Riviere De Soleil Community Care Center

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and wound care products were stored in accordance with currently accepted professional principles. The facility failed to ensure:1. Treatment carts were free from expired wound care products and medications; and2. Prescription medication had a pharmacy label and was stored in original packaging. A review of the facility policy titled Storage of Medication, revised [DATE], revealed in part. The facility stores all drugs and biologicals in a safe, secure, and orderly manner. 2. Drugs and biologicals are stored in the packaging, containers, or other dispensing systems in which they are received. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. A review of facility policy titled Labeling of Medication Containers, revised [DATE], revealed in part. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received services in the facility with reasonable accommodation of resident needs for 1 (Resident #44) of 4 (Resident #44, Resident #48, Resident #87, and Resident #90) resident's reviewed for accidents. The facility failed to ensure Resident #44 had a call light in reach in order to call for assistance. The total sample size was 41.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents with an order for psychotropic medication were not subjected to chemical restraints for 1 (#75) of the 5 residents (#4, #5, #12, #38, #75) reviewed for unnecessary medications. The facility failed to:1. Ensure as needed or PRN (pro re nata) orders for a psychotropic medication were limited to 14 days for Resident #75.

Inspectors wroteBased on observation, interview and record review the facility failed to provide respiratory care consistent with professional standards for 2 (Resident #42 and Resident #70) of 3 (Resident #24, Resident #42, and Resident #70) sampled residents reviewed for respiratory care. The facility failed to ensure physician orders were followed for oxygen administration for Residents #42 and #70, and that oxygen equipment was stored appropriately for Resident #70.

Inspectors wroteBased on record review, observation, and interview, the facility failed to ensure an infection prevention and control program was maintained to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. During a COVID outbreak, the facility failed to ensure:1. Staff performed hand hygiene between residents while preparing and serving lunch trays to residents; and2. Staff donned PPE appropriately while preparing and serving lunch trays to residents. This deficient practice had the potential to affect all 12 residents who resided in Neighborhood X.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that each Resident was treated with respect and dignity and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) out of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents, by failing to ensure she was free of facial hair and by failing to honor her food choices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all Residents who were unable to carry out ADLs (Activities of Daily Living) received necessary services to maintain good grooming and personal hygiene. The facility failed to provide trimmed nails and oral care to dependent Residents for 1 (Resident #1) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents.

Inspectors wroteBased on interview and record review the Facility failed to ensure that a Resident maintains acceptable parameters of nutritional status, such as usual body weight or desirable weight range for 2 (Resident #1 and Resident #3) of 3 (Resident #1, Resident #2, and Resident #3) sampled Residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure residents obtained routine dental services for 1 (Resident #89) of 2 (Resident #89 and Resident #98) sampled residents for dental. Total sample size was 26.

Inspectors wroteBased on observation and interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation and interview the facility failed to ensure that each Resident was treated with respect and dignity in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life by failing to wait until all residents eating at a table were finished with their meal before picking up trays. Total sample size was 26.

Inspectors wroteBased on interview and record review, the facility failed to ensure a personal funds statement was provided quarterly for 1(#24) of 1 resident reviewed for personal funds.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident equipment, a Pommel cushion, was in good repair for 1 (#49) of 4 (#23, #43, #49 and #85) residents reviewed for environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 2 (Resident #26, and Resident #46) of 26 sampled Residents.

Inspectors wroteBased on observation and interview the facility failed to keep all information in the Medical Record confidential for 4 (Resident #92, Resident #74, Resident #57 and Resident #58) 6 residents receiving Dialysis outside of the facility. Total sample size was 26.

Inspectors wroteBased on interview and record revealed the facility failed to develop and implement a comprehensive person-centered care plan for services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents. The facility failed to ensure a comprehensive care plan was developed for a resident diagnosed with Chronic Diastolic (CHF) Congestive Heart Failure who required fluid restriction and to be weighed every 3 days.

Inspectors wroteBased on interview and record revealed the facility failed to provide care and services that meet professional standards of practice and quality care for 1 (Resident #1) of 2 (Resident #1 and Resident #3) sampled residents reviewed for hydration. The facility failed to ensure a resident diagnosed with Chronic Diastolic Congestive Heart Failure (CHF) with restricted fluids was weighed every 3 days as ordered.

Inspectors wroteBased on interview and record review the facility failed to ensure Resident #3's RP was informed of changes in the resident's condition for 1 (Resident #3) of 3 (Resident #1, Resident #2 and Resident #3) sampled residents.

Inspectors wroteBased on record review, and interview the facility failed to review and revise a resident's care plan to include interventions for increased staff supervision following elopements, and for a severely cognitively impaired resident who experienced frequent falls, for 2 (#1, #3) of 11 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, #R1, #R2, #R3, #R4, #R5, and #R6).

Inspectors wroteBased on record review and interview, the facility failed to supervise Resident # 1, identified as a high elopement risk, to prevent elopement on [DATE] and [DATE], and the facility failed to adequately supervise Resident #3, identified as a high fall risk to prevent an accident that resulted in a major injury, for 2 of 11 sampled residents (Resident #1, Resident #2, Resident #3, Resident #4, Resident#5, #R1, #R2, #R3, #R4, #R5, and #R6). I. Elopement This deficient practice resulted in an immediate jeopardy situation on [DATE] at 6:06 p.m. when Resident #1, a cognitively impaired resident who was at risk for elopement and wore a wander guard bracelet, exited the facility unsupervised, and was found approximately 700 feet from the front door of the facility near a free-standing physical therapy center. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (#1) of 11 residents (#1, #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5 and #R6) identified as at risk for elopement. The facility's administration failed to: 1. Ensure increase supervision of Resident #1 who eloped from the facility on 07/01/2023 and 08/18/2023; 2. Ensure an effective system of adequate supervision of the remaining 10 residents who were identified by the facility to be at risk for elopement (Residents #2, #3, #4, #5, #R1, #R2, #R3, #R4, #R5, and #R6). This deficient practice resulted in an immediate jeopardy situation on 07/01/2023 at 6:06 p.m. [...]

Inspectors wroteBased on observation, and interview the facility failed to follow infection control practices to prevent the development and transmission of COVID-19. The facility failed to ensure staff wore appropriate PPE during, and performed hand hygiene after direct contact with a resident for 1 (Resident #3) of 1 sampled residents on transmission based precautions for COVID-19.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff and a contract hospice staff properly placed a lift pad/sling underneath a resident prior to transferring the resident from the bed to the Geri-Chair with a mechanical lift, for 1 (Resident #5) of 1 residents sampled for accidents. An Actual Harm occurred for Resident #5 on 06/02/2023 at approximately 10:55 a.m., when S5 CNA, S6 CNA and S7 Hospice RN failed to ensure the lift pad had been properly placed underneath Resident #5 prior to transfer with a mechanical lift. Resident #5 fell from the mechanical lift to the floor during transfer from the bed to the Geri-Chair. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each Resident's drug regimen was free from unnecessary drugs. The facility failed to evaluate the appropriateness for the continued use of a PRN (as needed) psychotropic medication beyond 14 days for 1 (Resident #71) of 5 (Resident #7, Resident #71, Resident #87, Resident #93 and Resident #96) resident's sampled for Unnecessary Medications.