Riverside Post Acute

Inspectors wroteBased on interviews, record review, and a review of the facility's policies and procedures, the facility failed to ensure completion of the Pre-admission Screening and Resident Review (PASRR) process for two (Residents #51 and #127) residents who were identified with a newly evident or a possible serious Mental Disorder (MD), Intellectual Disability (ID) or related condition, from a total survey sample of 33 residents who were reviewed for PASRR.

Inspectors wroteBased on observations, record reviews, interviews, and a review of facility policies and procedures, the facility failed to provide appropriate fingernail care for two (Residents #182 and #196) residents who required assistance with grooming out of 56 residents whose fingernails were observed. Failure to provide consistent grooming and hygiene for residents who require assistance can negatively impact their sense of self-worth and dignity, as well as potentially spread infection and/or contribute to skin tears or other injuries.

Inspectors wroteBased on observations, interviews, record review, and facility policy and procedure review, the facility failed to provide respiratory therapy, consistent with professional standards of practice, for three (#9, #63, and #181) of 21 residents receiving oxygen therapy. Oxygen flow rates set for these residents were not in accordance with their physicians' orders.

Inspectors wroteBased on observation, interviews, record review, and a review of facility policies and procedures, the facility failed to demonstrate safe, sanitary infection control and prevention procedures while providing resident care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in regard to 1) call light not properly working in Resident #6's room, and 2) water dripping from a vent in the ceiling going into a trash bin in Resident #5's room, out of 8 resident rooms sampled.

Inspectors wroteBased on interviews, facility grievance log review, and complaint and grievance policy review, the facility failed to follow facility policy in providing required written notification of the outcome of the grievance investigation for 5 of 5 grievances submitted by four (Residents #4, #5, #6, and #7) residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision to prevent falls for one (Resident #135) of seven residents reviewed for falls, from a total sample of 41 residents.

Inspectors wroteBased on observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to ensure that the dietary staff was trained and knowledgeable about the proper procedures for hand hygiene and disposable glove use during meal service, as well as proper sanitation practices when cleaning and using the meat slicer to prevent cross contamination, with the potential to affect all of the residents in the facility who received food from the facility's kitchen. Specific instruction on hand hygiene and sanitation is important in health care settings serving nursing home residents due to the risk of serious complications from foodborne illness as a result of their compromised health status. Failure to thoroughly clean and sanitize the meat slicer could result in the development of a cross-contamination infection and clinical compromise. [...]

Inspectors wroteBased on interviews and record review, the the facility failed to provide documented evidence that all alleged violations of abuse, neglect, exploitation, and/or mistreatment were thoroughly investigated for one (Resident #75) of 41 residents sampled. Failure to thoroughly investigate alleged violations places other residents at risk for abuse, neglect, exploitation and mistreatment.

Inspectors wroteBased on observation, interview, resident record review, and facility policy review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) program under Medicaid, to the maximum extent practicable, to avoid duplicative testing and effort for one (Resident #17) of 41 residents sampled. The facility failed to refer residents with newly evident or possible serious mental disorders, intellectual disability, or a related condition for a level II resident review.

Inspectors wroteBased on observations, staff interviews, medical record review, and facility policy review, the facility failed to ensure that one (Resident #2) of 41 residents sampled, was appropriately screened for a mental disorder (MD), intellectual disability (ID) or other related conditions prior to admission. Failure to ensure residents are pre-screened for MD/ID or a related condition, prior to admission to the facility, could prevent the resident from attaining or maintaining his/her highest practicable level or result in decline in the resident's physical, mental or psychosocial well-being.

Inspectors wroteBased on observation, interview, medical record review, and facility policy and procedure review, the facility failed to provide an ongoing activity program that met residents' interests and supported the physical, mental, and psychosocial well-being of one (Resident #73) of 41 sampled residents. Facility activities programs that incorporate residents' interests, hobbies and cultural preferences are intregal in maintaining and/or improving residents' physical, mental, and psychosocial well-being and independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that two (Residents #53 and #20) of three residents sampled for review of respiratory care, from a total sample of 41 residents, were provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that two (Residents #41 and #17) of five residents sampled for medication review, from a total of 41 residents sampled, were free from unnecessary drugs. An unnecessary drug includes any drug used without adequate monitoring.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to ensure a medication error rate of less than 5% based on 32 opportunities for error with two errors identified, resulting in an error rate of 6.25 %. The errors affected two (Residents #454 and Resident # 86) of seven residents observed during medication administration, from a total of 41 residents in the sample. Failure to administer medications correctly, as ordered, could result in side effects including serious harm to a resident.

Inspectors wroteBased on observation, interview, and a policy and procedure review, the facility failed to secure/store medications in locked compartments to limit unauthorized access to medications for two (Residents #35 and #57) of 41 sampled residents. Failure to ensure medications are secure and/or inaccessible could result in residents ingesting medications and suffering significant adverse consequences.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure that alleged violations involving neglect, and misappropriation of resident property, were reported no later than 24 hours to the State Survey Agency for two (Residents #1 and #2) of 4 residents reviewed for reportable incidents.

Inspectors wroteBased on observations, interviews, record reviews and policy and procedure review for oxygen administration, the facility failed to administer oxygen at the ordered flow rate for one resident (Resident #45), and administered oxygen without a physician's order for two (Residents #92 and #8) of twenty-two residents on oxygen therapy, from a total sample of 40 residents. This could result in the resident not receiving appropriate care and/or clinical complications.

Inspectors wroteBased on observations, interviews, record review and facility policy and procedure review, the facility failed to implement a pressure ulcer/skin prevention person-centered care plan for one (Resident #33) of seven residents reviewed for care plans, from a total sample of 40 residents. Failure to implement the care plan puts the resident at risk of not receiving appropriate interventions and could potentiate medical or physical complications.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide assistance with bathing/showers for two (Residents #85 and #117) of three residents reviewed for activities of daily living (ADLs), out of a total sample of 40 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to appropriately address a resident's change in condition by failing to 1) comprehensively assess a resident's behavioral change in condition, and 2) promptly notify the resident's health care provider, and 3) implement person-centered interventions to address the change in condition for one (Resident #23) of three residents reviewed for change in condition, from a total sample of 40 residents.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide adequate assistance to prevent accidents for one (Resident #87) of three residents reviewed for accidents, and failed to appropriately monitor the neurological status for two (Residents #280 and #33) of three residents reviewed for falls, from a total sample of 40 residents.

Inspectors wroteBased on observations, staff interview and record reviews, the facility failed to follow physician's orders for one (Resident #2) of three residents receiving enteral feedings, from a total sample of 40 residents.

Inspectors wroteBased on observations, interview and record review, the facility failed to maintain a medication error rate of less than five percent. During the medication administration observations, there were two errors and a total of twenty-six opportunities, resulting in an error rate of 7.69%.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were safely stored for one resident (Resident #31) in a total sample of 40 residents.