Riverdale Center for Nursing and Healing

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled Food Receiving and Storage, the facility failed to ensure that opened food items in the dry storage area were properly labeled and dated. In addition, dietary staff failed to ensure that opened food items were properly refrigerated. This deficient practice had the potential to place the 130 residents receiving nutrition and hydration from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled Medication Administration, the facility failed to ensure that residents' medications were free from misappropriation by licensed nursing staff during medication administration observations.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled MDS 3.0 Completion, the facility failed to complete a Minimum Data Set (MDS) comprehensive assessment for one resident (R) (R70) out of 57 sampled residents.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled MDS 3.0 Completion, the facility failed to accurately reflect the status on the Minimum Data Set (MDS) assessments for two of 57 sampled residents (R) (R70 and R1).

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure one of 57 sampled residents (R) (R36) received restorative care services as recommended by therapy staff. This deficient practice had the potential to place R36 at risk of unmet needs and a diminished quality of life.

Inspectors wroteBased on observations, record review, staff interviews, and a review of the facility policy titled Hospice Services Facility Agreement, the facility failed to maintain communication and coordination of care with hospice for one of six residents (R) (R7) receiving hospice palliative care services. This deficient practice had the potential to place R7 at risk of unmet care needs.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policies titled Catheter Care and Infection Prevention and Control Program, the facility failed to follow infection control process during indwelling catheter care for one of 11 residents (R) (R1) with an indwelling urinary catheter. This deficient practice had the potential to place R1 at risk of avoidable infection due to cross-contamination.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Food Preparation and Service - Sanitation, the facility failed to ensure residents were free from safety and sanitation hazards in the kitchen to include: keeping an air vent soiled with dust and debris; allowing an electrical outlet without a face plate in the dishwashing room; allowing paint chips to hang over the stove and oven area; using metal food trays that were warped and unserviceable; and maintaining an eye wash sink with a visible, brown substance pooled in it. The deficient practice had the potential to affect 121 of 121 residents who receive an oral diet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Accommodation of Needs, the facility failed to ensure that one of 50 sampled residents (R) (R60) needs were being met in regards to the call light being within reach.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Care Plans, Comprehensive Person-Centered, the facility failed to implement an oxygen (O2) care plan for one of 50 sampled residents (R) (R60) to ensure the resident reaches his/her highest practicable physical, mental, and psychosocial well-being. The deficient practice had the potential for R60's needs to go unmet.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility's policy titled, Care Plans, Comprehensive Person- Centered, the facility failed to revise a care plan for three of 50 sampled residents (R) (R17, R60, and R98). The deficient practice had the potential for residents not to receive prescribed and needed care and services.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policy titled, Activities of Daily Living (ADLs), the facility failed to provide grooming care for one of 50 sampled residents (R)(R70) dependent on staff for care. This deficient practice had the potential to cause a decline in R70.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Oxygen (O2) Administration, the facility failed to ensure that two of four residents (R) (R60 and R17) receiving O2 were administered O2 therapy in accordance with the physician orders. The sample size was 15. The deficient practice had the potential to place R60 and R17 at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, record review, and resident/staff interviews, the facility failed to honor the rights for three of five sampled residents (R) (R26, R27 and R43) related to maintaining personal property within their possession and ensuring possessions are rightfully returned to the residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure money taken from the Resident Trust Account was accounted for and used for resident needs for six of 15 sampled residents (R 29, R33, R34, R35, R36, and R37).

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to ensure narcotic medications for Resident (R13) and resident funds for Residents (R29, R33, R34, R35, R36 and R37) were not misappropriated for seven of fifteen sampled residents reviewed for misappropriation. This had the potential to affect 58 residents which had physician orders for medications which were stored in the locked narcotic drawer and had the potential to affect 105 residents whose funds were managed by the facility.

Inspectors wroteBased on observation, interview, record review, and review of the facility policy titled, Resident and Family Grievances, the facility failed to make prompt efforts to resolve grievances and failed to ensure that grievances were documented and investigated thoroughly for three of 36 sampled residents (R) (R20, R8, and R19).

Inspectors wroteBased on interviews, record review, and review of the facility policy titled, Transfer and Discharge (including AMA), the facility failed to develop a discharge care plan and set up home health timely for one of four sampled residents (R) (R14).

Inspectors wroteBased on record review and interviews, the facility also failed to transcribe physician orders for one of four sampled residents (R30) which resulted in the resident receiving phosphate binders (inhibits phosphorus into the blood stream during meals) without food.

Inspectors wroteBased on observations, interviews, record review, and review of the facility policy titled, Medication Administration, the facility failed to ensure the medication error rate was less than a five percent for two of six sampled resident (R) (R2 and R30) observed during medication pass. This resulted from two errors out of twenty-five opportunities for a medication error rate of eight percent.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to honor food preferences for one of four sampled residents (R) (R28).

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Resident Rights, the facility failed to allow residents to receive visitors at a time of their choosing by putting in place a visiting schedule that did not allow residents to have visitors after 8:00 pm. This failure had the potential to deny 120 of 120 residents the right to have visitors after 8:00 pm.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Hand Hygiene and Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices, the facility failed to ensure proper sanitary conditions in the facility's only kitchen. Specifically, a dietary aide did not wash their hands properly, and a dietary cook's nametag fell onto a plate of food being prepared on the serving line. The deficient practices had the potential to contaminate food being served for the facility's 120 of 120 residents who received meals from the facility's kitchen.

Inspectors wroteBased on resident and staff interviews, record review, and review of the facility policy titled, Abuse, Neglect, and Exploitation, the facility failed to protect the resident's right to be free from physical abuse by a staff member and thoroughly investigate a staff to resident incident of abuse involving one resident (R) (R122) of 36 sampled residents. Specifically, the Administration failed to interview all staff members on duty the day the alleged abuse incident occurred.

Inspectors wroteBased on staff interviews, record review, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one of one resident's (R) (R54) Minimum Data Set (MDS) was completed and submitted in a timely manner from a sample of 36 residents.

Inspectors wroteBased on staff interview, record review, and review of the facility policy titled, Resident Assessment-Coordination with PASARR (preadmission screening and resident review) Program, the facility failed to ensure an accurate Level 1 pre-screening of the resident for a mental disorder or intellectual disability prior to admission to the facility was completed or correct for one of three Residents (R) (R30) reviewed for Level 1 Pre-admission Screening and Resident Review.

Inspectors wroteBased on observations, resident family member and staff interviews, record review, and review of the facility policies titled, Comprehensive Care Plans' and Resident Self Determination and Participation (Activities), the facility failed to develop a care plan to include activities for one resident (R) (R91) of 36 sampled residents.

Inspectors wroteBased on observations, resident and staff interviews, record review, and review of the facility policy titled, Resident Self Determination and Participation (Activities), the facility failed to provide an ongoing activity program to meet the individual interests and needs to enhance the quality of life for three Residents (R)11, R114 and R91) of 36 sampled residents reviewed for activities.

Inspectors wroteBased on staff interviews, record review, and review of the facility policy titled, Fall Prevention, the facility failed to ensure fall prevention interventions were implemented for one of two residents (R)176) identified for falls in the sample of 36 residents. Specifically, R176 sustained a fall without injury while receiving incontinence care by one staff instead of two staff.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Enteral Feeding Process, the facility failed to follow Physician Orders for enteral (delivering nutrition directly to the stomach or intestine) feeding for one of three residents (R) (R11) who received nutrition through a gastrostomy tube (a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications). The deficient practice had the potential for unintended weight loss.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Medication Storage, the facility failed to ensure that one of six medication carts (Front East Medication Cart) was secure when out of the site of the nursing staff. The deficient practice placed residents, staff, and visitors at risk of having unauthorized access to residents' medications.