Riviera Palms Rehabilitation Center

Inspectors wroteBased on interviews and record review the facility failed to protect the resident's right to be free from neglect for one resident (#59) out of two residents sampled for abuse/neglect. The facility neglected to properly report, assess, document, and intervene in a timely manner for Resident #59 related to an unwitnessed fall with major injury that occurred on [DATE]. This lack of intervention resulted in physical pain and suffering for the resident until his death on [DATE]. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #59 and resulted in the determination of Immediate Jeopardy on [DATE]. The findings of Immediate Jeopardy were determined to be removed on [DATE] and the severity and scope was reduced to a D after verification of removal of immediacy of harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure licensed nursing staff were knowledgeable and competent to provide care and services for four residents (#59, #74, #29, and #35) out of forty residents sampled related to: 1) failure to recognize and provide treatment for an unwitnessed fall; 2) failure to follow physician orders for laboratory testing; 3) failure to provide a safe hazard free environment; and 4) failure to complete resident identification prior to administration of medications. This failure created a situation that resulted in a worsened condition and the likelihood for serious injury and or death to Resident #59 and resulted in the determination of Immediate Jeopardy on 6/04/2025. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain a home-like environment for two rooms (124, 174) out of twenty-nine rooms sampled.

Inspectors wroteBased on observation, record review and interview, the facility failed to monitor side effects of Antipsychotic and Antidepressant medications for one (Resident #82) out of five residents sampled. Findings Included: During an observation on 06/02/2025 at 10:12 a.m., Resident #82 was observed sitting in a wheelchair in her room sleeping. During an observation on 06/02/2025 at 1:16 p.m., Resident #82 was observed sleeping in a wheelchair in the 2nd floor dining room. Review of Resident #82's admission record revealed an admission date of 03/24/2025. Resident #82 was admitted to the facility with diagnosis to include Major Depressive Disorder, Recurrent, Unspecified, Unspecified Dementia, Unspecified Severity, Without Behavioral Disturbance, Psychotic Disturbance, Mood Disturbance, And Anxiety. Review of Resident #82 Medicare 5 Day Minimum Data Set (MDS) dated [DATE], revealed Section C. [...]

Inspectors wroteBased on interviews and record review the facility failed to report an injury of unknown origin for one resident (#59) out of 40 sampled residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure a person centered care plan was implemented related to communication for one resident (#31) out of 24 residents sampled. Findings Included: During an observation on 06/02/2025 at 9:46 a.m., Resident #31 was observed lying in bed dressed in a hospital gown. Resident #31 was only able to respond to yes or no questions. Review of Resident#31 admission record revealed and admission date of 10/29/2021. [...]

Inspectors wroteBased on observation, interview, and document review, the facility failed to offer resident centered activities for two dependent residents (#77 and #99) of two reviewed for activities.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a safe environment free from hazards for one (Resident #29) out of 24 residents sampled. Findings Included: During an observation on 06/02/2025 at 9:55 a.m., A pink disposable razor was identified on top of the toilet bowl of Resident #29's bathroom. (photographic evidence obtained) During an interview on 06/02/2025 at 2:13 p.m., Resident #29 stated she uses the restroom in her room. She stated she was not sure whose razor was in the bathroom and thought it may belong to her roommate. During a phone interview on 06/04/2025 at 10:40 a.m., Resident #29's family member stated he would not bring in a razor for Resident #29 because it is sharp and would not be safe for her to use on her own. [...]

Inspectors wroteBased on observation, medical record review and interview, the facility failed to ensure care plans were revised to reflect the current care status for two residents (#66 and #3) of forty-two sampled residents, related to Activities of Daily Living (ADLs) for eating assistance (#66), and impaired mobility and contracture management (#3).

Inspectors wroteBased on interviews and record review the facility failed to ensure communication between the facility and dialysis centers consistent with professional standards of practice for ensuring ongoing assessment and oversight of the resident before, during, and after dialysis treatments for three residents (#6, #97, and #90) out of three sampled residents.

Inspectors wroteBased on observation and interview the facility failed to reasonably accommodate the needs for one resident (#5) related to not placing the call light within the resident's reach of six residents sampled for environmental concerns.

Inspectors wroteBased on observations, record review and staff interview, the facility failed to ensure a care planned intervention related to having the bed positioned in the lowest position was implemented for one resident (#3) of forty-two sampled residents for three days (1/23/2023, 1/24/2023, and 1/26/2023) of four days observed.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure the medication error rate was less than 5.00%. Thirty medication administration opportunities were observed with three errors identified for three residents (#451, #13, and #203) of eight residents sampled constituting a 10.00% medication error rate.

Inspectors wroteBased on record review and interviews the facility failed to ensure the correct medical diagnosis was documented in a resident's medical record. The failed practice was true for one resident (#32) of 42 sampled residents.

Inspectors wroteBased on observations, staff interview and medical record review, the facility failed to maintain a dignified dining experience for one of thirty-four sampled residents (#20), during two of four days observed (5/11/2021, and 5/12/2021). Staff were observed not providing timely meal set up and eating assistance, stood up and behind the resident while assisting with eating, and stopped the meal feeding assistance several times to reposition a resident.

Inspectors wroteBased on review of resident medical records, the Medical Examiner's (ME) report, and facility policies/procedures and interviews with the Staffing Agency Administrator, Nursing Home Administrator (NHA), the Director of Nursing (DON), Regional Nurse Consultant (RNC), nursing staff members, the facility Medical Director, and Resident #71's family member the facility failed to correctly report an allegation of neglect for one (Resident #71) of thirty-four sampled residents.

Inspectors wroteBased on medical record review, facility record review and staff interviews, the facility failed to ensure upon resident discharge from the facility, staff provided complete discharge notices to three of thirty-four sampled residents (#72, #121, and #33) and failed to send notice of discharge to the Ombudsman's office.

Inspectors wroteBased on observations, interviews, and policy review the facility did not ensure appropriate labeling of three opened insulin pens of seven insulin pens in one medication cart (medication cart #1) of four medication carts on one of four nursing units (unit one).

Inspectors wroteBased on record review, observations, interviews, and policy review the facility did not ensure food was served in a form the residents could tolerate and according their therapeutic diet orders for one (#60) of three residents receiving pureed diets without orders for mechanical soft snacks.