Rivergate Terrace

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure personal belongings were within reach for one (R169) of one resident reviewed for accommodation of needs, resulting in feelings of discontentment within living environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to protect one resident's (R246) of one resident's personal medical information, resulting in the potential for the disclosure of the resident's confidential health information.

Inspectors wroteBased on observation, interview and record review, the facility failed to apply splinting devices and perform range of motion exercises as care planned for two (R1 and R2) of three residents reviewed for limited range of motion (ROM), resulting in the potential for increased joint contracture, loss of range of motion, and increased pain.

Inspectors wroteBased on observation, interview and record review, the facility failed to verify tube placement and assess for gastric residual prior to medication administration for one resident (R185) of two residents observed receiving medications via peg tube, resulting in the potential for aspiration, improper medication delivery, and respiratory compromise.

Inspectors wroteDeficient Practice Statement #1Based on observation, interview, and record review, the facility failed to use the proper signage for two residents with highly contagious bacterial infections (R24 and R26) of seven residents evaluated for infection control. Deficient Practice Statement #2Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R185) of two residents reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.

Inspectors wroteBased on observation, interview and record review, the facility failed to consistently assess and monitor a laceration (cut) for one resident (R903) out of three residents reviewed for quality of care. This deficient practice placed the resident at risk for an infection.

Inspectors wroteBased on interview and record review the facility failed to ensure upon admission and annually the Preadmission Screening (PAS)/ Annual Resident (ARR) Mental Illness/ Intellectual Disability/ Related Conditions Identification forms DCH-3877 and DCH-3878 documents were reviewed, revised, and sent to the local state agency for review and/or evaluation for mental illness and dementia needs in a timely manner for four residents (R22, R52, R175, and R190) of five reviewed for PASSARs, resulting in the potential for residents not to receive care and services appropriate to their mental health and dementia care needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide wheelchair footrests for two residents (R86 and R93) of 18 residents reviewed for accommodation of needs, resulting in the potential for injury to the lower extremities.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly secure protected health information for one resident (R128) of 26 reviewed for privacy, resulting in the potential for unauthorized disclosure and access.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for three (R85, R91 and R206) of 36 residents reviewed for care plans, resulting in the potential for unmet care needs and the lack of coordination of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement interventions used to prevent the development or worsening of pressure injuries for two of five (R206 and R155) residents reviewed for pressure ulcers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an oxygen cylinder was stored properly in a resident's room (R85) resulting in the potential for fire hazards. This deficient practice had the potential to affect the two residents (R85 and R145) that resided in that room facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate and appropriate care for indwelling urinary catheters (foley) for one (R211) of three residents reviewed for catheter care resulting in R211's indwelling catheter not being changed or securely anchored as prescribed and a urology consult not being scheduled in accordance with physician's orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to administer oxygen as prescribed to one (R206) of six residents reviewed for oxygen therapy resulting in R206 sustaining a low pulse oximetry reading of 82% (device that measures the amount of oxygen in the blood, normal range is 90-100%).

Inspectors wroteThis citation includes two DPS. Deficient Practice Statement #1: Based on observation, interview, and record review the facility failed to don appropriate personal protective equipment (PPE) for one resident (R206) of one resident reviewed for enhanced-barrier precautions resulting in the potential for the transmission of infectious organisms.

Inspectors wroteThis citation pertains to intake MI00147768. Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R912) of three residents reviewed for elopement, resulting in a cognitively impaired resident walking through the front door and into the parking lot unsupervised with the potential for injury.

Inspectors wroteThis citation pertains to intake MI00146019. Based on observation, interview and record review the facility failed to ensure adequate assistance during a mechanical lift (Hoyer) transfer for one resident (R601) out of three residents reviewed for injuries of unknow origin, resulting in a fracture of the right lower leg and hospitalization.

Inspectors wroteThis citation pertains to Intake MI144703 Based on observation, interview, and record review the facility failed to provide adequate supervision for one resident (R701) or two residents reviewed for elopements, resulting in a cognitively impaired resident with risk for elopementr exiting the facility unsupervised and the potential for injury.

Inspectors wroteR244 On 3/12/2024 at approximately 9:30 a.m. an oxygen tank was observed on the floor of R44's room not stored in an oxygen carrier. On 3/14/2024 at 1:33 p.m. an oxygen tank was observed still on the floor of R44's room not stored in an oxygen carrier. R44 was lying in bed alert and was able to be interviewed. During an interview R44 stated, The oxygen tank been sitting in the corner ever since I went out on an appointment, I believe Saturday (March 9th, 2024). I used it to go out with them (staff). There is some (oxygen) left in there when I returned. On 3/14/2024 at 1:40 p.m., Certified Nursing Assistant (CENA) X was interviewed and asked what the proper storing of oxygen tanks was. CENA X said oxygen tanks should not be on the floor, it should be in a wheel cart carrier. [...]

Inspectors wroteThis citation pertains to Intake MI00142807. Based on interview and record review, the facility failed to adequately provide infection control surveillance for all residents resulting in missed opportunities to decrease the potential risk of the spread of infections. Findings Include: Record review of the facility's Infection Control Book revealed no completed documentation of infection surveillance for January 2024 and February 2024. There was no evidence that data was compiled and monitored in a timely manner during those months to provide an overview of the facility's infection control practices. During an interview on 3/14/22 at 12:22 PM with Assistant Director of Nursing (ADON), it was reported that the facility did not have anyone consistently monitoring infection control program in January of 2024 until the end of February 2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program to ensure that the facility is free of pests, resulting in an increased potential for contamination of food, both food and non-food contact surfaces, and foodborne illness potentially affecting staff, visitors and all 219 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to: 1. Consistently complete neuro checks following unwitnessed falls for one resident (#77); 2. Ensure medications were ordered in a timely manner for two residents (#209, #379); and 3. Ensure skin assessments were consistently completed for one resident (#71). These deficient practices resulted in residents feeling anxious, delay in identification and treatment of a skin care concern, and the potential for delay in addressing other resident care needs.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, and sanitary environment for the facilities census of 219 residents to include (R222) and it's staff resulting in an increased potential for harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow unlimited visitation for one resident (R382) out of thirty-eight residents reviewed for resident's rights.

Inspectors wroteBased on interview and record review, the facility failed to ensure Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) were in place timely for two (R47 and R149) of 19 residents reviewed for Advance Directives, resulting in the potential for unmet medical needs in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to resolve a grievance in a timely manner for one (R173) of one resident reviewed for grievances, resulting in unresolved resolutions of grievances and frustration. Findings Include: On 3/13/24 at 2:21 P.M., R173 reported every weekend the facility ran out of bariatric briefs. The resident stated every week end her assigned aide would inform her of the shortage and to obtain additional bariatric briefs the aide would have to get someone to go to the shed which was outside of the facility. R173 reported the concern to Social Worker (SW) E R173 stated nothing had changed since reporting the concern about the bariatric briefs. R173 reported not having any bariatric briefs the previous weekend and that the staff member (not sure of name) promised to obtain a package but never came back with the bariatric briefs. [...]

Inspectors wroteThis citation pertains to Intake MI00142660. Based on interview and record review, the facility failed to report an unwitnessed fall which resulted in serious injury to the State Agency for one resident (#579) out of six residents reviewed for falls, resulting in the potential for future incidents of residents sustaining serious injury to go unreported.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow a post dental care physician's order for one (#178) out of one resident reviewed for physician's orders, resulting in the resident verbalizing oral discomfort and the potential for the resident oral cavity to become infected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper foot care for one resident (R93) out of two residents reviewed for skin conditions who were dependent upon staff for performance of activities of daily living (ADL), resulting in unmet care needs regarding skin care.

Inspectors wroteBased on interview and record review, the facility failed to offer, educate and administer vaccines in a timely manner for two residents (R20 and R379) out of three residents reviewed for influenza and pneumococcal vaccines. Findings Include: R20 Review of R20's Immunization Report and electronic medical records (EMR) revealed resident had not been offered, administered, or educated on influenza or pneumococcal vaccination in a timely manner in 2023 and 2024 until 3/14/24. Review of progress notes dated 3/14/24 at 1:07 PM documented, Note Text: Wrier contacted RP (representative) (resident's daughter) r/t (related to) not receiving vaccine consent via mail. RP confirmed vaccine consents with writer. Record review of R20's electronic medical record revealed admission into the facility on 3/22/19 with pertinent diagnosis of Alzheimer's disease. [...]

Inspectors wroteBased on interview and record review the facility failed to offer, educate and administer a COVID-19 vaccine in a timely manner for one resident (R379) out of three residents reviewed for COVID-19 vaccines. Findings Include: Review of R379's Immunization Report and electronic medical records (EMR) revealed resident had not been offered, administered, or educated on Covid-19 vaccinations in a timely manner in 2023 and 2024 until 3/14/24. Review of Progress Notes dated 3/14/24 at 12:57PM documented, Note Text: Writer went to residents' room this am to educate resident on vaccines and get consent, resident refused vaccines and education information. Resident refused to sign declinations and ask writer to leave the room. Record review of R379's electronic medical records (EMR) revealed resident was admitted into the facility on [DATE] with a pertinent diagnosis of paraplegia (paralysis). [...]

Inspectors wroteThis citation pertains to intake MI00141958 and MI00142078. Based on interview and record review the facility failed to prevent sexual abuse, for one resident (R902) out of three residents reviewed for abuse, resulting in an employee responding with inappropriate text messages to R902.

Inspectors wroteThis citation pertains to intake MI00141409. Based on observation, interview and record review the facility failed to apply splints (device to maintain position) to a contracture (tightenning of muscles and tendons), for one resident (R901) out of three residents reviewed for Activities of Daily Living (ADLS), resulting in splints not being applied daily and the potential for worsening of resident contractures.

Inspectors wroteThis citation pertains to intakes MI00136174 and MI00139020. Based on observation, interview, and record review, the facility failed to ensure meals were delivered in a timely manner and in accordance with the scheduled mealtimes for the residents observed during dining observations, resulting in resident dissatisfaction and the potential for diminished nutrient intake. It was reported to the State Agency that residents' meals were not served in a timely manner. On 10/18/23 at 1:02 PM, Certified Nurse Aide (CNA) J said they had one meal cart delivered to the Orange Court and they are waiting on one more. On 10/18/23 at 1:12 PM, the second meal cart for Orange Court was delivered. CNA L stated, The trays just got here. We're waiting on coffee cups. CNA M stated, Where's the coffee at? They didn't bring it. (The kitchen staff) usually don't bring the coffee down until the second cart. [...]

Inspectors wroteThis citation pertains to Intakes MI00136174 and MI00139020. Based on observation, interview, and record review, the facility failed to assist in ADL care for two (R603 and R616) of six residents reviewed who were dependent upon staff for performance of activities of daily living (ADL), resulting in unmet care needs regarding skin care, showers, and resident dissatisfaction.

Inspectors wroteThis citation pertains to intake MI00139265. Based on interview and record review, the facility failed to ensure that wound care treatments for pressure ulcers (damage to skin and underlying tissue from prolonged pressure to skin) were consistently provided for two resident (R618 and R642) of three residents reviewed for wound care, resulting in the potential for worsening of pressure ulcers.

Inspectors wroteThis citation pertains to intake MI00139265. Based on observation, interview, and record review the facility failed to follow the standards of infection control during wound care (hand hygiene and gloves), for one resident (R618) out of three residents reviewed for wound care, resulting in the potential for increased cross-contamination of diseases which place a vulnerable population at high risk for infections.