Riverview Estates

Inspectors wroteThe facility identified a census of 27 residents, with three residents reviewed for abuse, neglect, and exploitation. Based on record review, observation, and interview, the facility failed to ensure Resident (R) 2 and R1 remained free from verbal and mental abuse. This placed R2 and R1 at risk for continued abuse, embarrassment, humiliation, and decreased quality of life due to impaired psychosocial well-being.

Inspectors wroteThe facility had a census of 23 residents. The sample size included 12 residents, with 12 residents reviewed for neglect. Based on record review and interview, the facility failed to prevent the neglect of Resident (R) 26, when staff failed to timely and competently assess and provide care for R26, who had a known history of sepsis (a life-threatening systemic reaction that developed due to infections which cause inflammation throughout the entire body). On 01/05/25 at 06:58 PM, R26 struggled to talk and drink liquids. Licensed Nurse (LN) H contacted the on-call physician and reported R26 acted similar to the last time R26 was septic. Based on this information, the physician ordered one gram of Rocephin (an antibiotic) every 24 hours for seven days and stated if R26 did not show any signs of improvement, or her condition worsened, then LN H was to send R26 to the Emergency Room. [...]

Inspectors wroteThe facility had a census of 23 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to properly date opened bags of food with the open date and the expiration date. This practice placed the 23 residents at risk for foodborne illness and poor-quality food.

Inspectors wroteThe facility had a census of 23 residents. The sample size included 12 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities), for Resident (R) 13 who had Influenza A (a contagious viral infection of the nose, throat and lungs that is spread from person to person through respiratory droplets). This placed the residents at increased risk for infection.

Inspectors wroteThe facility had a census of 23 residents. Based on observation, interview, and record review, the facility failed to perform background checks as required for four employees. The employees were allowed access to residents without knowing if they had been found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law. This deficient practice placed the 23 residents of the facility at risk for potential abuse, neglect, or exploitation.

Inspectors wroteThe facility had a census of 23 residents. The sample includes 12 residents, with seven residents reviewed for immunizations, Resident (R) 5, R10, R11, R13, R16, R21, and R22, to include pneumococcal (a disease that refers to a range of illnesses that affect various parts of the body and are caused by infection) vaccinations. Based on record review and interviews, the facility failed to offer, or obtain an informed declination or a physician-documented contraindication for the pneumococcal PCV20 vaccination per the latest guidance from the Centers for Disease Control and Prevention (CDC). This placed the residents at risk for pneumococcal infection and related complications.

Inspectors wroteThe facility had a census of 23 residents. The sample size included 12 residents. Based on record review and interview, the facility failed to notify Resident (R) 26's physician or family when staff noted an abnormal bulge in R26's right abdomen on 01/03/25. The facility nursing staff also failed to notify the physician on 01/06/25 when R26 had a further deterioration in condition with shallow, labored respirations. R26's skin was pale and moist to the touch, and she had coarse lung sounds throughout. R26 did not respond when staff called her name, nor did she communicate with staff. LN H failed to call the physician or send R26 to the ER at that time. This deficient practice placed R26 at risk for serious health consequences.

Inspectors wroteThe facility had a census of 23 residents. The sample included 12 residents. Based on interviews and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R)13's facility-initiated discharge to the hospital. This placed R13 at risk for impaired rights.

Inspectors wroteThe facility had a census of 23 residents. The sample included 12 residents, with two residents reviewed for discharge. Based on observation, record review, and interview, the facility failed to provide Resident (R) 13 with written information regarding the facility's bed hold policy when she was transferred to the hospital. This placed the resident at risk of not being permitted to return and resume residence in the nursing facility.

Inspectors wroteThe facility had a census of 23 residents. The sample included 12 residents. Based on record review and interview, the facility failed to develop a discharge summary that included a complete recapitulation (a concise summary of the resident's stay and course of treatment in the facility) of the resident's stay and post-discharge plan for Resident (R) 27. This placed the resident at risk for receiving inadequate care.

Inspectors wroteThe facility had a census of 23 residents. The sample included 12 residents with one reviewed for urinary catheter (insertion of a catheter into the bladder to drain the urine into a collection bag). Based on observation, interview, and record review, the facility failed to provide Resident (R) 11 a device to secure the catheter tubing to keep it from pulling and causing discomfort. This deficient practice placed R11 at risk for pain or injury related to the catheter use and R11 developed two open sores related to the catheter rubbing.

Inspectors wroteThe facility had a census of 23 residents. The sample included 12 residents with one reviewed for hospice (a type of health care that focuses on the terminally ill patient's pain and symptoms and attending to their emotional and spiritual needs at the end of life) services. Based on observation, record review, and interview, the facility failed to ensure coordinated care and services provided by the facility with the care and services provided by hospice for Resident (R) 13. This placed the residents at risk for inadequate end-of-life care.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to employ a full time certified dietary manager for the 31 residents who resided in the facility and received meals from the facility kitchen. This placed the residents at risk for inadequate nutrition.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with one reviewed for Preadmission Screening and Resident Review (PASSAR-short series of questions designed to determine whether or not a more in-depth assessment for mental health services is required). Based on observation, record review and interview the facility failed to conduct a PASSAR Level II (an in-depth assessment for the purpose of determining whether the individual requires the level of services provided by a nursing facility or the level of services provided in a specialized program for persons with mental illness or developmental disabilities) for Resident (R)18 when it was noted on the PASSAR I R18 needed further evaluation (Level II). This placed the resident at risk for unmet needs.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with one reviewed for urinary tract infection (UTI-an infection in any part of the urinary system}. Based on observation, record review, and interview the facility staff failed to change gloves when providing incontinent cares for Resident (R) 16 and continued to provide care with the same soiled gloves.

Inspectors wroteThe facility had a census of 31 residents. Based on observation, record review, and interview the facility kitchen staff failed to provide food prepared by methods that conserve nutritive value, flavor and appearance, when dietary staff failed to follow a recipe while preparing two residents' pureed diets. This placed the residents at risk for impaired nutrition.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 31 residents in the facility, who received their meals from the facility kitchen.

Inspectors wroteThe facility identified a census of 31 residents. Based on observations, interviews, and record review, the facility failed to provide comfortable sound levels to allow for privacy and unwanted noise for the overhead intercom paging system. This placed all residents at risk for unwanted noise/sound levels in the facility.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with one reviewed for pressure ulcers (PU) (injuries to skin and underlying tissue resulting from prolonged pressure on the skin). Based on observation, interview, and record review, the facility failed to evaluate Resident (R) 11's PUs on her buttocks and toes each week from April to July 2021.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with two reviewed for nutrition. Based on observation, record review, and interview, the facility failed to develop and implement effective nutritional interventions to prevent weight loss for one of five sampled residents, Resident (R) 20 who had a weight loss.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to collaborate care consistently with the treating dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney) facility for one resident reviewed, Resident (R) 7.

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with five review for unnecessary medications. Based on observation, interview, and record review the facility's consultant pharmacist failed to notify the Director of Nursing (DON), physician, or medical director of three of five sampled residents' medication irregularities. Resident (R) 5 had blood pressures lower than physician ordered parameters without physician notification, R11 had a physician order for Lorazepam (anti-anxiety drug), as needed (PRN), without a required stop date, and R23 had an inappropriate diagnosis for the use of Seroquel (class of medications used to treat psychosis and other mental emotional conditions).

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents with five reviewed for unnecessary medications. Based on observation, interview, and record review the facility failed to notify the physician in a timely manner of Resident (R) 5's blood pressures which were lower than physician ordered parameters.

Inspectors wrote- R23's Physician's Order, dated 09/07/21, recorded the following diagnoses of vascular dementia without behavior disturbance (progressive mental disorder characterized by failing memory and confusion), paranoid schizophrenia (psychotic disorder characterized by gross distortion of reality, disturbances of language and communication and fragmentation of thought with a thought process believed to be heavily influenced by anxiety or fear to the point of irrational thinking) and depression (abnormal emotional state characterized by exaggerated feelings of sadness, worthlessness and emptiness). The admission Minimum Data Set (MDS), dated [DATE], recorded the resident had severely impaired cognition. The MDS recorded the resident required limited staff assistance with bed mobility, dressing, toileting, personal hygiene, and walked independently without an assistive mobility device. [...]

Inspectors wroteThe facility had a census of 31 residents. The sample included 12 residents. Based on observation, record review and interview, the facility failed to correctly prepare a pureed diet for two residents, Resident (R) 5 and R24.