensure one of 4 sampled residents (Resident 10) had a physician order to discontinue weekly/monthly weights. This failure had the potential for Resident 10's weight gain or loss to go unmonitored.

Inspectors wroteBased on interview and record review, the facility failed to implement their care plan (a comprehensive, personalized document created by an interdisciplinary team [IDT - a collaborative group of healthcare professionals, including nurses, doctors, therapists, social workers, and the resident/family, who work together to create and implement personalized care plans] to guide a resident's medical, nursing, and rehabilitative care) intervention for monitoring five of 13 sampled residents (Resident 27, Resident 67, Resident 36, Resident 42, and Resident 3). This failure had the potential to result in resident harm/injury, and/or failure to provide appropriate interventions for Resident 27, Resident 67, Resident 36, Resident 42, and Resident 3 safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of 29 sampled residents (Resident 5) was provided with meal at a palatable (pleasant to taste) and safe temperature. This failure had the potential for food borne illnesses to affect all residents eating from the facility kitchen and/or result in meals not being palatable leading to potential unintended weight loss.

Inspectors wroteBased on interview and record review, the facility failed to monitor refrigerator/freezer temperatures used to store residents' food. This failure had the potential to spread foodborne illnesses to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow standard practice for infection control when: 1. Two of eight sampled staff members (Certified Nursing Assistant [CNA] 1 and Physical Therapy Assistant [PTA] 1) did not apply appropriate personal protective equipment (PPE- gowns, gloves, face masks, face shields or other equipment designed to protect the wearer from injury or the spread of infection or illness) prior to providing high contact care (involving direct contact with a resident) to a resident on enhanced barrier precautions (EBP- an infection control practice that utilizes the use of gown and gloves during high contact care activities to stop the spread of multi-drug resistant organisms [MDRO]).2. Facility failed to implement their policy and procedure on Handling Soiled Linen, for one of 29 sampled residents (Resident 65). [...]

Inspectors wroteBased on interview, and record review, the facility failed to follow its policy and procedure (P&P) titled Psychotropic Medication [medication that affects brain activity, resulting in changes in mood, behavior, thoughts, and perception] Use for one of two sampled residents (Resident 45) when psychotropic medication was administered to Resident 45 for 50 days without IDT (Interdisciplinary team- a collaborative group of healthcare professionals, including nurses, doctors, therapists, social workers, and the resident/family, who work together to create and implement personalized care plans) approval and consent. This failure had the potential for Resident 45 receiving a larger dose of medication than what the facility determined was appropriate causing potential for harm and/or serious side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to follow the steps in checking the placement of G-Tube (surgical tube place in stomach delivering nutrient supplement) prior to administering two medications for one of four sampled Residents (Resident 79). This failure the had potential for Resident 79 to have discomfort and aspiration (food or liquid enters the airway).

Inspectors wroteBased on interview and record review, the facility failed to re-assess and monitor one of three sampled resident (Resident 1) with bruising to the right forearm. This failure had the potential Resident 1's bruise to the right forearm to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure:1. Expired food was disposed of;2. Food was labeled and dated in the refrigerator and freezer once opened;3. Frozen food items were stored properly and;4. Steam table was kept free of debris. These failures had the potential for residents to consume expired food items and the potential for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to implement the care plan (specific healthcare goals, interventions, and monitoring strategies) for one of two sampled residents (Resident 1) when the bowel and bladder retraining (scheduled toileting) was not implemented for Resident 1 who was at high risk for falls and had a history of falls related to toileting needs. This failure resulted in Resident 1 going to the bathroom on 8/20/25, independently, falling and sustaining an acute (new) left femoral neck fracture (break in the bone that connects the head of the femur (ball of the hip joint) to the shaft of the femur) extending to the lesser trochanter (attachment point for hip flexor muscles) and requiring hospitalization and surgical repair.

Inspectors wroteBased on interview and record review, the facility failed to notify the physician when one of two sampled residents (Resident 1) had blue discoloration to his left foot. This failure resulted in the facility being unaware of Resident 1's nondisplaced (bone fragments are in their original position) fracture (break in the bone) proximal (closer to the center) aspect proximal phalanx (toe bone) left first digit and a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to follow Physicians Order (PO) for one of three sampled residents (Resident 1) when a follow up wound clinic appointment was not scheduled. This failure had the potential for Resident 1's wound to worsen.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure for a change of condition for one of three sampled residents (Resident 1) when a S (Situation) B (Background) A (Appearance) R (Review and Notify) (SBAR-document used to notify the physician of a change of condition) was not completed, and Resident 1 was not monitored for a change of condition when experiencing a dislocated hip. This failure had the potential for staff to be unaware of Resident 1's worsening condition and the potential for a delay in care.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided with a detailed discharge summary. This failure had the potential for Resident 1 to be unaware of how to care for his wounds and the potential for the wounds to worsen.

Inspectors wroteBased on interview and record review, the facility failed to ensure physician's orders were followed for one of three sampled residents (Resident 1) when: 1. The physician was not notified when blood sugar results were greater than 400; 2. Antibiotics were not administered for osteomyelitis (bone infection). These failures had the potential for Resident 1 to experience adverse side effects such as delayed wound healing and the potential for wounds to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the therapeutic menu was followed for one of three sampled residents (Resident 1). This failure resulted in Resident 1 being served the incorrect dessert.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was provided: 1. A restorative nursing program (program where restorative nursing assistants [RNA]-assist residents with performing exercises to maintain their ability to perform daily activities and tasks, impacting their quality of life and overall well-being and independence) from February 2024-December 2024. 2. Physical therapy (PT-exercises, massages and various treatments used to relieve pain, help you move better or strengthen weakened muscles) and Occupational therapy (OT-focuses on everyday tasks and activities that people value and need to do, such as self-care, work, play, and social participation) as ordered by the physician in August 2024 and December 2024. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure physician orders were followed for one of three sampled residents (Resident 1) when treatments were not done as ordered. This failure had the potential for Resident 1's wounds to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure professional standard of care for one of two sampled residents (Resident 1) when blood glucose (sugar) test (measures the sugar level in the blood) was not checked timely as ordered by the physician. This failure had the potential for Resident 1 to have adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication administration competency assessment was completed for one of two licensed nurses (Registered Nurse-RN). This failure had the potential for medication errors and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide supervision for one of two sampled residents (Resident 1) with a diagnosis of dementia (a progressive state of decline in mental abilities), is a high risk for elopement and had a history of elopement. This failure resulted in Resident 1 eloping from the facility without staff being aware and potential for harm.

Inspectors wroteBased on interview and record review, the facility failed to follow its policy and procedure on Care Plans, Comprehensive Person-Centered for one of three sampled residents (Resident 341) to reduce the risk of falls and minimize injuries. This failure resulted in Resident 341 falling multiple times in six months and sustaining a fracture (broken bone) to his left hip and left shoulder requiring surgical repair.

Inspectors wroteBased on interview, and record review, the facility failed to follow the facility's policy and procedure (P&P) titled, Advanced Directives, when 26 of 30 sampled residents (Resident 292, Resident 63, Resident 341, Resident 49, Resident 17, Resident 50, Resident 32, Resident 61, Resident 46, Resident 52, Resident 2, Resident 12, Resident 5, Resident 4, Resident 65, Resident 15, Resident 85, Resident 60, Resident 56, Resident 35, Resident 31, Resident 23, Resident 57, Resident 69, Resident 78, and Resident 39) did not have an Advance Directive, including the right to accept or refuse medical or surgical treatment, in the residents' medical record. This failure had the potential for the facility to provide treatment and services against multiple residents wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their policy and procedure (P&P) titled, Laundry and Bedding, Soiled, when one of eight sampled residents (Resident 60) was observed with brown stains on the bed linen. This failure had the potential for Resident 60 to be exposed to infectious disease. During a concurrent observation and interview on 10/14/24 at 10:34 a.m. with Family Member (FM) 2 in Resident 60's room, an unoccupied bed had multiple brown spots on the bed linen. FM 2 stated the bed linen has been dirty for 2 days. FM 2 stated she did not want to sit in a room with dirty bed linen. During a concurrent observation and interview on 10/14/24 at 10:40 a.m. with House Keeping (HK) 1 in Resident 60's room, HK 1 confirmed there were dried brown colored spots on the bed linen. HK 1 stated dirty bed linen should be changed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, when oral care was not provided for one of eight sampled residents (Resident 51). This failure had the potential to result in oral discomfort or infections and dental cavities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policy and procedure (P&P) titled, Enteral Feedings - Safety Precautions, for one of four sampled residents (Resident 51) when: 1. Enteral nutrition feeding bottle was not labeled. This failure had the potential for old, spoiled, or expired nutritional feedings to be administered to Resident 51. 2. Enteral tubing was disconnected from gastrostomy (G-tube - a surgical inserted tube that provides direct access into the stomach) site a three-way-valve. The three-way-valve was not closed, and stomach contents were leaking onto Resident 51's abdomen and clothing. This failure had the potential for Resident 51's skin to develop sores.

Inspectors wroteBased on interview and record review, the facility failed to implement pharmacy recommendations for one of 19 sampled residents (Resident 341) after multiple falls. This failure had the potential for staff to be unaware of Resident 341 experiencing adverse consequences from medication and Resident 341 to experience subsequent falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy and procedure (P&P) titled, Activities of Daily Living (ADL), Supporting, for providing services for maintaining independence in activities of daily living (ADLs - routine tasks/activities such as eating, bathing, dressing) for one of three sampled residents (Resident 52) when Resident 52 did not have an adaptive device to enable her to drink water independently. This failure resulted in Resident 52 to be dependent upon facility staff.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were in-serviced on the elopement binder. This failure had the potential for staff to be unaware of residents that were at risk for elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect when Certified Nursing Assistant (CNA 1) used foul language and shooed (make someone go away) Resident 1 away with her hands. This failure resulted in Resident 1 becoming agitated (to feel bothered or worried) and violated Resident 1 ' s rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure wound treatments were completed for three of three sampled residents (Resident 1, Resident 2, and Resident 3). This failure had the potential for the residents' wounds to worsen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to monitor the temperature in the dry food storage room. This failure had the potential to decrease quality and palatability in the food items being stored.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain a safe and homelike environment when: 1. Eight of 39 sampled residents (Resident 24, Resident 53, Resident 30, Resident 32, Resident 43, Resident 22, Resident 67, and Resident 74) had holes in the ceiling and dark brown/black stained ceiling tiles in their rooms. This failure resulted in Resident 24, Resident 53, Resident 30, Resident 32, Resident 43, Resident 22, Resident 67, and Resident 74 not having a home like environment and had the potential to adversely affect the health and safety of the residents residing in the facility. 2. The baseboard along the wall of the head of one of one resident's (Resident 33) bed was broken. This failure resulted Resident 33 not having a home like environment and the potential for exposure to vermin infestation. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure five of five sampled residents (Resident 6, Resident 23, Resident 3, Resident 39 and Resident 51) were free from verbal abuse, when Resident 6 and Resident 23 repeatedly yelled/screamed at each other. This failure resulted in Resident 6, Resident 23, Resident 3, Resident 39, and Resident 51 experiencing mental distress and discomfort, including weeping.

Inspectors wroteBased on interview and record review, the facility failed to follow standard practices of care when: 1. Physician was not informed of one of one sampled resident's (Resident 23) ongoing and increased behaviors related to schizophrenia (a mental disorder)], which resulted in a discontinuation of Zyprexa [a psychotropic medication used to treat mental disorders]. This failure resulted in the unmet care needs for Resident 23's ongoing psychological conditions. 2. Staff did not follow physician orders to change Lopez valve (a device which allows the administration of medications and feeding through a gastrostomy tube (G-Tube, a feeding tube inserted through the stomach) for one of one sampled G-Tube residents (Resident 33). 3. Staff did not follow physician orders to clean G-tube site as ordered for one of one sampled G-Tube residents (Resident 33). 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to accurately complete the annual Pre-admission Screening Assessment and Resident Review (PASARR-federal requirement to help ensure that individuals are not incorrectly placed in nursing homes or long term care instead of a psychiatric setting) for one out of one sampled residents (Resident 23). This failure had the potential for Resident 23 to be placed in an inappropriate setting and not receive required services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a baseline care plan was developed and implemented for one of one edentulous [no natural teeth] residents (Resident 41). This failure had the potential for Resident 41 to have unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 39 sampled residents (Resident 23 and Resident 71) had comprehensive care plans developed and implemented for their person-centered care. This failure resulted in Resident 23 and Resident 71 not having their needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide hearing aids or other devices to maintain resident's communication abilities for one of one sampled residents identified of being hard of hearing (Resident 71). This failure resulted in Resident 71 not being able to communicate effectively.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an alternative means of communication for one of one sampled non-English speaking residents (Resident 41). This failure resulted in Resident 41 unable to communicate her needs and had the potential for unmet care needs.

Inspectors wroteBased on an observation, interview, and record review, the facility failed to provide foot care for one of two sampled residents (Resident 53). This failure resulted in Resident 53 having untrimmed toenails which had the potential to result in skin irritation including skin tears/damage and toenail infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure a safe environment for two of two sampled residents (Resident 41 and Resident 54) when: 1. One screener (unlicensed, untrained person, whose function is to screen visitors and staff for symptoms of COVID-19) assisted Resident 41 with a transfer from her bed to her wheelchair. This failure resulted in Resident 41's fall during transfer from her bed to the wheelchair. 2. Licensed nurses did not complete the post fall monitoring and a neuro checks for Resident 54 for multiple unwitnessed falls. This failure had the potential for Resident 54 to have unknown injuries during seven unwitnessed falls and two fractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a plan of care for one of one sampled resident's (Resident 23) prosthetic (artificial device to replace a missing body part) eye. This failure resulted in the staff being unaware of the plan of care for Resident 23's missing eye.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide effective pain management for one of one sampled residents (Resident 23). This failure resulted in Resident 23's unmanaged pain, psychological distress, and refusal of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff provided non-pharmological interventions for one of one sampled residents (Resident 33) on a psychotropic medication (medication that affects brain activities associated with mental processes and behavior). This failure had the potential for Resident 33 to experience increased risks such as dizziness, severe drowsiness, loss of consciousness and nausea or vomiting associated with the use of Buspirone HCL [hydrochloride] [Buspar - a psychotropic medication used to treat anxiety].

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a dental follow-up and services were provided to one of one sampled residents (Resident 41) with dentures. This failure resulted in Resident 41 not receiving dental services.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate Treatment Administration Record (TAR), for one of one sampled residents (Resident 71). This failure resulted in the incorrect documentation of Resident 71 had compression stockings (specialized hosiery for residents with swollen legs) applied according to the physician order (PO).

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Label and date irrigation syringes for two of two sampled residents (Resident 80 and Resident 33) with gastrostomy tube (G-tube - a feeding tube inserted through the stomach) feedings. 2. Follow facility policy and procedure (P&P) for hand hygiene for two of two sampled residents (Resident 33 and Resident 67) when exiting or entering resident rooms and between resident care 3. Follow facility policy and procedure (P&P) for hand hygiene for one of one sampled residents (Resident 78) during wound care. These failures had the potential to place residents, staff, and visitors at risk for infection.