Riverview Post Acute

Inspectors wroteBased on staff interview, policy review, observation, and medical record review, the facility failed to develop a care for the resident's care and services for the diagnosis of seizure disorder. This affected one (#2) of 21 residents reviewed for care plans. The facility census was 79.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to ensure a resident who was dependent on staff for Activities of Daily Living (ADLs) received timely and appropriate nail care. This affected one (#6) of six residents reviewed for ADLs. The facility census was 79.

Inspectors wroteBased on record reviews, interviews, and review of facility policy, the facility failed to ensure residents with Post Traumatic Stress Disorder (PTSD) received timely assessment and care to prevent re-triggering of traumatic events. This affected two (#10 and #12) of four residents reviewed for mood and behavior. The facility census was 79.

Inspectors wroteBased on medical record review, observation, and staff interview, the facility failed to ensure staff assisted residents with feeding in a dignified manner. This affected two (Residents #8 and #72) of five facility-identified residents who required assistance with eating. The facility census was 100 residents.

Inspectors wroteBased on medical record review, resident interview, staff interview and review of the facility policy, the facility policy failed to notify local health department and visitors to the facility of an outbreak of a stomach virus which infected residents and staff. This affected 19 of 19 residents reviewed for stomach virus symptoms. The facility census was 89 residents.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure a residents received adequate supervision to prevent accidents. This affected one (Resident #87) of three residents reviewed for wandering behavior. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure a residents received adequate supervision to prevent accidents. This affected one (Resident #87) of three residents reviewed for wandering behavior. The facility census was 89.

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure resident Pre-admission Screening and Resident Review (PASARR) documents accurately reflected resident current conditions and diagnoses. This affected one (Resident #54) of three residents reviewed for PASARR documents. The census was 93.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure all significant mental health changes were communicated to the state mental health agency. This affected one (Resident #54) of three residents reviewed for Pre-admission Screening and Resident Review (PASARR) documents. The census was 93. Findings Include: Review of the medical record for Resident #54 revealed an admission date of 10/02/20 with diagnoses including were non-Hodgkin's lymphoma, dysphagia, cognitive social or emotional deficits, dementia, anxiety, depression, hypertension, foot drop, suicidal ideations, noncompliance with medical treatment, traumatic brain injury, unspecified psychosis, and chronic pain syndrome. Review of the Minimum Data Set (MDS) assessment for Resident #54 dated 09/01/23 revealed the resident had severe cognitive impairment. [...]

Inspectors wroteBased on medical record review and staff interview the facility failed to timely complete a discharge summary for residents upon discharge from the facility and failed to provide residents and their representatives with discharge instructions. This affected one (Resident #51) of three residents reviewed for discharge. The facility census was 93.

Inspectors wroteBased on medical record review, observations, and staff interview the facility failed to provide timely and appropriate nail care for a resident who was dependent upon staff for assistance with activities of daily living (ADLs). This affected one (Resident #254) of two residents reviewed for ADLs. The facility census was 93.

Inspectors wroteBased on medical record review, observation, staff interview, and review of the facility policy, the facility failed to ensure pressure ulcer prevention interventions were in place per the plan of care. This affected one (Resident #25) of one resident who was reviewed for positioning during the annual survey. The facility identified two residents with pressure ulcers. The facility census was 93.

Inspectors wroteBased on medical record review and staff interview the facility to ensure antibiotic medications were prescribed and administered only when necessary. This affected one (Resident #10) of the three residents reviewed for antibiotic use. The facility census was 93.

Inspectors wroteBased on medical record review, observation, staff interview, and review of facility policy the facility failed to ensure physician-ordered laboratory tests and specimens were obtained timely and as ordered. This affected two residents (#10 and #84) out of the eight residents reviewed for antibiotic use and unnecessary medications during the annual survey. The facility census was 93.

Inspectors wroteBased on observation, record review, interview and review of the facility policy titled Restorative Nursing Guidelines the facility failed to ensure Resident #17 received the appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Actual Harm occurred when Resident #17, who was cognitively impaired and required extensive assistance/dependence on staff for activities of daily living was identified to have a decline in range of motion of her neck and left wrist with new onset contractures resulting in the resident's neck being bent to the left side with her head touching her shoulder and her left hand being in a bent downward position from her wrist. [...]

Inspectors wroteBased on record review and interview the facility failed to adequately monitor and assess Resident #44 for adverse consequences following the initiation of the psychoactive medication, Ambien. The facility also failed to provide an appropriate diagnosis for the use of the antipsychotic medication, Risperidone for Resident #46. Actual harm occurred on 07/23/21 when Resident #44 sustained a fall resulting in a fractured arm (humerus) related to possible side effects of the new Ambien medication being prescribed for the resident without proper monitoring and notification of the physician of the presence of adverse side effects prior to the resident's fall/fracture. This affected one resident (#44) of three residents reviewed for falls and one resident (#46) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review, review of the Centers for Disease Control (CDC) guidelines, interview and facility policy and procedure review the facility failed to maintain acceptable infection control practices, including the proper use of personal protective equipment (PPE), proper isolation procedures and during blood glucose monitoring to prevent the spread of infection inlcuding COVID 19. This affected eight residents (#62, #25, #329, #70, #61, #14, #28 and #75) and had the potential to affect all 87 residents residing in the facility.

Inspectors wroteBased on observation, record review, interview and facility policy and procedure review the facility failed to ensure residents were assessed for oxygen use, had physician's orders in place for oxygen and/or failed to ensure oxygen tubing was dated and stored in a sanitary manner. This affected five residents (#15, #61, #226, #228 and #328) of six residents reviewed for oxygen therapy.

Inspectors wroteBased on observation, record review, interview and review of the facility policy and procedure the facility failed to ensure each resident received food that was palatable and failed to ensure meals were served at appetizing temperatures. This affected seven residents (#12, #28, #47, #48, #67, #70, and #75) of 27 sampled residents. The facility census was 87.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #47 had the right to make choices about aspects of his/her life in the facility, including a change in rooms, that was significant to the resident. This affected one resident (#47) of two residents reviewed for choices.

Inspectors wroteBased on record review, interview and facility policy and procedure review the facility failed to notify Resident #15's family of a change in condition and new medication orders. This affected one resident (#15) of one reviewed for change in condition.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were complete and accurate. This affected two residents (#25 and #54) of 27 sampled residents whose MDS assessments were reviewed.

Inspectors wroteBased on record review, review of pre-admission screening review results and interview the facility failed to ensure Resident #67, a resident with a newly evident mental disorder was referred to the appropriate State-designated mental health authority for review for the need for level two services. This affected one resident (#67) of one resident reviewed for pre-admission screening and resident review (PASARR).

Inspectors wroteBased on obsesrvation, record review, interview and facility policy and procedure review the facility failed ensure baseline care plans for Resident #61 and Resident #226 included the use of oxygen. This affected two residents (#61 and #226) of 27 sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, record review, staff interview and facility policy and procedure review the facility failed to develop a comprehensive plan of care related to oxygen use for Resident #15. This affected one resident (#15) of 27 sampled residents whose care plans were reviewed.

Inspectors wroteBased on record review and interview the facility failed to revise Resident #17's plan of care related to range of motion following the discontinuation of therapy services. This affected one resident (#17) of 27 sampled residents whose care plans were reviewed.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #48 and Resident #61, who required extensive assistance/dependence on staff for activities of daily living received adequate and routine showers to maintain proper hygiene. This affected two residents (#48 and #61) of two residents reviewed for activities of daily living.

Inspectors wroteBased on record review and interview the facility failed to ensure collaborative and coordinated care with Hospice to meet the total care needs of Resident #15. The facility failed to maintain any documentation from Hospice with regards to care or services provided in the resident's medical record. This affected one resident (#15) of one resident reviewed for Hospice services.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Resident #54's left hip was comprehensively assessed prior to implementing a skin treatment and failed to ensure a physician order was in place for the treatment. This affected one resident (#54) of three sampled residents reviewed for skin/wound care.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure fall risk interventions were in place as care planned to prevent falls for residents. This affected three residents (#24, #44 and #54) of three residents reviewed for falls.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure pharmacy services met the needs of Resident #4 when insulin was not available in the emergency supply stock. This affected one resident (#4) of seven residents observed for medication administration.

Inspectors wroteBased on observation, record review, interview, and review of the facility policy and procedure for medication administration the facility failed to maintain a medication error rate less than five (5) percent (%). The medication error rate was calculated to be 8.33% and included three medication errors of 36 medication administration opportunities. This affected two residents (#4 and #70) of seven residents observed for medication administration.

Inspectors wroteBased on record review, interview and facility policy and procedure review the facility failed to ensure laboratory testing was obtained for Resident #61 as ordered by the physician to ensure proper and justified use of antibiotic treatment for a urinary tract infection. This affected one resident (#61) of six residents reviewed for laboratory testing and unnecessary medication use.