Riverview

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to ensure that medications were stored securely. This had the potential to affect 74 residents, #1, #2, #3, #4, #7, #8, #10, #12, #13, #14, #15, #17, #20, #25, #28, #29, #32, #33, #34, #36, #37, #40, #41, #42, #43, #44, #45, #50, #51, #52, #58, #61, #62, #76, #77, #78, #79, #84, #85, #86, #88, #89, #90, #92, #93, #94, #95, #102, #103, #104, #107, #110, #112, #116, #117, #120, #121, #122, #138, #175, #178, #179, #180, #226, #227, #229, #231, and #232 The facility also failed to ensure that medications, including three cups containing various types of pills, were stored appropriately. The facility census was 120.

Inspectors wroteBased on observations, resident interview, staff interview, and review of facility policy, the facility failed to provide food and drink at a palatable, attractive, and at a safe and appetizing temperature. This affected one resident (Resident #75) and had the potential to affect all 65 of the residents on units #2 and #4 except for Resident #68 and Resident #114, who did not eat or drink food from the kitchen. The facility census was 120 residents.

Inspectors wroteBased on observation, staff interview, and policy review the facility failed to distribute and serve food under sanitary conditions. This had the potential to affect all residents residing in the facility who receive food from the kitchen except for residents #68 and #114 who did not eat or drink food from the kitchen. The census was 120.

Inspectors wroteBased on medical record review, staff interview, review of the Electronic Information Dissemination and Collection (EIDC) system, and review of the facility policy, the facility failed to report an injury of unknown origin to the State Survey Agency (SSA). This affected one resident (Resident #7) of two residents reviewed for abuse. The facility census was 120.

Inspectors wroteBased on medical record review, resident interview, staff interview and review of the facility policy, the facility failed to thoroughly investigate an injury of unknown origin. This affected one (#7) of two residents reviewed for abuse. The facility census was 120.

Inspectors wroteBased on record review, staff interview, and policy review the facility failed to ensure residents receive care consistent with professional standards of practice when they failed to timely transcribe a new physician order for a pressure ulcer dressing change for Resident #105. This affected one (Resident #105) of four Residents reviewed for pressure ulcers. The facility census was 120.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to timely respond to monthly medication regimen reviews (MRR) for two Residents (#51 and #76) out of five residents (#10, #51, #57, #76 and #89) reviewed for unnecessary medications. The facility census was 120.

Inspectors wroteBased on record review, interview and policy review, the facility failed to ensure accurate physician order reconciliation was conducted following a hospital admission for one (Resident #82) of two residents reviewed for hospitalizations. The facility census was 120.

Inspectors wroteBased on record review, observation, staff interview, and review of facility policy, the facility failed to ensure hand hygiene was performed prior to medication administration and failed to ensure proper sanitary practices were followed when preparing medications for administration. This failure affected one resident (Resident #82) out of the six residents observed during medication administration. The facility census was 120.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure resident dignity was maintained during medication administration. This affected one (Resident #93) of nine residents observed for dining. The facility census was 136 residents.

Inspectors wroteBased on medical record review, review of hospital records, observation, staff interviews, interview with the Local County Health Department (LCHD), interview with the physician, review of a death certificate, review of the facility's Legionella bacteria prevention plan, review of email communications with the LCHD, review of facility policy and procedures, review of the Legionella risk assessment, and review of the Centers for Disease Control and Prevention (CDC) website, the facility failed to follow their water management plan to ensure all shower heads were descaled semi-annually and flushes were completed weekly which resulted in elevated risk levels of Legionella bacteria in the facility's water system and exposure to the residents. [...]

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure the milk served during meal service remained in a safe and palatable temperature for serving. This had the potential to affect 56 residents (Residents #1, #2, #3, #5, #6, #8, #9, #10, #12, #13, #14, #15, #18, #19, #20, #21, #22, #23, #25, #27, #28, #32, #34, #35, #36, #37, #40, #41, #42, #43, #47, #48, #49, #51, #52, #54, #59, #60, #63, #69, #74, #75, #76, #81, #82, #84, #89, #93, #101, #102, #103, #113, #116, #120, #130 and #238) who regularly consume milk. The facility census was 133.

Inspectors wroteBased on medical record review, resident and staff interview, and review of a self-reported incident, the facility failed to ensure residents received proper assistance with transfers and toileting per the plan of care. This affected one (#1) of three residents reviewed for accidents. The facility census was 132.

Inspectors wroteBased on medical record review, staff interviews, and review of the facility policy, the facility failed to ensure a resident's pressure ulcer was assessed and monitored and the treatment to the pressure ulcer was administered as physician ordered. This affected one (Resident #100) of three residents reviewed for pressure ulcer care.

Inspectors wroteBased on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure a resident received the physician ordered catheter care. This affected one (Resident #200) of two residents reviewed for urinary catheter care. The facility census was 135.

Inspectors wroteBased on record review, resident and staff interview, and review of the facility policy, the facility failed to ensure residents received the physician ordered care of their ostomy. This affected one (Resident #200) of two residents reviewed for ostomy care. The facility census was 135.

Inspectors wroteBased on record review, resident and staff interview, observation, and review of the facility policy, the facility failed to ensure residents received care and services for their intravenous catheter (IV). This affected one (Resident #200) of two residents reviewed for IV care. The facility census was 135.

Inspectors wroteBased on record review, resident interview, staff interview, and review of the facility policy, the facility failed to ensure residents were free from significant medication errors. This affected one (Resident #200) of one resident reviewed for significant medication errors. The facility census was 135.

Inspectors wroteBased on observation, record review, staff interviews, review of wound notes, and facility policy review, the facility failed to accurately assess, timely notify the physician of an identified pressure area, and implement interventions to prevent a middle lumbar pressure ulcer from worsening for Resident #16. Additionally, the facility failed to comprehensively assess, notify the physician, and implement a treatment plan timely for Resident #9 and Resident #67 who were admitted to the facility with pressure ulcers/injuries. Actual Harm occurred on 10/22/23 when Resident #16, who required extensive assistance from two staff and was incontinent, had a middle lumbar wound that was not accurately assessed as a Stage II (Partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough or bruising. [...]

Inspectors wroteBased on observation, record review, interview and facility policy review, the facility failed to ensure two residents (#9 and #67), who were dependent on staff for personal hygiene was shaved. This affected two (Resident #9 and #67) of three residents reviewed for personal hygiene. The facility census was 130. Findings Include: 1. Review of the medical record for Resident #67 revealed an initial admission date of 03/27/23 with the latest readmission of 01/20/24 with the diagnoses including metabolic encephalopathy, pseudomonas, sepsis due to pseudomonas, acute and chronic respiratory failure, hydronephrosis, chronic obstructive pulmonary disease (COPD), paraplegia, neuromuscular dysfunction of bladder, paralytic syndromes, spinal stenosis of cervical region, hypertension, insomnia, benign prostatic hyperplasia, depression, chronic pain syndrome and neurogenic bowel. [...]

Inspectors wroteBased on medical record review, observations, staff interview and policy review the facility failed to ensure bladder incontinence care was provided correctly. This affected one (#101) of two residents observed for incontinence care. The facility identified there were 73 residents who were incontinent and required assistance. The facility census was 128.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #4 and Resident #60, who required staff assistance with activities of daily living care received adequate and timely assistance with nail care to promote proper hygiene. This affected two residents (#4 and #60) of four residents reviewed for activities of daily living (ADL). Findings Include: 1. Review of Resident #4's medical record revealed an initial admission date of 06/22/21 with the latest readmission of 01/28/22 and diagnoses including cerebrovascular accident (CVA) with left sided weakness, dysphasia, chronic obstructive pulmonary disease (COPD), diabetes mellitus, bipolar disorder, borderline personality disorder, viral hepatitis B, gastrostomy, anemia, major depressive disorder, insomnia, liver disease, alcohol dependence, hypertension and emphysema. [...]

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #8's suprapubic urinary catheter collection bag was placed properly to prevent infection and promote proper flow/drainage of urine. This affected one resident (#8) of one resident reviewed for urinary catheters. The facility identified four residents with indwelling urinary catheters. Findings Include: Review of Resident #8's medical record revealed an initial admission date of 08/29/19 with the latest readmission of 07/26/21 and diagnoses including acquired absence of left leg above the knee, chronic kidney disease, hydronephrosis, diabetes mellitus, anemia, hyperlipidemia, disorders of the bladder, urogenital implants, hypertension, gastroesophageal reflux disease, insomnia, systemic lupus, obstructive and reflux uropathy and dysphasia. [...]

Inspectors wroteBased observation, staff interview, and menu review the facility failed to follow the menu for residents who received a consistent carbohydrate diet, and renal diet. This had the potential to affected 23 (#5, #16, #29, #34, #40, #43, #50, #53, #56, #57, #60, #76, #82, #85, #89, #91, #97, #100, #409, #412, #414, #419, and #425) out of 116 residents residing in the facility and who receive consistent carbohydrate diets and/or renal diets Facility census was 116.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure pans were stored dry. This had the potential to affect 111 of the 116 residents residing in the facility, all except Resident #18, #22, #87, #89, and #416 who were identified as not received meals from the facility kitchen. Facility census was 116.

Inspectors wroteBased on observation, staff and resident resident interview, and medical record review, the facility failed to honor resident's food choices. This affected two (#60 and #82) of six sampled residents reviewed for food concerns. Facility census was 116.

Inspectors wroteBased on medical record review, resident and staff interview and facility policy, the facility failed to maintain signed physician orders for an advance directive. This affected one (#412) out of 24 residents reviewed for advanced directives. Facility census was 116.

Inspectors wroteBased on observations, resident and staff interviews and review of facility policy, the facility failed to maintain resident rooms and equipment in a clean and homelike manner. This affected two (#412 and #71) out of 24 residents reviewed for a clean and homelike environment. Facility census was 116.

Inspectors wroteBased on medical record review, staff interview and policy review, the facility failed to incorporate recommendations from the pre-admission screening and resident review (PASRR) II into the care plan and submit a re-determination once the initial level II PASRR expired. This affected one (#28) of 24 residents reviewed for PASRR's. The census was 116.

Inspectors wroteBased on medical record review, observations, staff and family interview, the facility failed to assist a resident who was dependent on care with their personal hygiene needs. This affected one (#87) out of 24 residents reviewed for ADL care. Facility census was 116.

Inspectors wroteBased on medical record and resident and staff interview, the facility failed to ensure a resident who was incontinent received care and treatment to restore as much continence as possible. This affected one (#84) out of three sampled residents reviewed for continence. Facility census was 116.

Inspectors wroteBased on medical record review, observation, staff interview and policy review, the facility failed to ensure residents with respiratory care needs were given adequate care when they failed to change oxygen tubing weekly. This affected one (#78) out of one resident reviewed for oxygen usage. The facility census was 116.

Inspectors wroteBased on observation, staff interview, and review of facility policy, the facility failed to keep a treatment cart on 100 hall locked. This affected one (#87) of 24 residents who were reviewed for ensuring all biologicals were kept in locked compartments. The census was 116.