RIVERVIEW AT THE PARK CARE AND REHABILITATION CTR

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to maintain and/or
enhance the dignity for four residents (Resident #5, #43, #47, and #76) out of 18 sampled
residents and 22 residents (Resident #1, #17, #22, #23, #26, #27, #28, #30, #31, #35, #39,
#40, #42, #44, #53, #64, #74, #78, #84, #101, #102, and #103) outside of the sample. The
facility did not serve meals to residents sitting at the same table, at the same time and
caused the residents to wait extended periods of time. The facility failed to ensure one
resident (Resident #73) was clothed while in the dining room. The facility’s census was
88.
1. Observation on 6/4/19 of the 300 Hall Dining Room showed:
– Scheduled dinner time from 5:00 P.M. to 5:30 P.M.;
– Residents #30, #39 and #47 sat at a table together. Resident #39 received his/her meal
at 5:43 P.M. and Resident’s #30 and #47 received their meals eight minutes later at 5:51
P.M.;
– Residents #53, #74 and #101 sat at a table together. Resident #101 received his/her meal
at 5:45 P.M. and Resident’s #53 and #74 received their meals eight minutes later at 5:53
P.M.;
– Residents #1 and #5 sat at a table together. Resident #5 received his/her meal at 5:46
P.M., and Resident #1 received his/her meal nine minutes later at 5:55 P.M.;
Observation on 6/4/19 of the 400 Hall Dining Room showed:
– Residents #22 and #44 sat at a table together.
– Resident #44 received his/her meal at 5:20 P.M. and Resident #22 received his/her meal
nine minutes later at 5:20 P.M.
Observation of the 300 Hall dining room on 6/5/19 from 7:30 A.M. through 8:05 A.M. showed:
– Scheduled breakfast meal time to be 7:00 A.M. to 7:30 A.M.;
– At 7:32 A.M., 13 residents sat waiting for breakfast;
– At 7:39 A.M., Resident #30 said, I’ve been down here for an hour and a half and still no
breakfast. They wake us up early and then we sit and wait;
– At 7:47 A.M., the first meal served to Resident #102;
– At 7:48 A.M., Resident #39 served meal. Resident #39 said, Resident #47 needs to eat.
His/her tablemates Resident #23 and #47 served at 7:58 A.M.,10 minutes later, and Resident
#30 served at 7:59 A.M., 11 minutes later;
– At 7:57 A.M., Resident #74 yelled out Can I have some breakfast? This is ridiculous.;
– At 8:00 A.M., Resident #74 served. His/her tablemate Resident #53 served the last meal
at 8:02 A.M.
Observation of the 100 Hall dining room on 6/05/19 from 7:30 A.M. to 8:15 A.M., showed:
– Scheduled breakfast meal time to be 7:30 A.M. to 8:00 A.M.;
– At 7:42 A.M., the first meal served to Resident #58. His/her tablemate Resident #76
served at 7:43 A.M.;
– At 7:44 A.M., Resident #31 served meal. His/her tablemate Resident #27 served at 7:49
A.M., five minutes later;
– At 7:47 A.M., Resident #42 served meal. His/her table mate Resident #84 served at 7:48
A.M.;
– At 7:48 A.M., Resident #43 served meal. His/her tablemate Resident #78 served at 7:49
A.M.;
– At 7:49 A.M., Resident #64 became agitated, had a verbal altercation with another
resident and went to his/her room, food taken to his/her room at 7:49 A.M.; His/her

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to consider and accommodate
resident’s preferences for one resident (Resident #78) out of 18 sampled residents. The
facility’s census was 88.
1. Record review of Resident #78’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– Order dated 5/6/19 for urinary catheter (a tube inserted in the bladder to drain urine).
Record review of the resident’s admission Minimum Data Set (MDS; a federally mandated
assessment instrument completed by the facility staff) dated 4/25/19, showed a Brief
Interview for Mental Status (BIMS; a screening tool to assess cognition) score of 15
(cognition intact).
Record review of the resident’s Comprehensive Care Plan, last updated 5/6/19, showed:
– The resident with a urinary catheter;
– The resident will be free from catheter related trauma;
– Check for kinks in tubing every shift;
– Monitor for signs and symptoms of a urinary tract infection.
Observation on 6/03/19 at 12:34 P.M. showed the resident appeared to be angry, frowning,
jerking his/her chair around to move about. Observation showed the resident wearing a
catheter leg bag attached to his/her right upper leg.
During an interview on 6/3/19 at 12:35 P.M., the resident said the facility is out of
regular catheter bags, and he/she has to wear leg bag until they get some regular bags in.
The resident said he/she does not like leg bags and is mad about having to wear it.
Observation on 6/4/19 at 12:00 P.M. showed the resident wore shorts and an uncovered

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to document preparation and
orientation for transfer to the hospital for eight residents (Resident #12, #38, #46, #51,
#56, #62, #71, and #76) out of 18 sampled residents. The facility’s census was 88.
1. Record review of the facility’s policy, titled Orienting Residents to Transfers and
Discharges, dated 5/1/12, showed:
– Our facility shall prepare a resident for a transfer or discharge;
– The purpose of the orientation is to provide the resident and family with sufficient
preparation and to ensure a safe and orderly transfer or discharge from the facility;
– Inquiries concerning our orientation program should be referred to the Director of
Nursing Services.
2. Record review of Resident #12’s Progress Notes showed the resident transferred to the
hospital:
– On 3/7/19 and readmitted to the facility on [DATE];
– On 4/10/19 and readmitted to the facility on the same date.
Record review of the resident’s medical record did not contain documentation which showed
the resident was prepped and oriented for transfer out of the facility.
3. Record review of Resident #38’s Progress Notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Record review of the resident’s medical record did not contain documentation which showed
the resident was prepped and oriented for transfer out of the facility.
4. Record review of Resident #46’s Progress Notes showed the resident transferred to the
hospital on [DATE] and readmitted to the facility on [DATE].
Record review of the resident’s medical record did not contain documentation which showed
the resident was prepped and oriented for transfer out of the facility.
5. Record review of Resident #51’s Progress Notes showed the resident transferred to the
hospital:
– On 2/23/19 and readmitted to the facility on the same date;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to revise and
update comprehensive care plans with specific interventions to meet the individual needs
of three residents (Resident #12, #64, and #73) out of 18 sampled residents. The
facility’s census was 88.
1. Record review of Resident #12’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– Orders written on 5/17/19 for regular diet with regular consistency.
Record review of the resident’s care plan, revised on 3/10/19, showed:
– Resident is on a regular diet, changed to puree consistency on 3/12/19;
– Returned from hospital on mechanical soft diet 3/20/19;
– Current diet was not updated.
2. Record review of Resident #64’s POS, dated 6/4/19, showed:
– [DIAGNOSES REDACTED].(sudden feelings of terror when there is no real danger), Type I
Diabetes (a chronic condition in which the pancreas produces little or no insulin).
Record review of the resident’s health status note, dated 5/14/19, shows [DIAGNOSES
REDACTED].
Record review of the resident’s care plan, revised on 5/11/19, showed no updates for
antibiotic treatment and UTI.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow physician’s orders for
one resident (Resident #50) outside of the sample. The facility’s census was 88.
Record review of Resident #50’s Physician’s Order Set (POS), dated 6/6/19, showed:
– [DIAGNOSES REDACTED].
– An order dated 4/18/19 for neurology (a branch of medicine dealing with disorders of the
nervous system) consult for [DIAGNOSES REDACTED].
During an interview on 6/4/19 at 5:20 P.M., the resident said the doctor wanted him/her to
see a neurologist (a doctor with specialized training in diagnosing and treating diseases
of the brain and spinal cord) and he/she does not have an appointment.
During an interview on 6/6/19 at 2:25 P.M., the Social Worker said an appointment with the
neurologist has not been made.
During an interview on 6/6/19 at 4:03 P.M., the Director of Nursing (DON) said she would
expect an appointment for a consult to be made within five days of receiving the order.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure a discharge plan which
focused on the resident’s discharge goals and effective transition to post-discharge care
for one resident (Resident #56) out of the 18 sampled residents. The facility’s census was
88.
Record review of Resident #56’s physician’s orders [REDACTED].
Record review of the resident’s admission Minimum Data Set (MDS; a federally mandated
assessment instrument completed by the facility staff), dated 3/4/19, showed a Brief
Interview for Mental Status (BIMS; a screening tool to assess cognition) score of 15
(cognition intact).
During an interview on 6/3/19 at 11:50 A.M., the resident said:
– He/she was admitted to this facility from a hospital and was not given a choice of a
private or semi-private room;
– His/her Medicare benefits ended on 5/27/19 and he/she cannot afford to stay in the
facility;
– He/she told the doctor and the Social Worker (SW) about not being able to afford to stay
in the facility but they told the resident that he/she had an infection andcould not go
home;
– They said the resident would have to stay at least another week or two;
– He/she has requested to talk to the SW but the SW has not been available;

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to provide
assistance with personal hygiene for two residents (Resident #12 and #38) out of 18
sampled residents. The facility’s census was 88.
Record review of the resident’s physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– Shower schedule for Monday/Wednesday/Friday, no bedbaths.
Record review of the resident’s quarterly Minimum Data Set (MDS, a federally mandated
comprehensive assessment instrument, completed by the facility staff) dated 3/21/19
showed:
– Brief Interview for Mental Status (BIMS; a screening tool to assess cognition) a score
of 14 (cognition intact);
– Activities of Daily Living (ADLs) showed total dependence for all ADLs, including
personal hygiene;
– Functional range of motion decreased on upper and lower extremities.
Record review of the resident’s care plan, dated 6/2/19, showed the resident is total
dependence for all care from the staff every shift and as needed.
Observation on 6/3/19 at 12:15 P.M. showed Resident #12 lay in bed after his/her shower.
The resident’s hair was not combed.

Based on interview and record review, the facility failed to complete a performance review
of every nurse aide at least once every 12 months and failed to provide in-service
education based on the outcome of these reviews. The facility’s census was 88.
Record review of the facility’s in-services and educational reviews showed the facility
administrative staff did not complete performance reviews for the nurse aides.
During an interview on 6/6/19 at 11:05 A.M., the Director of Nursing (DON) said the
facility does not do routine performance appraisals. She has done a few so that some
Certified Nurse Aides (CNAs) could get a raise but they do not normally do them.
During an interview on 6/6/19 at 4:03 P.M., the DON said she likes to do abuse and
neglect, dementia and behavioral training yearly for everybody as a reminder and if
anything new comes up, it is good to have that refresher. It is hard to remember because
we have a lot of aides go on leave so it is easier to do it all for all of them, that way
they aren’t missed. They might think we don’t like them, not anything wrong just keeping
you up to date.
The facility did not provide a policy for Certified Nurse Aide education and training.

Based on observation and interview, the facility failed to post the nurse staffing data in
a clear and readable format in a prominent place readily accessible to residents and
visitors on a daily basis at the beginning of each shift. The facility’s census was 88.
Observations on 6/3/19 through 6/6/19 showed the facility did not post the nurse staffing
data in a prominent place.
During an interview on 6/6/19 at 4:00 P.M., the Director of Nursing (DON) said she did
expect staffing hours to be posted. She did try to have it in the box outside of the
activity room and then two or three weeks ago got busy and quit putting it in there.
The facility did not provide a policy for posting nurse staffing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to label and store
drugs in accordance with accepted professional standards of practice. This deficient
practice had the potential to affect all residents in the facility. The facility’s census
was 88.
Observation on [DATE] at 3:30 P.M., showed the ,[DATE] Medication Room had an
unlabeled/dated apple pie in the medication refrigerator. The medication refrigerator did
not have a temperature log to track temperatures. The Medication Room had clothes lying on
the counter.
Observation on [DATE] at 3:45 P.M., showed the ,[DATE] medication cart had a bottle of
Aspirin [MEDICATION NAME] coated regular strength 325 mg (milligram) which expired
,[DATE]. The bottle contained a total of 19 tablets out of the 100 tablet bottle. The
Certified Medication Technician (CMT) B walked away from the medication cart and left it
unlocked.
During an interview on [DATE] at 4:03 P.M., the Director of Nursing (DON) said she would
expect the refrigerator to be free of food. The DON said the night shift is responsible
for the refrigerator log and should record the temperature each night. She said she would
expect the medication in the medication cart to not be expired and the cart to be locked
when not in attendance.
Record review of the facility’s policy, titled Storage of Medications, revised (MONTH)
2007, showed:
– The facility shall store all drugs and biologicals in a safe, secure, and orderly
manner;
– The nursing staff shall be responsible for maintaining medication storage AND
preparation areas in a clean, safe, and sanitary manner;
– The facility shall not use discontinued, outdated, or deteriorated drugs or biologicals.
All such drugs shall be returned to the dispensing pharmacy or destroyed;
– Compartments (including, but not limited to, drawers, cabinets, rooms, refrigerators,
carts, and boxes) containing drugs and biologicals shall be locked when not in use, and
trays or carts used to transport such items shall not be left unattended if open or
otherwise potentially available to others;
– Medications requiring refrigeration must be stored in a refrigerator located in the drug
room at the nurses’ station or other secured location. Medications must be stored
separately from food and must be labeled accordingly.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, record review, and interview, the facility failed to provide or
arrange for dental services for two residents (Resident #36 and #38) out of 18 sampled
residents. The facility’s census was 88.
1. Record review of Resident #36’s physician’s orders [REDACTED].
– admission date of [DATE];

Based on observation, interview, and record review, the facility failed to provide
palatable, attractive food at a safe and appetizing temperatures for four residents
(Resident #25, #38, #62, and #78) out of 18 sampled residents and four residents (Resident
#50, #53, #74, and #101) outside the sample. This deficient practice had the potential to
affect all residents in the facility. The facility’s census was 88.
Record review of the facility’s Resident Council minutes showed:
– On 3/5/19, residents asked if a menu could be hung in the activity room every day with
the meals of the day. Resident #50 said he/she is not getting enough food and when he/she
wants double, they don’t always give it to him/her. No old business documented;
– On 4/2/19, Resident #74 said breakfast has been late and they need more scrambled eggs.
There was nothing left from breakfast on 4/2/19. No old business documented;
– On 5/7/19, Resident #53 said they need more help in the kitchen. Old business showed
memorial service on 5/5/19;
– The facility did not document follow up for concerns and did not address the issues.
During an interview on 6/3/19 at 11:24 A.M., Resident #38 said:
– The food is usually served cold;
– The food itself is poor quality frozen food;
– The food served is not always what is posted on the menu;
– Kitchen staff say they don’t have the budget for extra things like condiments;
– Sometimes they run out of food.
Interviews on 6/3/19 showed:
– At 11:48 A.M., Resident #53 said the food isn’t always good;
– Resident #101 said he/she got a hamburger on 6/1/19 that wasn’t done. When he/she
complained, the cook got an attitude and said to eat it anyway;
– At 12:40 P.M., Resident #78 said the food isn’t good, he/she mostly eats cereal and
bananas;
– At 1:33 P.M., Resident #25 said food is not hot and not very good.
During an interview on 6/4/19 at 5:15 P.M., Resident #62 said sometimes the food isn’t fit
to eat. The food is cold when you get it.
Observation on 6/4/19 at 12:45 P.M. showed a test tray with a lid to cover the food:
– Oven baked chicken with soggy breading with a temperature of 140.2 degrees Fahrenheit
(°F);
– Mashed potatoes and gravy (not cheesy mashed potatoes as stated on menu) with a
temperature of 111.3 °F;
– Unseasoned, shriveled/dried-up looking green peas with a temperature of 113.7 °F.
During an interview on 6/5/19 at 3:59 P.M., the Dietary Manager (DM) said they serve both
ends of the building at the same time. One cook serves at each end. Staff take their order
while they’re seated in the dining room waiting on the meal. Staff transport the pans of
food in hot boxes to the halls and put them in pre-heated wells. One of our hot boxes
isn’t currently working and takes each tray to each resident. When asked how she knows how

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to maintain an infection
prevention and control program by not properly assessing the results and standardized
testing methods of the [MEDICATION NAME] Skin Test (TST), also known as a purified protein
derivative (PPD) (a screening method developed to evaluate an individual’s status for
active TB or latent TB infection) for five residents (Residents #38, #46, #51, #56 and
#61) out of 18 sampled residents. The facility’s census was 88.
1. Record review of the facility’s policy, titled [MEDICAL CONDITION] Control Policy,
dated 5/18/16, showed:
– All new facility admission/residents shall receive a 2-step Mantoux PPD skin test,
unless they have a documented past positive PPD;
– Step one should be administered with one month prior to admission or within 24 hours
after admission;
– Step one should be read within 48 to 72 hours after administration, following the
criteria outlined:
– Result is negative of less than 10 mm induration;
– Result is positive if more than 10 mm induration:
– Results must be documented in the resident’s clinical record (electronic) in the
immunization tab;
– If step one is negative, step two should be administered within 2-3 weeks after step
one;
– The step 2 PPD should be read within 48 to 72 after administration and the results
documented in the resident’s clinical electronic record;
– If step one is positive, the resident’s physician should be notified and orders obtained
to discharge the resident to an acute hospital/facility with a negative pressure isolation
room until active [MEDICAL CONDITION] is ruled out or the resident is no longer
infectious;
– The Local Public Health Department shall be notified;

Based on interview and record review, the facility failed to include all core elements of
an antibiotic stewardship program. This deficient practice had the potential to affect all
residents in the facility. The facility’s census was 88.
Record review of the facility’s Infection Prevention and Control Program (IPCP) dated