Riverwood Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide restorative nursing therapy to ensure that a resident's abilities in activities of daily living did not diminish for two (Residents #193 and #56) of two residents reviewed for the dining restorative program, from a total of 11 residents participating in the dining restorative program, in a total survey sample of 56 residents. The 11 residents on the dining restorative program were at risk of further decline. Resident #193 suffered a significant weight loss.

Inspectors wroteBased on observations, resident and staff interviews, and record review, the facility failed to ensure that one (Resident #50) of 52 sampled residents currently residing in the facility, had access to his call light.

Inspectors wroteBased on observations, interviews, record review, and policy and procedure review, the facility failed to honor the personal privacy of one resident (#81) reviewed for personal privacy from a total survey sample of 56 residents.

Inspectors wroteBased on observations, interviews, record review, and policy and procedure review, the facility failed to implement the comprehensive care plan to meet the resident's medical needs for one (Resident #43) of one resident reviewed for transmission based precautions from a total of 56 residents in the survey sample. Specifically, isolation precautions were not followed as indicated in the care plan.

Inspectors wroteBased on observations, interviews, record review, and policy and procedure review, the facility failed to provide fingernail care for one (Resident #47) of four residents reviewed for Activities of Daily Living (ADLs), from a total survey sample of 56 residents.

Inspectors wroteBased on observations, record reviews, and staff interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one (Resident #18) out of four residents observed during medication administration, from a total survey sample of 56 residents. Failure to administer medications correctly as ordered could result in side effects with serious harm to residents.

Inspectors wroteBased on observations, record reviews, staff interviews, and policy and procedure reviews, the facility failed to ensure a medication error rate of less than 5% based on three errors out of 26 opportunities for error. The three errors (failure to administer medications and crushing enteric coated medication) resulted in an error rate of 11.54%. Two (Residents #18 and #51) of four residents observed during medication administration from a total survey sample of 56 residents were affected. Failure to administer medications correctly as ordered could result in side effects with serious harm to residents.

Inspectors wroteBased on observations, interviews, record review, and policy and procedure review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Resident #84) of two residents reviewed for dental care, from a total survey sample of 56 residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to ensure that residents unable to carry out activities of daily living (ADLs), received necessary care and services to maintain proper grooming and personal hygiene, by failing to provide nail care for two (Residents #8 and #11) of four residents reviewed for ADLs, from a total sample of 16 residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan by failing to ensure wound care was provided as ordered for two (Residents #2 and #3) of two residents reviewed for wound care, from a total sample of 16 residents.

Inspectors wroteBased on observations, record review, interviews, and facility policy review, the facility failed to practice proper infection control measures by 1) failing to wear required personal protective equipment (PPE) for one (Resident #12) of one resident reviewed for transmission base precautions, and 2) failing to prevent the potential development and transmission of infection by not following infection prevention techniques during a wound care dressing change for one (Resident #2) of one resident observed during wound care, from a total sample of 16 residents.

Inspectors wroteBased on interviews, record review, and policy and procedure review, the facility failed to ensure that resident meals were served at a safe and appetizing temperature, for five (Residents #478, #467, #104, #31, and #184) out of 55 sampled residents. Failure to provide palatable, attractive, and appetizing food in accordance with professional standards for food service, can decrease the amount of food all residents eat and drink. Residents at nutritional and hydration risk could be affected, potentially impacting their ability to heal, and possibly resulting in an overall health status decline.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and facility policy review, the facility failed to assist five (Residents #115, #65, #37, #98, and #70) of 55 sampled residents, reviewed for activities of daily living (ADLs), necessary to maintain grooming and personal hygiene for dependent residents.

Inspectors wroteBased on interviews, record reviews, and policy and procedure reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices, by failing to 1) Carry out physician's orders for consultations for Resident #30, and 2) Promptly identify and intervene for a change in condition (dehydration), report low blood pressures (hypotension) to the physician, consult the physician about low blood pressures prior to the administration of blood pressure medications for a resident with hypotension, and follow physician's orders for laboratory tests, for Resident #517, two residents reviewed from a total sample of 55 residents.

Inspectors wroteBased on observations, staff and resident interviews, medical record review, and policy and procedure review, the facility failed to ensure that two (Residents #37 and #74) of a total sample of 55 residents were provided with foot care consistent with professional standards of practice, including assisting residents in making necessary appointments with qualified healthcare providers such as podiatrists.

Inspectors wroteBased on observations, staff and resident interviews, and facility policy review, the facility did not ensure the resident environment remained as free of accident hazards as is possible for one (Resident #106) of a total sample of 55 residents. The facility, which is responsible for resident safety, had no protocol for verifying the safety of individual resident refrigerators and/or maintaining safe temperatures inside to ensure foodborne illness did not result from temperatures that were too warm to keep foods properly cooled.

Inspectors wroteBased on record review and interviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of one resident (#35) who required blood pressure and pain medication, out of four residents reviewed for unnecessary medication, from a total sample of 55 residents.

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, by 1) Failing to maintain the dishwasher at appropriate temperatures during the wash and final rinse cycles, 2) Failing to ensure kitchen employees wore face coverings and gloves appropriately, and 3) Failing to ensure three of three nourishment rooms were clean and stored/labeled food appropriately. The facility census was 154. All residents receiving food from the kitchen and/or nourishment rooms had the potential to be affected by this deficient practice.

Inspectors wroteBased on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to maintain a clean living environment for one (Resident #251) of five residents receiving enteral feedings through a gastrostomy tube (g-tube), from a total of 54 sampled residents. Food product was splattered on the wall adjacent to the bed, on the bed frame, the feeding pump pole, the floor under the pole and the nightstand beside the resident's bed. Failure to provide a clean living environment can present the potential for infection and illness for the residents.

Inspectors wroteBased on observation, clinical record review, staff interview and facility policy and procedure review, the facility failed to develop a baseline care plan for catheter care for one (Resident #252) of six newly admitted residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling Foley catheter and a urinary tract infection (UTI). Failure to develop a plan of care for catheter care could potentially exacerbate the urinary tract infection.

Inspectors wroteBased on record reviews and staff interviews, the facility failed to coordinate hospice services for one (Resident #57) of eight residents receiving hospice services, from a total sample of 54 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the residents' environment remained as free of accident hazards as possible, by failing to ensure medications were not left at residents' bedsides for one (Resident #47) of a total of 54 residents in the sample.

Inspectors wroteBased on observation, clinical record reviews and staff interviews, the facility failed to provide urinary catheter care for one (Resident #252) of six sampled residents, from a total of 54 sampled residents. Resident #252 was admitted with an indwelling urinary catheter and a urinary tract infection (UTI). Failure to provide catheter care could potentially exacerbate the urinary tract infection.

Inspectors wroteBased on record reviews, staff and resident interviews and observations, the facility failed to ensure that residents requiring respiratory care, received appropriate care, consistent with professional standards of practice, by failing to follow physician's orders for the administration for oxygen for two (Residents #102 and #131) of two residents sampled for oxygen administration from a total sample of 54 residents.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that medications were properly stored/disposed of safely for two (Residents #138 and #61) of six residents observed during medication administration.