River View Nursing And Rehabilitation Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide adaptive dining equipment, specifically Kennedy cups, as ordered by physicians and indicated in care plans for three residents with significant medical needs. Clinical record reviews showed that these residents had diagnoses such as dysphagia, protein-calorie malnutrition, muscle wasting, lack of coordination, and legal blindness, all of which required the use of adaptive equipment to ensure safe and adequate nutrition. Despite physician orders and care plan interventions specifying the use of Kennedy cups, observations during meal service revealed that dietary staff did not provide the required equipment on the residents' meal trays. Further, meal tickets for these residents clearly indicated the need for Kennedy cups, yet the equipment was not supplied at the time of meal delivery. Staff interviews confirmed that this was a recurring issue, with nurse aides reporting frequent omissions by dietary staff, resulting in interruptions to meal service as nursing staff had to contact the kitchen to obtain the necessary equipment. The Dietary Manager acknowledged the facility's failure to consistently provide the adaptive dining equipment as ordered.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide nursing services consistent with professional standards of quality by not ensuring that licensed nurses administered medications as prescribed to three residents. Specifically, a review of clinical records and staff interviews revealed that three residents did not receive their scheduled medications on a particular day. One resident with dementia and bipolar disorder did not receive a prescribed dose of oxycodone for back pain, while two other residents, one with neuropathy and depression and another with COPD and a hip fracture, did not receive their scheduled doses of gabapentin for neuropathy. The missed medication administrations were linked to a breakdown in staff coverage and communication during a shift change. One LPN left her assignment early due to a family emergency and handed over her responsibilities to another LPN. The incoming LPN, who had been assisting on other units, did not verify that all medications and treatments had been provided before the end of her shift. As a result, the scheduled medications for the three residents were not administered at the prescribed time. Documentation and interviews confirmed that the nurses involved did not ensure the completion of medication administration or maintain accurate records as required by facility policy and state regulations. The facility's own investigation found that the handoff between staff was incomplete, and alternative coverage was not secured, directly resulting in the missed medication doses for the affected residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement procedures to ensure accurate accounting and administration of controlled medications for one resident. A review of the facility's policy on administering medications indicated that medications should be given according to prescriber orders and documented in the resident's medical record, including the date and time of administration. For one resident with a physician's order for Oxycodone 10 mg to be administered three times daily for back pain, discrepancies were found between the controlled substance record and the Medication Administration Record (MAR). Specifically, nursing staff signed out doses of Oxycodone on two separate dates and times in the controlled substance record, but there was no corresponding documentation in the MAR to indicate that the medication was actually administered to the resident at those times. The Nursing Home Administrator confirmed these discrepancies during an interview. The findings indicate a failure to accurately document and account for the administration of controlled substances as required by facility policy and state regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement and maintain a comprehensive infection prevention and control program, specifically in the case of a resident diagnosed with Respiratory Syncytial Virus (RSV). Despite a physician's order to initiate contact precautions following a positive RSV laboratory result, no signage or personal protective equipment (PPE) was present outside the resident's room for over 24 hours. Multiple observations confirmed the absence of required precautions, and staff interviews revealed a lack of awareness regarding the need for contact precautions for the affected resident. The facility's own policies required the use of contact precautions for residents with RSV, including the use of gloves and gowns and appropriate signage, but these were not followed in practice. The resident involved had significant medical conditions, including chronic obstructive pulmonary disease (COPD) and severe cognitive impairment, as indicated by a low BIMS score. The failure to implement contact precautions was confirmed by both the DON and NHA, who acknowledged that the precautions were not put in place until prompted by surveyor inquiry, well after the physician's order was issued. Staff responsible for the resident's care were either unaware of the need for precautions or did not have the necessary resources available to implement them. Additionally, the facility's infection prevention and control program was found to be deficient in its surveillance and data analysis functions. The infection Preventionist had not kept up with infection control data analysis, and surveillance logs were incomplete, lacking critical information such as resident location, organism identification, infection onset dates, and whether infections were facility- or community-acquired. The NHA confirmed that the facility did not have a functional system for tracking infection clusters or analyzing changes in infection trends for several months, further contributing to the deficiency.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect several residents from abuse and neglect, as evidenced by multiple incidents involving both resident-to-resident abuse and staff neglect. Four residents experienced physical abuse from other residents, despite the facility being aware of the aggressors' behavioral risks and having care plans in place. Specifically, one resident with severe cognitive impairment and a history of aggression physically assaulted three other residents on separate occasions, including slapping, punching, and pushing, even while under one-to-one supervision. Another resident, who was cognitively intact but had a documented low tolerance for confused residents, repeatedly struck a severely cognitively impaired resident with a door, resulting in pain and injury. In both cases, the facility failed to implement effective interventions or adequate supervision to prevent these altercations, despite being aware of the risks and having care plans that addressed these behaviors. Additionally, the facility failed to prevent neglect in the case of a resident with end-stage renal disease and bilateral below-the-knee amputations, who required two-person assistance and a mechanical lift for all transfers as per physician orders and care plan. An agency nurse aide transferred this resident without the required lift or second staff member, resulting in the resident falling to the floor and sustaining a rib contusion and significant pain. The aide had received training and was documented as competent in transfer techniques, yet did not follow the established protocols. The incident was further compounded by the presence of clutter and spilled water on the floor, which contributed to the fall. Interviews with staff and the Nursing Home Administrator confirmed the facility's responsibility to prevent abuse and neglect, and acknowledged that the required interventions and supervision were not effectively implemented. Documentation also revealed gaps in the facility's investigation, such as the lack of a resident interview following the fall. The facility's failure to adhere to its own policies and care plans resulted in residents experiencing physical harm and emotional distress.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide respiratory and tracheostomy care in accordance with physician orders for a resident diagnosed with chronic respiratory failure and cerebral palsy. The resident had specific physician orders for oxygen as needed to maintain oxygen saturation above 89%, continuous humidification via tracheostomy even when on room air, initiation of vest therapy twice daily for airway clearance, and administration of Albuterol nebulizer twice daily with vest therapy. On observation, the resident was not receiving oxygen or humidification via the tracheostomy, and there was no evidence of a SmartVest in the resident's room. Staff confirmed that humidification was not being used when the resident was on room air and that the resident had not yet received a SmartVest. Further review of the clinical record showed no documentation that arrangements had been made to obtain a SmartVest for the resident, despite the physician's order. The director of nursing was unable to provide evidence that the physician's orders related to respiratory and tracheostomy care were implemented in a timely manner. These findings indicate that the facility did not ensure the resident received the ordered respiratory interventions, as required by the physician's plan of care.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to accurately identify and honor a resident's advance directive regarding life-sustaining treatment. A review of the clinical record for a resident with osteoarthritis and atrial fibrillation showed that the resident had a completed and signed POLST form indicating a Do Not Resuscitate (DNR) status, with a goal of allowing a natural death. However, the resident's current physician orders in the electronic health record incorrectly listed the code status as Full Code, which would require CPR in the event of cardiopulmonary arrest. There was no documentation in the clinical notes or care conference records to indicate that the resident had revised the advance directive or changed the preference documented on the POLST. An interview with the Director of Nursing confirmed that physician orders are required to align with the most current, signed POLST, and acknowledged the discrepancy between the resident's documented wishes and the physician orders. This failure resulted in the resident's treatment preferences not being properly reflected in the medical record.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to thoroughly investigate an incident involving a resident's fall with minor injury and did not determine whether neglect occurred. The resident, who had end-stage renal disease, bilateral below-the-knee amputations, and required dialysis, was care planned and had physician orders for all transfers to be performed with a mechanical lift and two staff members. Despite these orders, an agency nurse aide attempted to transfer the resident manually and alone, resulting in the resident's stump becoming stuck in the wheelchair arm and a subsequent fall to the floor. The incident occurred in the presence of floor clutter and spilled water, which contributed to the event. The facility's investigation did not include a statement from the resident at the time of the incident, nor did it identify or document that the mechanical lift was not used and that only one staff member was involved in the transfer. The investigation also failed to evaluate whether the resident's care plan was implemented as directed or to recognize the deviation from established protocols. The nurse aide involved had completed required training and was deemed competent, yet did not follow the care plan or physician's orders during the transfer. Following the fall, the resident experienced rib pain and required pain management, with a physician later diagnosing a rib contusion. The facility did not provide evidence of a comprehensive investigation to rule out neglect or mistreatment, nor did it identify the lack of adherence to planned interventions or implement measures to prevent recurrence. The deficiency was cited under relevant federal and state regulations for failure to protect residents from neglect and to ensure care plans are followed.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for three residents, as identified through clinical record reviews and staff interviews. For one resident with chronic respiratory failure and atrial fibrillation, the MDS assessment did not reflect the administration of anticoagulant medications during the required seven-day look-back period, despite documentation in the Medication Administration Record showing that anticoagulants were given. The registered nurse assessment coordinator (RNAC) confirmed the inaccuracy of this assessment. Another resident with dementia and peripheral vascular disease had an MDS assessment indicating active infections of a multi-drug resistant organism (MDRO) and pneumonia, but there was no clinical documentation supporting the presence of these infections during the look-back period. Additionally, a third resident with diabetes had an MDS assessment stating no insulin was administered, while the Medication Administration Record showed multiple insulin injections during the same period. In each case, the RNAC confirmed the MDS assessments did not accurately reflect the residents' clinical status.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that nursing services met professional standards of quality regarding the administration of intravenous (IV) medication via a peripheral IV. Specifically, the facility did not have a written policy or protocols specifying which licensed nursing staff (RN or LPN) were responsible for the infusion of physician-ordered IV fluids or medications. Additionally, there was no documented evidence that LPNs employed at the facility had completed a Board-approved educational program for IV therapy, nor was there evidence of annual in-service training on IV administration for LPNs who may have completed such a program. A clinical record review revealed that a resident with dementia was ordered to receive Meropenem-Sodium Chloride Intravenous Solution for a urinary tract infection. The resident had a peripheral IV placed, and the Medication Administration Record (MAR) indicated that several LPNs signed as having administered the IV antibiotic over a period of several days. However, during staff interviews, one LPN stated she had not actually administered the IV medication but had signed the MAR, while an RN had performed the administration. The LPN also confirmed she had not received education on IV medication administration at the facility. Interviews with the administrator and DON confirmed the absence of written policies or protocols for LPNs to administer IV fluids or medications and the lack of documentation regarding LPNs' completion of required IV therapy education. The DON also confirmed that facility policy required the nurse administering the medication to sign the MAR, but there was no evidence of education or supervision for LPNs regarding IV administration. These findings demonstrate a failure to ensure that nursing services, specifically IV medication administration, met professional standards of quality as required by state regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide safe and appropriate pain management for one resident, as required by professional standards, facility policy, and physician orders. The facility's policy mandated that residents experiencing acute or significant changes in chronic pain be monitored at least each shift using standardized assessment tools. Physician orders for the resident included documenting verbal and nonverbal signs and symptoms of pain every shift and administering oxycodone three times daily for back pain. The resident, who had diagnoses including sciatica and mobility abnormalities and was moderately cognitively impaired, reported experiencing significant pain, particularly at night. Despite these requirements, there was no documented evidence of pain assessments or monitoring for the resident after a specific date. During interviews, facility leadership, including the NHA and DON, were unable to provide documentation showing that pain monitoring had been conducted as ordered. This lack of documentation and monitoring constituted a failure to follow both physician orders and facility policy regarding pain management.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement an individualized, person-centered care plan to provide trauma-informed care for a resident diagnosed with Post-Traumatic Stress Disorder (PTSD). The resident, who had a history of serving two tours in Vietnam and experienced nightly nightmares prior to medication intervention, was admitted with a diagnosis of PTSD. Although there was a physician's order for Prazosin HCL to address nightmares related to PTSD, the resident's care plan did not identify PTSD symptoms, triggers, or specific interventions to minimize triggers and prevent re-traumatization. During interviews, the resident confirmed ongoing symptoms prior to medication, and facility leadership acknowledged that they could not demonstrate the provision of culturally competent, trauma-informed care in accordance with professional standards. The care plan lacked documentation of the resident's PTSD-related needs, experiences, and preferences, and did not include strategies to eliminate or mitigate potential triggers for re-traumatization.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's drug regimen was free from unnecessary antibiotics. Upon admission from an emergency department, a resident with a history of epilepsy was prescribed Cephalexin 500 mg for a urinary tract infection (UTI) based on hospital orders. The facility's policy requires that antibiotic use be guided by its antibiotic stewardship program, including review of lab results and clinical status to determine the necessity of continued antibiotic therapy. Despite this, the resident received 25 doses of Cephalexin over several days without documented clinical signs or symptoms of a UTI, such as dysuria, fever, urinary urgency, suprapubic pain, increased incontinence, or hematuria. Laboratory results during this period showed no significant bacterial growth in the urine culture, and although the urinalysis indicated an elevated white blood cell count, there was no clinical documentation correlating this finding with active infection. Staff interviews confirmed the absence of a documented clinical rationale for the continued use of Cephalexin. The Nursing Home Administrator acknowledged the lack of supporting documentation and the facility's responsibility to ensure residents are not administered unnecessary antibiotics.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the automatic sprinkler system as required, which was evidenced by a supervisory signal indicating a fire pump loss of power on the fire alarm panel. This issue was observed during an inspection on April 8, 2025, affecting all three floors of the facility. Although the facility had a new fire pump on site, it had not yet been installed. Previous fire alarm testing conducted on April 1, 2025, did not reveal any deficiencies. The deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager.

Plan Of Correction

1. The facility has contracted with Beach Lake Sprinkler to replace the fire pump panel on the week of May 5, 2025. 2. The facility fire pump controller will be reviewed and updated as needed. 3. NHA will educate the Maintenance Director, to assure the fire pump is updated as needed. 4. Fire pump will be audited weekly x4 then monthly x3 by Maintenance Director/Designee to ensure fire alarm pump is up to date. Audits will be reviewed at QAPI for further recommendations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the automatic sprinkler system, affecting all three floors. During an observation on April 8, 2025, it was noted that a quarterly sprinkler inspection report from February 4, 2025, indicated that while the fire pump was operational, the control panel was nonresponsive, and the emergency stop was used to shut down the pump. This issue persisted at the time of the survey. Additionally, several deficiencies were observed: an unsealed penetration in a ceiling tile in the laundry area, five sprinkler heads in the dietary area loaded with dust, and another unsealed penetration in a corridor ceiling tile near the nurse's station on the second floor. These deficiencies were confirmed during an exit interview with the Facility Administrator and the Facilities Manager.

Plan Of Correction

1. The facilities fire pump panel will be replaced the week of May 5th 2025 with Beach Lake Sprinkler company. Maintenance has sealed the penetrations located in the laundry area. The five Dietary Sprinkler heads have been replaced. The second floor Birch penetration near the nurses' station has been sealed. 2. Maintenance Director /Designee will check the ceiling in the laundry from any additional penetrations, and seal if needed. Maintenance Director/Designee will check all sprinkler heads in the dietary for dust, and replace if needed. Maintenance/designee will inspect the Birch unit for penetrations, and seal if needed. 3. Maintenance Director /designee will complete audit x4 weeks, then monthlyx3. 4. Maintenance Director will report to QAPI audits and findings.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Riverview Nursing and Rehabilitation Center was found to be non-compliant with the emergency preparedness requirements outlined in 42 CFR 483.73. During an emergency preparedness survey conducted on April 8, 2025, it was observed that the facility failed to maintain an updated Delegation of Authority succession plan. The plan, last updated in August 2020, contained names that did not match the current staff roster. This deficiency affected all three floors of the facility. The issue was confirmed during an exit interview with the Facility Administrator and Facilities Manager.

Plan Of Correction

1. Facility has updated the Delegation of Authority succession Plan. 2. The facility Delegation of Authority will be reviewed and updated as needed. 3. NHA will educate the Receptionist to ensure the Delegation of Authority is completed as needed. 4. Facility Delegation of Authority will be audited weekly x4 then monthly x3 by NHA/Designee to ensure the plan is up to date. Audits will be reviewed at QAPI for further recommendations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain exit access in accordance with NFPA 101 standards, specifically on the third floor of the Pine Ridge, C-Tower. During an observation conducted on April 8, 2025, at 12:11 pm, it was noted that a wheelchair was stored in the corridor, obstructing access to the exit door. This obstruction was confirmed during an exit interview with the Facility Administrator and Facilities Manager later that day at 1:15 pm.

Plan Of Correction

1. The wheelchair on the 3rd floor Pine Ridge C-Tower exit was removed upon discovery. 2. Education will be provided to all staff by the Maintenance Director/Designee on ensuring wheelchairs are not stored blocking access to the exit doors. 3. The Maintenance Director or designee will audit weekly x4 then monthly x3 to ensure wheelchairs are not stored blocking access to the exit doors. 4. Monthly audits will be reviewed at QAPI for further recommendations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain three hazardous area enclosures, affecting two of three floors. On the 1st floor, the Holding Room door did not latch into the frame when tested, compromising the enclosure's integrity. Additionally, the Elevator machine room on the same floor was improperly used for storage, containing six plastic folding tables. On the 3rd floor, in the Sycamore area, the Soiled Linen room had unsealed wall penetrations due to damage, further compromising the enclosure's effectiveness. These deficiencies were confirmed during an exit interview with the Facility Administrator and Facilities Manager.

Plan Of Correction

1. The first floor holding room door mechanism has been repaired. The 6 plastic folding tables have been removed from the first-floor elevator machine room. Third floor Sycamore Soiled Linen penetration has been sealed and repaired. 2. NHA will in-service Maintenance Director on maintaining enclosed areas free of hazards and penetrations. 3. Maintenance Director/designee will complete a random weekly audit x 4 then monthly x 3. 4. Audits will be reported to QAPI for further recommendations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain three corridor openings, which affected two of the three floors. During an observation on April 8, 2025, several deficiencies were noted. At 11:27 am, the door to the Dietary, Food Service Room required adjustment to fully latch into the frame. This indicates that the door was not properly aligned or maintained to ensure it could close securely, potentially compromising the safety and smoke resistance of the corridor. Further observations revealed additional issues on the 2nd floor. At 12:24 pm, the Personal Laundry Room door failed to latch into the frame because the strike plate was taped over, preventing the door from securing properly. Additionally, at 12:32 pm, the door to Resident Room 202 in the Aspen area also failed to latch into the frame. These deficiencies were confirmed during an exit interview with the Facility Administrator and Facilities Manager, highlighting a lapse in maintaining the integrity of corridor doors as required by regulations.

Plan Of Correction

1. The food service door latch has been adjusted to ensure latching; the Personal Laundry Room door latch has been replaced, Aspen Resident Room 202 latch has been adjusted to ensure latching. 2. Dietary doors will be checked to ensure they latch into their frame. Resident room doors in Aspen will be checked to ensure they latch into their frames. 3. NHA/Designee will in-service Maintenance Director on assuring self-closure doors latch correctly. 4. Maintenance/Designee will audit weekly x4, then monthly x3. Audits will be reported to QAPI, for further recommendations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain smoking regulations as required by NFPA 101, affecting one of three floors. During an observation on April 8, 2025, at 11:50 am, surveyors found discarded cigarette butts within the exterior mulch bed outside the main entrance of the facility. This observation indicates non-compliance with the smoking regulations that mandate proper disposal of smoking materials in designated areas. An exit interview with the Facility Administrator and Facilities Manager on the same day confirmed the deficiency in adhering to the smoking regulations.

Plan Of Correction

1. Cigarette butts have been removed from the exterior mulch bed, outside the main entrance. 2. Cigarette butts have been removed from all exterior mulch beds. 3. Maintenance/Designee will provide education to all staff on the facility non-smoking policy. 4. Maintenance will complete audits x4 weeks and then monthly x3. Audits will be reviewed at QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain the electrical system properly in one location, specifically affecting one of the three floors. During an observation on April 8, 2025, at 12:02 pm, it was noted that items were stored within 36 inches of electrical components in the 3rd floor storage room near the nurse's station. This proximity of stored items to electrical components constitutes a deficiency in maintaining the electrical system as per NFPA 99 Chapter 10 requirements. The deficiency was confirmed during an exit interview with the Facility Administrator and Facilities Manager on the same day at 1:15 pm, where they acknowledged the issue with the electrical systems in the specified location.

Plan Of Correction

1. Storage items have been moved away from all electrical panel's components in the third floor storage room near the nurses' station. 2. Items have been moved to at least 36 inches of electrical components in facility storage rooms. 3. Maintenance/Designee will educate all staff about maintaining a 3 foot clearance from all electrical panels. 4. Maintenance/Designee will complete audits weekly x4, then monthly x3. Audits will be reported to QAPI.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to comply with Federal, State, and Local laws and professional standards by not ensuring timely payment for goods and services necessary for daily operations. A review of the facility's accounts payable ledger revealed numerous outstanding balances for more than 121 days beyond the terms of payment. These unpaid invoices included essential services and supplies from various vendors, such as medical equipment, pharmacy services, and utility providers, which are critical for maintaining the health and safety of the residents. During an interview, the Nursing Home Administrator confirmed that the facility owners had not provided evidence of payments or payment agreements for these outstanding invoices. This lack of timely payment for essential goods and services demonstrates non-compliance with regulations that require facilities to pay bills promptly to prevent jeopardizing the health and safety of residents.

Plan Of Correction

1. There are no goods or services that are being withheld from the residents due to the status of the A/P liabilities of River View Nursing and Rehabilitation Center. 2. The facility will systematically work to make payments on cited delinquent balances not in dispute, using discretion to ensure that current, essential vendors are paid then paying down cited delinquent balances. 3. The Regional Director of Operations Consultant will educate NHA on the monthly AP/Aging report to ensure vital services are not interrupted. 4. NHA will audit the monthly AP/Aging report monthly for 3 months to ensure vital services are not interrupted due to the status of A/P liabilities. Results of the monthly audits will be submitted to the QAPI Committee for review.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to implement effective infection control practices for cohorting residents with respiratory infections and testing for COVID-19, which increased the risk of COVID-19 transmission among at least 12 residents. The facility did not have specific COVID-19 policies and procedures available during the survey, and the Nursing Home Administrator stated that they followed CDC guidelines. However, the facility did not adhere to the Pennsylvania Department of Health's recommendations for COVID-19 infection prevention and control, which included implementing transmission-based precautions and cohorting residents with confirmed COVID-19 separately from those who were negative. Several residents who tested positive for COVID-19 were cohorted with COVID-19 negative roommates, leading to the spread of the virus. For instance, Resident 3, who was COVID-19 positive, was cohorted with Resident 4, who was negative, resulting in Resident 4 testing positive later. Similar incidents occurred with other residents, such as Resident 5 with Resident 6, and Resident 7 with Resident 8, among others. The facility's failure to separate COVID-19 positive residents from negative ones contributed to the transmission of the virus within the facility. Additionally, the facility did not provide COVID-19 testing logs for staff, and there was no documentation of contact tracing for residents or staff. The infection control logs did not identify any signs or symptoms displayed by residents or staff. During an interview, the Nursing Home Administrator and the Director of Nursing confirmed that they did not move COVID-19 positive residents or their negative roommates, mistakenly believing that cohorting COVID-19 positive residents was no longer recommended. This lack of adherence to infection control guidelines and procedures resulted in a deficiency in the facility's infection prevention and control program.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide timely assistance to residents, as reported by nine out of eleven residents during a group interview. Residents expressed concerns about long wait times for staff assistance, with some waiting 15 to 20 minutes, while others reported waiting up to 45 minutes or more. This delay in response led to residents attempting to care for themselves, despite it being unsafe, and experiencing discomfort and distress from sitting in soiled briefs for extended periods. Residents also reported that staff refused to provide showers outside of scheduled days, which were limited to twice a week, and denied requests for clean linens except on these days. This restriction left residents feeling unclean and uncomfortable. Additionally, residents were told not to ring their call bells during meal times, forcing them to wait for assistance and sometimes sit in their own waste until staff were available. The Nursing Home Administrator and Director of Nursing acknowledged that all residents should be treated with dignity and respect but could not explain the reasons behind the reported issues. The deficiencies noted in the report include untimely staff responses, refusal to accommodate residents' hygiene needs, and restrictions on call bell usage, all of which negatively impacted the residents' quality of life.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect four residents from physical abuse by another resident, as evidenced by multiple incidents involving Resident 97. Resident 97, who has severe cognitive impairment due to Alzheimer's disease and dementia, exhibited aggressive behavior towards other residents. The incidents included elbowing Resident 62 in the chest, pushing Resident 85 to the floor, hitting Resident 62 in the back of the head, and striking Resident 119 in the head with a closed fist. These events were witnessed by staff and visitors, and in some cases, staff intervened to separate the residents. The facility's policy on abuse prevention mandates that residents should be free from abuse, including physical abuse by other residents. Despite this policy, the facility did not effectively implement protocols to prevent these incidents. The clinical records and witness statements indicate that Resident 97's aggressive behavior was not adequately managed, leading to repeated physical altercations with other residents. The facility's failure to assess Resident 85 for injuries after being pushed to the floor further highlights the lack of appropriate response to these incidents. Interviews with the Director of Nursing and the Nursing Home Administrator confirmed the facility's failure to protect residents from physical abuse by other residents. The facility's inability to prevent and appropriately respond to these incidents resulted in a violation of residents' rights to be free from abuse, as outlined in the facility's policies and state regulations.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notice of its bed-hold policy to residents and their representatives upon transfer to a hospital, as required by its own policy and state regulations. This deficiency was identified for eight residents out of a sample of 27. The facility's policy, last reviewed on April 18, 2024, mandates that residents and their representatives be informed in writing about the bed-hold policy at admission and at the time of transfer, or within 24 hours if the transfer is an emergency. However, documentation reviews revealed that residents 7, 114, 101, 9, 63, 112, 2, and 106 were not provided with this information upon their transfers to the hospital. Interviews with residents and facility staff further confirmed the lack of communication regarding the bed-hold policy. For instance, Resident 114 expressed distress upon returning to the facility and finding she had been moved to a different room, having not been informed of the bed-hold policy prior to her hospital transfer. The Nursing Home Administrator and Director of Nursing were unable to provide evidence that the required notifications were made for the affected residents. This oversight violates the facility's policy and state regulations, specifically 28 Pa Code 201.18 (e)(1) Management and 28 Pa Code 201.29 (b) Resident rights.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide restorative nursing services to maintain mobility and functional abilities for four residents. Resident 63, who was admitted with conditions such as cerebrovascular disease and hemiplegia, was recommended for a restorative range of motion program following occupational therapy. However, the program was not implemented as per the discharge recommendations, and the Director of Nursing (DON) could not provide evidence of its execution. Resident 114, diagnosed with cauda equina syndrome, was also not provided with the recommended restorative services. Despite being cognitively intact and expressing interest in participating in restorative nursing services, the resident's care plan was not updated to include the necessary interventions. The DON confirmed the lack of implementation of the recommended exercises for the resident's lower extremities. Similarly, Resident 72, with a history of poliomyelitis, and Resident 2, diagnosed with cerebral palsy, were not provided with the restorative range of motion programs recommended upon discharge from therapy. The clinical records for both residents lacked documentation of the implementation of these programs, and the DON was unable to provide evidence of their execution.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the timely administration of physician-ordered intravenous antibiotics for two residents, resulting in medication errors. Resident 86, who was admitted with diagnoses including quadriplegia, infection due to an indwelling urethral catheter, and sepsis, had a physician order for Vancomycin to be administered twice daily. However, the Medication Administration Record (MAR) and real-time administration detail report revealed multiple instances where the medication was administered more than an hour late, and one instance where a dose was missed entirely without notifying the physician or documenting the reason. Similarly, Resident 72, admitted with diagnoses including poliomyelitis and sepsis secondary to chronic infected wounds, had a physician order for Vancomycin to be administered every eight hours. The MAR and administration detail report indicated several instances of late administration and two missed doses without proper documentation or physician notification. The Director of Nursing confirmed these deficiencies during an interview. The facility's policy on administering medications requires that medications be administered in a safe and timely manner, within one hour of the prescribed time unless specified otherwise. The policy also mandates documentation and physician notification in the event of medication errors. The facility's failure to adhere to these policies resulted in the untimely administration of antibiotics for both residents, compromising the prescribed treatment regimen.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the Medical Director or a designated physician attended the quarterly Quality Assurance Process Improvement (QAPI) Committee meetings as required. A review of the QAPI Committee meeting sign-in sheets for the period from August 2023 through June 2024 revealed that the Medical Director or another physician was absent from the meetings held in October 2023 and December 2023. This resulted in the Medical Director missing two of the three quarterly meetings reviewed. An interview with the Nursing Home Administrator confirmed the absence of documented evidence of the physician's attendance at these meetings, which is a requirement under the relevant state codes.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that the self-administration of medications was clinically appropriate for one of the residents, identified as Resident 7. The facility's policy allows residents to self-administer medications if deemed clinically appropriate and safe by the interdisciplinary team, with documentation required in the medical record and care plan. However, a review of Resident 7's clinical records revealed no documented evidence of an assessment or approval for self-administration of medications. Despite this, Resident 7 was observed with five pills on her bedside table, which she stated were left by the nurses for her to take one at a time due to difficulty swallowing them all at once. An interview with an LPN confirmed that the pills were left with Resident 7 because of her swallowing difficulty, but the LPN could not confirm if an assessment for self-administration had been conducted. Further review of the resident's records showed an undated form indicating that Resident 7 elected not to self-administer medications. The Director of Nursing confirmed the lack of documented assessment and approval, acknowledging that Resident 7 should not have been allowed to self-administer her medications without it. This oversight was a violation of the facility's policies and relevant state codes regarding pharmacy services, resident care policies, and nursing services.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that a resident's mail was delivered unopened, violating the resident's right to personal privacy. During a resident group interview, a resident reported that he did not receive his incoming mail and packages unopened. The resident mentioned a previous incident where there was a mix-up with prescription medication arriving in a package addressed to him instead of being sent directly to the facility. This incident involved Buprenorphine patches, a controlled substance, which were found in the resident's room after being sent from a local healthcare clinic. The facility's incident report confirmed the mistake of sending medication directly to the resident. The local healthcare clinic was contacted to address this error. The director of nursing confirmed that residents, including the involved resident, have the right to receive mail and packages unopened, and that any packages addressed to the care of the nursing supervisor should still be opened by the resident with the nursing supervisor present. The report highlights the facility's failure to respect the resident's right to receive unopened mail and packages.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that necessary resident information was communicated to the receiving health care provider during a facility-initiated transfer. A clinical record review revealed that a resident was transferred to a community hospital and returned to the facility. However, there was no documented evidence that specific information, such as contact information of the practitioner responsible for the resident's care, resident representative information, advance directive information, and special instructions or precautions for ongoing care, was communicated to the receiving provider. This deficiency was confirmed during an interview with the Director of Nursing and Nursing Home Administrator, who acknowledged the lack of evidence for the communication of necessary information during the transfer.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to submit the Minimum Data Set (MDS) assessments to the CMS Quality Improvement and Evaluation System (QIES) Assessment Submission and Processing (ASAP) System within the required timeframe for one resident. According to the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual, discharge assessments-return anticipated (non-comprehensive) must be completed no later than 14 calendar days after the resident's discharge date. Resident 72 was transferred to the hospital on April 30, 2024, and returned to the facility on May 3, 2024. However, a review of the clinical records showed no documented evidence that the required MDS discharge assessment-return anticipated was completed for this resident. The director of nursing confirmed during an interview that the assessment was not completed and submitted within the required timeframes.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop and implement a comprehensive care plan for Resident 112, who was admitted with diagnoses including diabetes, Parkinson's disease, and peripheral vascular disease. The care plan did not address these active diagnoses or the resident's preferred language, which is Spanish. Despite the resident's need for an interpreter to communicate with healthcare staff, the care plan lacked any mention of assistive communication devices or methods to facilitate communication. Observations revealed that Resident 112's room did not contain any communication tools such as a board, tablet, or picture book, and there was no visible information on how to access interpreter services. Staff interviews confirmed the absence of these resources, and the Director of Nursing acknowledged the facility's failure to create a person-centered care plan that included individualized interventions for the resident's health and communication needs.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to adequately assess and address the bladder function of a resident with Parkinson's disease, diabetes, and hypertension, who experienced a decline in urinary continence. Despite the resident's Minimum Data Set (MDS) assessments indicating a change from frequent incontinence to always incontinent, there was no documented evidence of incontinence evaluations or implementation of scheduled toileting programs. The resident's care plan included measures for monitoring urinary incontinence and potential urinary tract infection (UTI) symptoms, but these were not effectively executed, as confirmed by the Director of Nursing (DON). Additionally, the facility did not maintain proper catheter care for another resident with benign prostatic hyperplasia and Alzheimer's disease, who had a physician order for a foley catheter. Observations revealed that the resident's urinary collection bag was in direct contact with the floor, contrary to guidelines for preventing catheter-associated UTIs. This improper maintenance was confirmed by both a Licensed Practical Nurse (LPN) and the DON, indicating a failure to adhere to infection prevention protocols.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to timely implement a nutritional support regimen for a resident, identified as Resident 90, who was at risk of weight loss due to diet restrictions, obesity, and variable oral intake. Despite a significant weight loss of 6.87% within a week, the facility did not obtain a re-weight to confirm the loss, nor did they notify the resident's physician. The resident's care plan included interventions such as meal assistance and monitoring of meal refusals, but these were not adequately executed. Observations revealed that the resident often refused meals or consumed less than 50% of them, and on one occasion, was left unattended with an untouched meal tray. The facility did not act upon the resident's decreased meal intake or significant weight loss, failing to implement necessary nutritional support interventions. Additionally, the facility did not accurately monitor a fluid restriction for another resident, identified as Resident 178, who had a physician order for a 1500 cc fluid restriction due to congestive heart failure. The resident's lunch meal tag did not indicate the fluid restriction, and there was no documented evidence that the restriction was implemented to ensure the resident did not exceed the prescribed fluid intake. The Director of Nursing confirmed that the facility failed to implement the physician-prescribed fluid restriction for this resident.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure the availability of necessary emergency supplies for a resident receiving hemodialysis, identified as Resident 59. This resident was admitted with end-stage renal disease and was dependent on hemodialysis, which was administered through a Tesio port in the right upper chest. The resident's clinical record included a physician's order for an emergency kit to be kept at the bedside for the dialysis port, dated June 11, 2024. Additionally, the resident's care plan required staff to check for a pressure dressing and clamp at the bedside every shift and document this in the Treatment Administration Record (TAR). Observations conducted on June 11 and June 12, 2024, revealed that there were no emergency supplies available at the resident's bedside. Interviews with a registered nurse supervisor and the Director of Nursing confirmed the absence of the emergency kit, which was a requirement for residents receiving dialysis. The facility's failure to provide these supplies was a violation of the nursing services regulation, as noted under 28 Pa. Code 211.12 (d)(3)(5).

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to clinically justify the use of an as-needed antipsychotic medication for a resident diagnosed with Alzheimer's disease and dementia. The resident, who was severely cognitively impaired with a BIMS score of 7, was involved in an incident where they attempted to push another resident in a wheelchair, leading to frustration and aggression. Despite this incident, there was no documented evidence of increased behaviors or symptoms justifying the administration of the PRN antipsychotic medication, Seroquel, on the day it was given. The clinical records lacked documentation of any clinical justification for the PRN use of Seroquel, as confirmed by interviews with the nursing home administrator and director of nursing. The medication was administered without documented symptoms, and the facility's records did not provide evidence of the necessity for the antipsychotic medication at the time it was given. This deficiency was identified during a survey, highlighting a failure in adhering to regulations regarding the use of psychotropic medications.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to post nurse staffing information on a daily basis, which includes the resident census and the total number and actual hours worked by licensed and unlicensed staff. Observations in the facility lobby on June 11, 2024, at 8:45 AM and 3:10 PM, and on June 12, 2024, at 9:00 AM revealed that the required nurse staffing information was not posted in the designated area. An interview with the Director of Nursing on June 12, 2024, at 9:10 AM confirmed that the nurse staffing information should be posted daily at the beginning of each shift in a prominent location, as per the facility's protocol.

Penalty

34 days payment denial

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide written notices of facility-initiated transfers to residents and their representatives for eight out of the 27 residents reviewed. This deficiency was identified through clinical record reviews and staff interviews. The residents involved were transferred to hospitals on various dates, but there was no documented evidence that they or their representatives received the required notices of transfer or discharge. This lack of documentation was confirmed by the Nursing Home Administrator and Director of Nursing during an interview. The residents affected by this deficiency include those who were transferred to hospitals multiple times without receiving the necessary notifications. For instance, one resident was transferred on several occasions between December 2023 and May 2024, yet no notices were documented. Another resident was transferred and readmitted as a new admission after a stay in a specialty hospital unit, again without documented notification. This pattern of inaction indicates a systemic issue in the facility's process for notifying residents and their representatives about transfers, as required by resident rights regulations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to promptly and sufficiently resolve grievances for two residents. Resident 11 submitted a grievance regarding a neighboring resident's disruptive and threatening behaviors, which were not addressed until five days later, and only after a second grievance was submitted. The facility did not communicate the resident's concerns to the necessary departments for a timely response, as required by their policy. This delay in addressing the grievance led to continued distress for Resident 11, who reported ongoing violent and disruptive behavior from the neighboring resident during a Resident Council meeting. Similarly, the family of Resident CR1 submitted a grievance regarding the resident's missing glasses, which were essential for daily use. The glasses were missing for 12 days before being found, with no evidence of the facility's efforts to locate them or resolve the concern promptly. The Nursing Home Administrator confirmed that there was no documented evidence of timely and sufficient efforts to resolve the grievances, as required by the facility's policy.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The baseline care plan failed to fully address the immediate individual needs of Resident 111, who was admitted with bilateral above-the-knee amputations. Upon review, it was found that the care plan did not identify the resident's needs for assistance with activities of daily living due to the amputations. The care plan only included interventions for fall risk related to gait/balance problems, such as ensuring the call light was within reach and encouraging the use of appropriate footwear. An interview with the Director of Nursing confirmed that the facility did not include the necessary healthcare information to properly care for the resident immediately upon admission.