Riverside Health and Rehab

Inspectors wroteBased on observation, interview, record review, and facility policy, the facility failed to fully investigate an allegation of staff to resident abuse. Specifically, the facility did not conduct a record review related to the alleged violation to acknowledge that the incident occurred. There were no clinical progress notes, incident reports, or Care Plan updates, for 1 of 5 residents reviewed for abuse, Resident (R)7. This failure has the potential to result in continued psychosocial harm or place the resident at risk for further abuse.

Inspectors wroteBased on review of the facility policies, observations, and interviews, and facility policy the facility failed to ensure proper cleaning of kitchen equipment (deep fryer, stove and 2 of 2 ovens), failed to ensure that kitchen staff hair was completely covered with a hair net and or/cap, and facial hair was covered with a hair net or beard guard. In addition, the facility failed to ensure dietary staff correctly demonstrated the calibration technique to ensure the temperature readings on the thermometers.

Inspectors wroteBased on observation, interview, and facility policy, the facility failed to provide or obtain the required specialized rehabilitative services for 1 of 2 residents reviewed. Specifically, Resident (R)42 did not receive rehabilitative services although recommended by the Occupational Therapist.

Inspectors wroteBased on observation and interview, the facility failed to ensure food stored in the refrigerator was labeled and dated; failed to ensure dietary equipment was clean; failed to ensure dry storage bins were free of a Styrofoam cup directly touching the flour and sugar instead of a scoop; and failed to ensure dirty dishes and trays were not stored in the dietary prep area. This deficient practice had the potential to affect 128 of 147 residents who received meals prepared in the facility and had the potential to affect the spread of food borne illness.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to implement therapy recommendations for the use of hand splints for three of three residents (Resident (R)40, R102, and R15) reviewed for contractures out of a total sample of 34. This failure had the potential to increase limited range of motion, deformities, and pain.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to: 1.) promote the resident's right to dignity for 128 of 147 residents who ate food from the kitchen when meals were served in Styrofoam containers, and 2.) protect the resident's right to physical privacy during medication administration for one of 34 sampled residents (Resident (R)77), reviewed for resident rights. These failures had the potential to affect the dignity and psychosocial wellbeing of the residents.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to assess a resident's ability to self-administer medications for two of two residents (Resident (R)77 and R108) reviewed for self-administration of medications out of a total sample of 34. This had the potential to cause medication administration errors and adverse consequences.

Inspectors wroteBased on observation and interview, the facility failed to dispose of garbage in a sanitary manner in the kitchen. Specifically, the garbage container was overflowing with garbage on the floor. This deficient practice had the potential to affect 128 of 147 residents who received meals prepared in the kitchen.

Inspectors wroteBased on observations, interviews, and review of facility policy, the facility failed to ensure staff properly handled soiled linen. Specifically, Licensed Practical Nurse (LPN)1 carried unbagged soiled linen out of one of one resident's room (Resident (R) 102) and placed the linen in the soiled linen cart. Failure to properly handle soiled linen can lead to cross contamination.

Inspectors wroteBased on observation and interview, the facility failed to post current nurse staffing information daily. Specifically, the facility had a nurse staffing posting displayed in a common area accessible to residents and visitors; however, the information was not current for the date reviewed. This practice has the potential to mislead all residents and visitors regarding staffing levels and may impact transparency and trust in the facility's operations.

Inspectors wroteBased on interviews, record reviews and review of the facility policy, the facility neglected to identify and acknowledge that Resident (R)3 was missing from the facility. The facility further failed to implement emergency protocol in a timely manner in order to locate the missing resident. On 11/18/24 at 3:15 PM, the Administrator was notified that the facility neglected to acknowledge a resident was missing from the facility and implement emergency protocol timely for locating the missing resident, which constituted IJ at F600. On 11/18/24 at 3:15 PM, the survey team provided the Administrator with a copy of the CMS IJ Templates, informing the facility IJ existed as of 11/04/24. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On 11/19/24 the facility provided an acceptable IJ Removal Plan for F600. [...]

Inspectors wroteBased on interviews, record review and review of the facility policy, the facility failed to provide adequate supervision for Resident (R)3, who successfully eloped from the facility. On 11/18/24 at 3:15 PM, the Administrator was notified that the failure to provide adequate supervision to prevent an elopement constituted Immediate Jeopardy (IJ) at F689. On 11/18/24 at 3:15 PM, the survey team provided the Administrator with a copy of the CMS IJ Templates, informing the facility IJ existed as of 11/04/24. The IJ was related to 42 CFR 483.25 - Quality of Care. On 11/19/24 the facility provided an acceptable IJ Removal Plan for F689. On 11/19/24, the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. The IJ is considered at Past Non-Compliance as of 11/07/24. [...]

Inspectors wroteBased on review of facility policy, record review, interviews, and observations, the facility failed to conduct smoking assessments for 4 out of 10 residents (Resident (R)84, R116, R133, and R75) who smoke. Additionally, the facility failed to provide proper safety protocols for 10 out of 10 residents (R80, R84, R116, R595, R60, R133, R75, R93, R37, and R103) who smoke. On 03/13/24 at 4:32 PM, the Administrator was notified that the failure to conduct assessments on residents who smoke and failing to provide proper safety protocols for residents who smoke constituted Immediate Jeopardy (IJ) at F689. On 03/13/24 at 4:32 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template and informed the facility IJ existed as of 03/10/24. The IJ was related to 42 CFR 483.25 - Quality of Care. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide clean linen/washcloths to residents throughout the facility.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide sufficient Registered Nurse (RN) staffing on a 24-hour basis to ensure all residents receive adequate care.

Inspectors wroteBased on observations, manufacturer's recommendation review, and interviews, the facility failed to: 1) provide the date medications were opened in 3 of 4 medication administration carts, 2) failed to ensure that the medication carts were free of loose pills in 2 of 4 medication carts and 1 of 2 narcotic lockboxes, and 3) failed to remove expired medications and biologicals in 2 of 2 medication storage rooms, 1 of 1 treatment supply room, and 1 of 1 central supply room reviewed for medication storage.

Inspectors wroteBased on review of facility policy, record reviews and interviews, the facility failed to ensure Resident (R)30 was afforded the right to formulate an advance directive for 2 of 3 residents reviewed for Advance Directives.

Inspectors wroteBased on review of facility policy, record reviews, and interviews, the facility failed to ensure Resident (R)30 or his personal representative received discharge notification, upon discharge to the hospital, in writing and in a language they could understand. The facility further failed to ensure the state Ombudsman received a copy of the notification in timely manner, for 1 of 3 residents reviewed for hospitalizations.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to implement interventions outlined in Resident's (R)53's Care Plan, for 1 of 5 residents reviewed.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide nail care, maintain personal hygiene, and provide showers for residents that require, extensive assistance with Activities of Daily Living (ADLs) for 1 of 2 residents (Resident (R)44) reviewed for ADLs. Findings Include: Review of the facility's policy titled, Activities of Daily Living, Optimal Function, with a complete revision date of 05/05/23, states, Activities of daily living (ADLs), refer to tasks related to personal care including, grooming, dressing, oral hygiene, transfer, bed mobility, eating, bathing and communication system. The Facility provides necessary care to all residents that are unable to carry out activities of daily living on their own to ensure they maintain proper nutrition, grooming, and hygiene. [...]

Inspectors wroteBased on review of the facility policy, observations, and interview, the facility failed to follow a procedure during wound care for Resident (R)85, to promote healing and to reduce the risk of infection for 1 of 3 residents observed during wound care.

Inspectors wroteBased on The Institute For Family Health, Insulin Pen Instructions, observations and interviews, the facility failed to ensure a medication administration error rate of less than 5 percent. Specifically, insulin administered via an insulin pen was primed incorrectly and administered incorrectly for Resident (R)100. The facility additionally failed to ensure R14 received the correct dose of insulin due to incorrect priming of the pen for 2 of 25 opportunities for error. The medication administration error rate was 8 percent.