| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0583 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Keep residents’ personal and medical records private and confidential. Based on observation, interview, and record review, facility staff failed to maintain |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0583 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 1) expects the staff to pull the privacy curtain during care, and if someone were to open the door, he/she would expect the staff to stop the care and close the door to ensure the resident’s privacy. He/She said he/she expects staff to maintain resident confidentially by closing the MAR indicated [REDACTED]. | |
| F 0584 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Honor the resident’s right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based on observation and interview, facility staff failed to maintain sound levels at a | |
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Assess the resident when there is a significant change in condition |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 2) **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview facility staff failed to complete a Comprehensive Significant Change Minimum Data Set (MDS), a federally mandated resident assessment tool, for three residents (Resident #34, #36, and #40) out of 13 sampled residents. The census was 40. 1. Review of the Resident Assessment Instrument (RAI) Manual, dated 10/1/17, showed it directs staff as follows: -Comprehensive Assessments are required comprehensive assessments include the completion of both the Minimum Data Set (MDS) (a federally required resident assessment) and the Care Area Assessment (CAA) process, as well as care planning. Comprehensive assessments are completed upon admission, annually, and when a significant change in a resident’s status has occurred or a significant correction to a prior comprehensive assessment is required. They consist of: -Admission Assessment -Annual Assessment -Significant Change in Status Assessment -Significant Correction to Prior Comprehensive Assessment -The Significant Change in Status Assessment (SCSA) is a comprehensive assessment for a resident that must be completed when the interdisciplinary team (IDT) has determined that a resident meets the significant change guidelines for either major improvement or decline. It can be performed at any time after the completion of an Admission assessment, and its completion dates (MDS/CAA(s)/care plan) depend on the date that the IDT’s determination was made that the resident had a significant change. A significant change is a major decline or improvement in a resident’s status that: -Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered self-limiting; -Impacts more than one area of the resident’s health status; and -Requires interdisciplinary review and/or revision of the care plan. -Assessment Completion refers to the date that all information needed has been collected and recorded for a particular assessment type and staff have signed and dated that the assessment is complete. -For required Comprehensive assessments, assessment completion is defined as completion of the CAA process in addition to the MDS items, meaning that the registered nurse (RN) assessment coordinator has signed and dated both the MDS (Item Z0500) and CAA(s) (Item V0200B) completion attestations. Since a Comprehensive assessment includes completion of both the MDS and the CAA process, the assessment timing requirements for a comprehensive assessment apply to both the completion of the MDS and the CAA process. 2. Review of the facility’s MDS Completion and Submission Timeframes Policy, dated (MONTH) (YEAR), showed resident assessments shall be developed and reviewed in accordance with current federal and state submission timeframes. -The assessment coordinator or designee is responsible for ensuring that resident assessments are submitted to CMS Assessment Submission and Processing (ASAP) system in accordance with current federal and state guidelines; and -Timeframes for completion and submission of assessments is based on the current requirements published in the Resident Assessment Instrument Manual. 3. Review of the facility’s Change in a Resident’s Condition or Status Policy, dated (MONTH) (YEAR), showed staff are directed as follows: -A significant change of condition is a decline or improvement in the resident’s status |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) that; -Will not normally resolve itself without interventions by staff or by implementing standard disease-related clinical interventions; -Impacts more than one area of the resident’s health status; -Requires interdisciplinary review and/or revision to the care plan; -And ultimately on the judgement of the clinical staff and the guidelines outlined in the resident assessment instrument and 42 CFR 483.20(b)(ii). -If a significant change in the resident’s physical or mental condition occurs, a comprehensive assessment of the resident’s condition will be conducted as required by current OBRA regulations governing resident assessments and as outlined in the MDS RAI Instruction Manual. 4. Review of Resident #34’s admission MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Independent with bed mobility; -Required limited assistance of one staff for transfers, eating, dressing, and personal hygiene; -Required extensive physical assistance of one staff member for toileting and bathing; -Mood indicators as follows: short tempered and a poor appetite 7-11 days; and -Behaviors as follows: no verbal behaviors, no delusions, and wandered daily. Review of the resident’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Supervision and set up assistance with eating; -Required limited assistance of one staff for bed mobility and dressing; -Required total assistance of one staff for personal hygiene and bathing; -Required total assistance of two staff for transfers and toileting; -Mood indicators as follows: short tempered and poor appetite 1-3 days; and -Behaviors as follows: verbal behaviors 1-3 days, experienced delusions, and wandered 1-3 days. Review of the resident’s record showed it did not contain a significant change MDS to address the resident’s changes in care needs and behaviors. 5. Review of Resident #36’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively Intact; -Inattention fluctuates; -Disorganized thinking fluctuates; -No mood indicators; -Required limited assistance of one staff for toileting, eating, dressing, and personal hygiene; -Required extensive physical assistance of one staff members for bathing. Review of the resident’s annual MDS, dated [DATE], showed staff assessed the resident as follows: -Severe cognitive impairment; -Mood indicators as follows: little interest and being short tempered 7-11 days, and trouble falling asleep and trouble concentrating 1-3 days; -Supervision and set up assistance with eating, and transfers; -Requires supervision of one staff for bed mobility; -Required limited assistance of one staff for toileting, personal hygiene, and dressing; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 4) -Required extensive assistance of one staff for bathing. Review of the resident’s record showed it did not contain a significant change MDS to address the resident’s changes in care needs, cognition, and mood indicators. 6. Review of Resident #40’s admission MDS, dated [DATE], showed staff assessed the resident as follows: -Cognitively intact; -Required limited assistance with transfers; -Pain Frequency, not assessed; -Mood indicators as follows: feeling depressed, down or hopeless 2-6 days (several days), tired and a poor appetite never or 1 day. Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the resident as follows: -Cognitively intact; -Required total assistance of two staff for transfers; -Pain Frequency, Frequently and pain rated as 8 on a scale of 1-10; -Mood indicators as follows: feeling depressed, down or hopeless 12-14 days (nearly every day), tired and a poor appetite 12-14 days. Review of the resident’s record showed it did not contain a significant change MDS to address the resident’s changes in care needs, pain, and mood indicators. 7. During an interview on 4/18/19 at 9:55 A.M., the MDS coordinator said he/she is responsible to complete the MDS assessments and is to follow the RAI manual. He/She said a significant change MDS should be done after three or more changes in care areas, anytime there is something new that affects the resident’s care, and anytime a resident goes on or off hospice. He/She said the position is new to him/her and he/she is still learning the process. During an interview on 4/18/19 at 12:43 P.M., the Director of Nursing said he/she is responsible to sign the MDS assessments when they are completed. Furthermore, he/she said he/she expects staff to complete the MDS assessments per CMS guidelines. | |
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0657 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 5) observation showed the resident did not have a water pitcher at bedside. Review of the resident’s Physician order [REDACTED]. Review of the resident’s plan of care, dated 4/01/19, showed staff are directed to restrict fluids for the resident to 2000 cc per day. Staff did not update the resident’s care plan to reflect the change in the resident’s fluid orders. 3. Observation on 4/15/19 at 11:49 A.M., showed Resident #34 in the Main Dining Room (MDR). Further observation showed the resident required a sectional plate at meals and used his/her hands to consume meals. Review of the resident’s POS’s, dated 3/15/19-4/14/19, showed the resident had a diet order for a regular diet and did not contain direction to use a sectional plate. Review of the resident’s plan of care, dated 12/05/18, showed staff identified the resident at risk for weight loss. The care plan did not contain direction for staff related to adaptive plates, utensils, or finger foods. 4. Observation on 4/15/19 at 12:28 P.M., showed Resident #36 in the MDR in a wheelchair at the table. Further observation showed the resident received a mechanically altered diet. Review of the resident’s POS’s, dated 3/15/19-4/14/19 showed the resident had a diet order for mechanical soft diet. Review of the resident’s plan of care, dated 12/11/18, showed staff are directed the resident is at risk for weight loss. The care plan did not contain direction for staff to provide the resident with a mechanical soft diet. 5. Observation on 4/15/19 at 12:49 P.M., showed Resident #37 in the Main Dining Room (MDR). Further observation showed the resident drank thickened liquids with the assistance of one staff member. Review of the resident’s Physician order [REDACTED]. Review of the resident’s plan of care, dated 3/19/19, showed staff are directed the resident is at risk for weight loss. The care plan did not contain direction for the staff to provide the resident with thickened liquids. 6. During an interview on 4/18/19 at 9:55 A.M., the MDS Coordinator said that the care plan should be updated with any new information or any change to the residents care that is expected to last longer than two weeks. During an interview on 4/18/19 at 12:02 P.M., Certified Nursing Assistant (CNA) J said that the resident receives thickened liquids. He/she said he/she knows this because that’s what the nurses’s have told her. During an interview on 4/18/19 at 12:52 P.M.,. the Director of Nursing (DON) said he/she expects the careplans to be accurate and up to date. Furthermore, he/she said he/she expects the care plan to contain information such as the resident’s current diet and fluid orders and any care they require. | |
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide care and assistance to perform activities of daily living for any resident who is unable. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 6) (Resident #7, #34, and #36), who required staff assistance with meals, with the necessary care and services to maintain good nutrition. The facility census was 40. 1. Review of the facility’s Shaving the Resident Policy, dated (MONTH) 2010, showed it did not contain direction for staff in regards to timeliness of shaving for residents. 2. Review of the facility’s Assistance with Meals Policy, dated (MONTH) 2013, showed it directs the staff as follows: -All residents will be encouraged to eat in the dining room; -Facility staff will serve resident trays and will help residents who require assistance with eating; -Residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity. 3. Review of Resident # 7’s quarterly Minimum Data Set (MDS), a federally mandated assessment tool completed by facility staff, dated 1/18/19, showed the facility assessed the resident with cognitive impairment, requires supervision and set up assistance of one person for eating, requires extensive assistance of one staff member for personal hygiene, has limitations on one side to both upper and lower extremities, and requires a mechanically altered diet. Observation on 4/15/19 at 12:31 P.M., showed the dining room full of residents but no staff were present. Observation on 4/15/19 at 12:32 P.M., showed the resident in a wheelchair in the dining room with unkempt hair. Further observation showed the resident had a whole biscuit on his/her plate covered in gravy as he/she tried to get a bite the food just kept falling off the fork. Additional observation showed the resident unable to use his/her left side as he/she leaned over the plate and attempted to take bites of the biscuit as food fell into his/her lap. Staff passed trays in the dining room but did not offer the resident assistance or cues. He/She continued to try to eat his/her meal for approximately 30 minutes until he/she pushed the plate away and a staff member came over and pushed him/her out of the dining room. 4. Review of Resident # 15’s quarterly MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, and requires extensive assistance of one person for personal hygiene. Observation on 4/15/19 at 11:49 A.M., showed the resident walked in the hallway. Further observation showed the resident with unkempt hair, and long chin hair. Observation on 4/17/19 at 12:14 P.M., showed the resident in the dining room. Further observation showed the resident with unkempt hair, and long chin hair. 5. Review of Resident # 32’s Quarterly MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, and required supervision of one person for personal hygiene. Observation on 4/15/19 at 12:19 P.M., showed the resident in a chair in the dining room. Further observation showed the resident with long chin hair. 6. Review of Resident #34’s Quarterly MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, dependent on assistance of one person for personal hygiene and required supervision of one person for eating. Observation on 4/15/19 at 12:14 P.M., showed the resident sitting in the dining room. Further observation showed the resident with unkempt hair and long chin hairs. Observation on 4/15/19 at 12:23 P.M., showed the resident in a wheelchair in the dining room. Further observation showed the resident with a red sectional plate and as he/she picked up the red plate and lifted it to his/her mouth the food fell into his/her face and lap. Additional observation showed him/her picking up pieces of salad with his/her |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0677 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 7) fingers. An unidentified staff member moved the resident to a different table but did not assist the resident to eat his/her salad. Staff continued to pass trays in the dining room and did not assist the resident to eat his/her meal. 7. Review of Resident #36’s Annual MDS, dated [DATE], showed staff assessed the resident with cognitive impairment, limited assistance of one person for personal hygiene, required supervision of one person for eating, and required a mechanical soft diet. Observation on 4/15/19 at 11:49 A.M., showed the resident in his/her bed. Further observation showed the resident with unkempt facial hair. Observation on 4/15/19 at 12:28 P.M., showed the resident in the dining room with unkempt facial hair. Further observation showed the resident with a whole biscuit covered in gravy on his/her plate. Additional observation showed the resident used his/her fork to pick up the biscuit and tried to take bites. The biscuit fell into his/her lap. 8. During an interview on 4/17/19 at 12:28 P.M., Certified Nurse Assistant (CNA) C said residents should be shaved during their shower and all staff are responsible to make sure residents are clean and groomed. He/She said if a resident received a whole biscuit and was on a mechanical soft diet, he/she would return it back to the kitchen because they are supposed to send trays out already cut up. During an interview on 4/17/19 at 12:30 P.M., Certified Nurse Assistant (CNA) B said female residents are only shaved upon request, and male residents are shaved during their showers. He/She said if there was a resident with an order for [REDACTED]. During an interview on 4/18/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said he/she expects staff to do shaves everyday both for male and female residents. He/She said female residents should not have long chin hairs and anytime a resident refuses a shower or a shave staff should keep trying. All residents’ hair should be washed with showers and anytime it appears greasy. The staff have dry shampoo available to use anytime a resident may refuse a shower. Staff are expected to assist residents during meals and he/she expects staff to cut up any resident’s biscuit into small bite size pieces for someone on a mechanically altered diet. During an interview on 4/18/19 at 12:54 P.M., the Director of Nursing (DON) said he/she expects if a resident requires assistance with grooming that they ask for assistance. Furthermore, he/she said if the resident is unable to ask for assistance he/she expects the staff to ensure they are neat in appearance. He/she said if a resident refused to eat something or was unable to eat something, he/she expects the staff to assist the resident in getting something else to eat, and that if the the resident required assistance from the staff to setup their meal that he/she expects the staff to do so. | |
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) follows: -After an observed or probable fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred; -Within 24 hours of a fall, the staff will clarify the details of the fall, such as when the fall occurred and what the individual was trying to do at the time the fall occurred; -When a resident falls, the following should be recorded in the resident’s medical record: Appropriate Interventions taken to prevent future falls. 2. Review of Resident #15’s care plan, dated 8/03/18, showed staff are directed: -The resident is at risk for falls due to cognitive impairment, high risk medication, incontinence, fall history, and wandering; -Needs frequent cues and reminders due to short attention span and confusion; -Potential to wander due to [MEDICAL CONDITION]; and -Resides on a special care unit. Further review of the resident’s care plan showed it did not contain direction for staff on interventions to prevent future falls. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident assessment, dated 1/31/19, showed staff assessed the resident as follows: -Brief Interview for Mental Status (BIMS) score of 7 (score of 0-7 indicates a severe cognitive impairment); -[DIAGNOSES REDACTED]. -Sustained two or more non injury falls since prior assessment; -Sustained two or more minor injury falls since prior assessment. Review of the resident’s Physician order [REDACTED]. -[MEDICATION NAME] (a medication used to treat anxiety) 0.5 milligrams (mg) take ½ tab by mouth (PO) once daily for [MEDICAL CONDITION]; -[MEDICATION NAME] (a medication used for [MEDICAL CONDITION] disorders) Delayed Release (DR) 250 mg one po twice daily (BID) for [MEDICAL CONDITION]; -Quetiapine [MEDICATION NAME] (an antipsychotic medication) 25 mg three tablets po at bedtime (HS) for anxiety; -Trazadone (a medication used to treat depression) 100 mg po at hs for [MEDICAL CONDITION]. Review of the facility’s Fall Logs showed the resident sustained [REDACTED]. -April 15, at 7:00 p.m., staff did not document in the action taken column; -April 15, at 11:45 a.m., staff did not document in the action taken column; -April 2, at 11:45 a.m., staff did not document in the action taken column; -April 1, at 16:45 p.m., staff did not document in the action taken column; -March 18, at 7:00 p.m., staff did not document in the action taken column; -March 12, at 4:00 p.m., staff did not document in the action taken column; -January 20, at 5:00 p.m., staff did not document in the action taken column; and -January 3, at 11:15 a.m., staff did not document in the action taken column. Observation on 4/15/19 at 11:49 A.M., showed the resident walked in the hallway. Further observation showed the resident shuffled his/her feet and leaned forward as he/she walked. Additional observation showed he/she continued to shuffle his/her feet as he/she walked slowly into his/her room, leaned more forward, reached the edge of his/her bed, and fell across the bed. Observation on 4/15/19 at 11:52 A.M., showed the resident lay on the hallway floor without any staff present. Licensed Practical Nurse A and a second unidentified staff member entered the area and one staff said What were they doing, they are supposed to be walking |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0689 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) with him/her. Additional observation showed staff assessed the resident and said the resident complained of pain to his/her knee. Observation on 4/15/19 at 12:07 P.M., showed the resident in a wheelchair in the dining room at a table. Further observation showed the resident stood up out of the wheelchair and walked out of the dining room with an unsteady gait. CNA E looked up at her while he/she passed drinks but did not stop passing the drinks. As the resident neared the nurse’s station his/her gait worsened and he/she leaned forward toward the floor, CNA B came out of the nurse’s station and assisted him/her. CNA B assisted him/her back to the dining room and told CNA E, That was a close one he/she almost did it again, he/she was almost in the floor. During an interview on 4/16/19 at 9:35 A.M., CNA B said staff are supposed to assist the resident to walk at all times. He/She said with the newest fall staff are expected to be sure the resident uses a wheelchair and monitor him/her one on one. CNA B said he/she went to monitor a door but he/she shouldn’t have left the resident because there was no one to supervise him/her. During an interview on 4/17/19 at 12:28 P.M., CNA C said prior to the resident’s fall today he/she was up independently and did fairly well taking care of him/herself. During an interview on 4/18/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said he/she expected staff to walk with the resident due to his/her unsteady gait and risk for falls. He/She said the resident stumbles when he/she walks. During an interview on 4/18/19 at 12:58 P.M., the Director of Nursing (DON) said if a resident has a fall, he/she expects the staff to assess the resident for injury, and attempt to determine how they fell , why they fell , and how they can prevent another fall in the future. He/she said he/she expects the staff to implement a new intervention for each fall, and ensure that all staff are aware of the new intervention. He/she said the careplan should be updated with the information. 3. Observation on 04/16/19 at 11:41 A.M., showed LPN A left the medication/treatment cart next to room [ROOM NUMBER], he/she then drew up insulin for the resident. Further observation showed LPN A entered the room and closed the curtain. Additional observation showed the cart was unlocked and unattended, with insulin and needles left on the top of the cart in the dementia care unit and with residents observed walking in the hallway unattended. During an interview on 4/17/19 at 11:47 A.M., LPN A said, I shouldn’t have left the cart unlocked, unattended, and with medications on it, I know that is a no, no, especially back here. | |
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide enough food/fluids to maintain a resident’s health. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 10) -Nurses’ Aides will provide and encourage intake of bedside, snack and meal fluids, on a daily and routine basis as part of the daily care. Intake will be documented in the medical records. Aides will report intake of less than 1200 ml/day to nursing staff; -Nursing will monitor and document fluid intake. 2. Review of Resident #7’s care plan, dated 8/01/18, showed it directs the staff as follows: -Observe for changes in appetite; -Offer an alternative if refuses; -At risk for weight loss/poor fluid intake; and -There was no direction for staff on how to assure the resident received fluids. Review of the resident’s quarterly Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 1/18/19, showed staff assessed the resident as: -Moderate cognitive impairment; -Supervision of one staff member for eating; -Dependent on one staff member for transfers, and toilet use. Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s orders [REDACTED]. Observation on 4/15/19 at 12:32 P.M., showed staff served one glass 180 cc of fluids to the resident during the lunch meal. Staff did not serve additional fluids to the resident during the meal. Observation on 4/16/19 at 11:37 A.M., showed staff provided care to the resident in his/her room. Further observation showed staff did not offer fluids to the resident before, during, or after care. Additional observation showed the resident did not have a water pitcher or fluids in his/her room. 3. Review of Resident #15’s care plan, dated 8/03/18, showed it directs the staff as follows: -Observe for changes in appetite; -Offer an alternative if refuses; -At risk for weight loss/poor fluid intake due to being easily distracted; and -There was no direction for staff on how to assure the resident received fluids. Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Moderate cognitive impairment; -Supervision of one staff member for bed mobility, transfers, eating, and toileting; -Limited assistance with one staff member for dressing; -Extensive assistance of one staff member for personal hygiene; -Dependent on one staff member for bathing. Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s orders [REDACTED]. Observation on 4/16/19 at 9:53 A.M., showed the resident did not have a water pitcher at his/her bedside. Observation on 4/17/19 at 9:13 A.M., showed the resident did not have a water pitcher or fluids to drink in his/her room. Observation on 4/17/19 at 12:14 P.M., showed staff served one glass 180 cc of fluids to the resident during the meal. Staff did not serve the resident additional fluids during the meal. 4. Review of Resident #18’s Annual MDS, dated [DATE], showed the staff assessed the resident as: -Moderate cognitive impairment; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 11) -Independent with toileting; -Limited assistance with one staff member for bed mobility, transfers, personal hygiene, and eating; -Extensive assistance of one staff member for dressing, and bathing. Review of the resident’s care plan, dated 4/01/19, directs the staff as follows: -Offer an alternative if refuse; -At risk for weight and fluid fluctuations due to [MEDICAL CONDITION] and diuretic therapy; -There was no direction for staff on how to assure the resident received fluids. Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, shows a physician’s orders [REDACTED]. Additional review showed a physician’s orders [REDACTED]. Observation on 4/16/19 at 9:54 A.M., showed the resident did not have a water pitcher at his/her bedside. Observation on 4/17/19 at 9:14 A.M., showed the resident did not have a water pitcher or fluids to drink in his/her room. Observation on 4/17/19 at 12:15 P.M., showed staff served one glass 180 cc of fluids to the resident during the lunch meal. Additional observation showed staff did not offer additional fluids to the resident at the meal. 5. Review of Resident #34’s care plan, dated 12/05/18, directs the staff as follows: -Offer an alternative if refuses; -At risk for weight loss/poor fluid intake due to poor appetite; and -There was no direction for staff on how to assure the resident received fluids. Review of the resident’s quarterly MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Supervision of one staff member for eating; -Limited assistance with one staff member for dressing, and bed mobility; -Dependent on one staff member for personal hygiene; -Dependent on two staff members for toileting, and transfers. Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s orders [REDACTED]. Observation on 4/16/19 at 9:55 A.M., showed the resident did not have a water pitcher at his/her bedside. Observation on 4/17/19 at 9:15 A.M., showed the resident did not have a water pitcher or fluids to drink in his/her room. 6. Review of Resident #36’s care plan, dated 12/11/18, showed it directs the staff as follows: -Observe for changes in appetite; -Provide supplements per physician’s orders [REDACTED].>-Provide a divided plate at meals; -Offer an alternative if refuses; -At risk for weight loss/poor fluid intake; and -Did not provide direction for staff on how to assure the resident received fluids. Review of the resident’s annual MDS, dated [DATE], showed the staff assessed the resident as: -Severe cognitive impairment; -Supervision with set up of one staff member for transfers, and eating; -Supervision of one staff member for bed mobility; -Limited assistance with one staff member for dressing, toileting, and personal hygiene; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 12) -Extensive assist of one staff member for bathing. Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s orders [REDACTED]. Observation on 4/15/19 at 12:28 P.M., showed the resident in a wheelchair in the dining room. Further observation showed one cup of purple fluid in a 180 cc glass. Additional observation showed staff did not serve any other fluids to the resident at the meal. Observation on 4/16/19 at 9:56 A.M., showed the resident did not have a water pitcher or fluids to drink in his/her room. Observation on 4/17/19 at 10:50 A.M., showed the resident did not have a water pitcher or fluids to drink in his/her room. 7. Review of Resident #40’s Admission Minimum Data Set (MDS), a federally mandated resident assessment tool, dated 3/27/19, showed the staff assessed the resident as follows: -Cognitively intact; -Required total assistance of two staff members for transfers; -Supervision of one staff member for eating; -Required total assistance of one staff member for personal hygiene, dressing, and bathing; Review of the resident’s care plan, undated, showed it directs the staff as follows: -Offer an alternative if consumes less than 50% of meal; -Observe while eating meals, snacks and food in activities for any intolerance to the foods served; -Provide thickened liquids; -There was no direction for staff on how to assure the resident received fluids. Review of the resident’s Physicians Orders, dated 4/15/19 to 5/14/19, showed a physician’s orders [REDACTED]. Observation on 4/15/19 at 1:45 P.M., showed the resident did not have fluids in his/her room. During an interview on 4/15/19 at 1:45 P.M., the resident said I have a hard time getting a drink because it has to be thickened. A couple weeks ago my cup went missing and I haven’t had anything in my room since. Observation on 4/15/19 at 2:15 P.M., showed an unknown CNA provided a drink for the resident. Additional observation showed the DON said we do not leave drinks in the room. Observation on 4/16/19 at 1:45 P.M., showed the resident did not have fluids in his/her room. Observation on 4/17/19 at 10:00 A.M., showed resident did not have fluids in his/her room. 8. During an interview on 4/17/19 at 9:36 A.M., Certified Nurses Aid (CNA) B said, We only |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0692 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 13) During an interview on 4/18/19 at 1:03 P.M., the Director of Nursing (DON) said he/she expects the staff to pass ice and water to all the residents at the beginning of each shift. He/she said staff should offer dependent residents water every time they enter the room. Furthermore, he/she said each resident should have a cup with water in it at their bedside, including the residents on the SCU. He/she said if the residents did not have a cup in their room, he/she expects the staff to provide one. | |
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe, appropriate pain management for a resident who requires such services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 14) -Receives no non-medication intervention for pain; -Has pain almost constantly; -Pain has made it hard to sleep at night; -Pain has limited day-to-day activities; -Pain rated a 6 on a scale of 1-10; -And received no therapy services. Review of the resident’s Face Sheet, dated 1/7/19, showed the resident had the additional Diagnoses: [REDACTED].>-[MEDICAL CONDITION] (a disorder characterized by widespread musculoskeletal pain accompanied by fatigue, sleeplessness, memory and mood issues); -Spondylolysis (cracks or stress fractures in the vertebrae), of the cervical region (neck); -And low back pain. Review of the resident’s Pain Evaluation, dated 2/22/19, showed the facility staff assessed the resident as follows: -Currently in pain; -At risk for pain; -And experienced pain the past. Review of the resident’s plan of care, dated 3/26/19, showed staff are directed as follows: -Refer me to Occupational Therapy (OT)/Physical Therapy (PT) as needed; -Measure my pain level daily using pain scale of one to ten; -Coordinate with my physician to manage my pain medication for optimum control of my pain; -Observe me for effectiveness of medication; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) -3/17/19: 7-3 Shift-5; 3-11 Shift- 5; -3/18/19: 7-3 Shift- 7; 3-11 Shift- 5; -3/19/19: 7-3 Shift, did not document pain scale assessment; 3-11 Shift- 5; 3/20/19: 7-3 Shift- 6; 3-11 Shift- 5; 3/21/19: 7-3 Shift- 5; 3-11 Shift- 7; 3/22/19: 7-3 Shift- 4; 3-11 Shift- 8; 3/23/19: 7-3 Shift- 5; 3-11 Shift- 4; 3/24/19: 7-3 Shift- 4; 3-11 Shift- 6; 3/25/19: 7-3 Shift- 7; 3-11 Shift- 5; 3/26/19: 7-3 Shift- 7; 3-11 Shift- 6; 3/27/19: 7-3 Shift- 6; 3-11 Shift- 6; 3/28/19: 7-3 Shift- 7; 3-11 Shift- 8; 3/29/19: 7-3 Shift- 8; 3-11 Shift- 8; 3/30/19: 7-3 Shift- 5; 3-11 Shift- 5; 3/31/19: 7-3 Shift- 7; 3-11 Shift- 5; 4/1/19: 7-3 Shift- 7; 3-11 Shift- 6; 4/2/19: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) 7-3 Shift- 5; 3-11 Shift- 4; 4/3/19: 7-3 Shift- 5; 3-11 Shift- 5; 4/4/19: 7-3 Shift- 5; 3-11 Shift- 5; 4/5/19: 7-3 Shift- 2; 3-11 Shift- 6; 4/6/19: 7-3 Shift- 4; 3-11 Shift- 5; 4/7/19: 7-3 Shift- 7; 3-11 Shift- Did not document pain scale assessment; 4/8/19: 3-11 Shift- 6; 4/9/19: 7-3 Shift- 5; 3-11 Shift- 5; 4/10/19: 7-3 Shift- 5; 3-11 Shift- 5; 4/11/19: 3-11 Shift- 7; 4/12/19: 3-11 Shift- Did not document pain scale assessment; 4/13/19: 7-3 Shift- 5; 3-11 Shift- 5; 4/14/19: 7-3 Shift- 5; 3-11 Shift- 5; Review of the resident’s MAR, dated 4/15/19-5/14/19 showed staff assessed the resident’s pain as follows: 4/15/19; 3-11 Shift- 7; 4/16/19: 7-3 Shift- 5; 3-11 Shift-7; 4/17/19: 7-3 Shift- 5; 3-11 Shift- 5; Additional review of the resident’s Medical Record showed a pharmacy consultation, dated 4/1/19-4/8/19 that showed the following: -Resident receives [MEDICATION NAME] 15 mcg patch once weekly and [MEDICATION NAME]/Apap (Tylenol) 5/325 mg once daily for pain, but is not attaining adequate pain control |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) according to recent assessments and documentation in the medical record. Patient states that on an average his pain scale is a 7; -Recommendation: Please reevaluate pain status. If pain is uncontrolled, please consider increasing [MEDICATION NAME]/Apap 5/325 mg to three times daily for pain. Additional review of the consultation showed the Medical Director documented: Patient will say a seven no matter what. The consultation did not contain any further documentation or guidance. Observation and interview on 4/15/19 at 3:16 P.M., showed the resident is his/her room. Further observation showed the resident to have a furrowed brow and making several position changes in his/her recliner. The resident said he/she has a lot of pain in his/her lower back and neck, due to disc deterioration. He/she said staff give him/her pain medication for the pain, but it does not always help his/her pain. He/she said at one time he/she was getting patches to his/her back and that the patches did not work, so he/she refused to use them. The resident said he/she would be ok with a pain level of two to 4 on a scale of one to ten. He/she said he/she did not remember the last time he/she felt relief from pain. He/she rated his/her pain a seven on a scale of one to ten. Observation on 4/17/19 at 12:52 P.M., showed the resident in the Dining Room. Further observation showed the resident made frequent position changes in his/her chair, and had a furrowed brow. Observation and interview on 4/18/19 at 10:02 A.M., showed the resident in his/her room. Further observation showed the resident was rigid, and making frequent position changes in his/her recliner. The resident said that he/she is having a lot of pain today in his/her back. He/she said that he/she has notified someone, but he/she could not remember who it was. During an interview on 4/17/19 at 4:55 P.M., Licensed Practical Nurse (LPN) G said the resident has enough medication to alleviate his/her pain. He/she said the resident does have complaints of pain, and states he/she does have pain, but it does not keep the resident from walking to the snack cart. He/she said the resident does not cry out in pain, so he/she does not know if the resident is having pain. During an interview on 4/18/19 at 10:01 A.M., LPN A said the resident has a lot of complaints of pain. He/she said the resident used to get pain medication more often but it was reduced. LPN A said the resident says he/she is hurting, but he/she is not. Furthermore, LPN A said the resident does have pain with walking due to decreased circulation to his legs, but that he/she does not like to keep his/her legs elevated. Additionally, LPN A said the physician is updated weekly in regards to the resident’s pain, but he/she does not know where they document it. LPN A said the resident has no interest in non-pharmalogical pain relief. During an interview on 4/18/19 at 10:07 A.M., Certified Medication Technician (CMT) D said the resident is always in pain, but he is not a complainer, he/she said the resident is the silent type, but when he/she is asked he/she will say that his/her pain is between a five or an eight on a scale of one to ten. He/she said that the nurses have spoken to the doctor about his/her pain, but that he/she does not know any more than that. He/She said that he/she has not seen the nurses offer the resident any alternative pain relief options other than medication. During an interview on 4/18/19 at 10:10 A.M., the Director of Nursing (DON) said the resident shows no signs and symptoms of pain, and he/she never complains to him/her about pain. Furthermore, he/she said he/she expects the nurses to complete a pain assessment, and notify the physician if the resident was having unrelieved pain. Additionally, he/she said he/she expects the staff to try non-pharmalogical interventions to relieve the |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0697 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 18) resident’s pain, or at least mention these options to the physician. During an interview on 4/18/19 at 11:58 A.M , Certified Nursing Assistant (CNA) F said the resident does not complain about pain unless you ask him/her. Furthermore, he/she said you can tell when the resident’s legs hurt because he/she walks slower than usual. He/she said he/she has not seen the nurses offer the resident any alternative pain relief options other than medication. During an interview on 5/1/19 at 1:43 P.M., the Medical Director said the resident always has complaints of pain, and he/she always rates his/her pain a 7. He/she said the resident does not appear to have pain because he/she walks the length of his/her hall with a walker at a steady pace. The Medical Director said when the resident was initially admitted to the facility he/she received a lot of pain medication, and said I don’t think he/she has that much pain. Additionally, the physician said the resident has been seen by a pain clinic in the past and all they wanted to do was increase his/her pain medication, and said Why should they? The physician said he/she expects the facility staff to attempt non-pharmalogical interventions for pain, such as redirection, ice packs, and hot packs. | |
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 19) 2. Review of Resident #15’s quarterly MDS, dated [DATE], showed the facility staff assessed the resident as follows: -Cognitively Impaired; -[DIAGNOSES REDACTED]. -Trouble falling asleep, nearly everyday; -No physical behaviors; -No verbal behaviors; -Delusions; and -Wandered daily. Review of the resident’s Physician order [REDACTED]. -[MEDICATION NAME] (a medication used to treat anxiety) 0.5 milligrams (mg) take ½ tab by mouth (PO) once daily for [MEDICAL CONDITION]; -[MEDICATION NAME] (a medication used for [MEDICAL CONDITION] disorders) Delayed Release (DR) 250 mg one po twice daily (BID) for [MEDICAL CONDITION]; -Quetiapine [MEDICATION NAME] (an antipsychotic medication) 25 mg three tablets po at bedtime (HS) for anxiety; -Trazadone (a medication used to treat depression) 100 mg po at HS for [MEDICAL CONDITION]. Review of the resident’s medical record showed it did not contain documentation of a [DIAGNOSES REDACTED]. Further review of the resident’s medical record showed a pharmacy consultation, dated 4/1/19-4/8/19, showed the following recommendation: -[MEDICATION NAME] 0.25 mg daily for anxiety; please consider a trial discontinuation of the [MEDICATION NAME]. -[MEDICATION NAME] 250 mg twice daily for [MEDICAL CONDITION] disorder; Quetiapine 75 mg at bedtime for [MEDICAL CONDITION] disorder; and Trazadone 100 mg at bedtime for [MEDICAL CONDITION]; please consider a GDR of the above medications at this time. Additional observation showed the physician did not approve the recommendations, or provide a rationale for the continued use of the [MEDICAL CONDITION] medications without a GDR. 3. Review of Resident #28’s quarterly MDS, dated [DATE], showed the facility staff assessed the resident as follows: -Cognitively Intact; -Showing little interest or pleasure in doing things, nearly every day; -Feeling tired or having little energy, nearly every day; -Free of hallucinations (perceptual experiences in the absence of real external sensory stimuli), and delusions (misconceptions or beliefs that are firmly held, contrary to reality); -No physical behaviors symptoms, no verbal behavioral symptoms, or other behavioral symptoms directed towards others; -No rejection of care or evaluation of care; -[DIAGNOSES REDACTED]. to think, feel, and behave clearly), and [MEDICAL CONDITIONS]; -Received Antipsychotic medication seven out of seven days in the look back period (a period of time, typically seven days in which the facility gathers information to complete the mandated assessment); -And received Antidepressant medication seven out of seven days in the look back period; Review of the resident’s Physician order [REDACTED]. -8/4/15- Duloxetine [MEDICATION NAME] (HCL) Direct Release (DR) (for depression) 60 milligrams (mg) two times a day (BID) for anxiety and depression; |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 20) -8/4/15- [MEDICATION NAME] (an anticonvulsant medication used to treat [MEDICAL CONDITION] Disorder) 225 mg BID for [MEDICAL CONDITION] Disorder; -8/4/15-Ziprasidone HCL (medication used to treat [MEDICAL CONDITION] and [MEDICAL CONDITION] Disorder) 40 mg two times per day for [MEDICAL CONDITION]; -10/05/18-[MEDICATION NAME] (an anxiety medication) one mg three times per day (TID) for anxiety; -3/30/16- [MEDICATION NAME] (medication used in the treatment of [REDACTED]. -1/9/17- [MEDICATION NAME] 150 mg at HS for sleep; Review of the resident’s medical record showed a pharmacy consultation dated 8/1/2018-8/28/2018 that showed staff administered the following: -Duloxetine 60 mg twice daily for depression; -[MEDICATION NAME] 225 mg twice daily for [MEDICAL CONDITION]; -[MEDICATION NAME] (Ziprasidone HCL) 40 mg twice daily for [MEDICAL CONDITION]; -[MEDICATION NAME] 1 and ½ mg three times daily for anxiety; -[MEDICATION NAME] 3 mg at HS for [MEDICAL CONDITION]; -Trazadone 150 mg at bedtime for [MEDICAL CONDITION]/depression; Further review showed the pharmacy consultant recommended the physician consider a GDR of the resident’s [MEDICATION NAME] to 1 mg TID. Additionally, the review showed the pharmacy consultant recommended a review with possible reduction for the Duloxetine, [MEDICATION NAME], and Ziprasidone. The physician approved the GDR of the [MEDICATION NAME], but did not provide further guidance for the staff in regards to the additional medications, or documented contraindications for their continued use. 4. Review of Resident #34’s Quarterly MDS, dated [DATE], showed the facility staff assessed the resident as follows: -Severe Cognitive Impairment; -[DIAGNOSES REDACTED]. -Trouble falling asleep, nearly every day; -Poor appetite, nearly every day; -Feeling tired, nearly every day; -Trouble concentrating, nearly every day; -Short tempered, nearly every day; -Physical behavior symptoms, less than daily; -Verbal behavior symptoms, less than daily; -Delusions; and -Wandered, less than daily. Review of the resident’s Physician order [REDACTED]. -[MEDICATION NAME] 0.5 mg ½ tablet twice daily for anxiety; -[MEDICATION NAME] DR 500 mg one po BID for dementia; -Quetiapine [MEDICATION NAME] 25 mg ½ tablet po daily for anxiety; -Quetiapine [MEDICATION NAME] 50 mg one tablet po at HS for anxiety. Review of the resident’s medical record showed a pharmacy consultation, dated 3/1/19-3/5/19, showed the following recommendation: -Quetiapine 12.5 mg twice daily and Quetiapine 50 mg at bedtime; please attempt a GDR to Quetiapine 25 mg twice daily with the end goal of discontinuation of the above medications at this time. Additional observation showed the physician did not approve the recommendations, or provide a rationale for the continued use of the [MEDICAL CONDITION] medications. 5. Review of Resident #37’s quarterly MDS, dated [DATE], showed staff assessed the resident as follows: |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0758 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 21) -Cognitively Impaired; -Having little interest or pleasure in doing things, nearly every day; -Free of hallucinations or delusions; -No physical behaviors noted towards others; -Verbal behaviors directed toward others occurred one to three days out of the seven day look back period; -[DIAGNOSES REDACTED]. -And received antidepressant medication seven out of the seven days in the look back period. Review of the resident’s POS, dated 3/15/19-4/14/19, showed the following orders: -10/23/17- [MEDICATION NAME] (HBR) ( a medication used to treat depression) 5 mg daily for depression; -And [MEDICATION NAME] Delayed Release (DR) 125 mg BID for Dementia/Anxiety. Further review of the resident’s medical record showed a pharmacy consultation, dated 8/1/18 – 8/28/18, that showed staff administered the following [MEDICAL CONDITION] medications: [REDACTED] -[MEDICATION NAME] 250 mg twice daily for depression; -And [MEDICATION NAME] 5 mg daily for depression. Further review showed the pharmacy consultant recommended a GDR of the resident’s [MEDICATION NAME] to 125 mg twice daily. Additionally, the review showed the pharmacy consultant recommended a review with possible reduction for the [MEDICATION NAME]. The physician approved the GDR of the [MEDICATION NAME], but did not provide further guidance for the staff in regards to the [MEDICATION NAME], or document a rationale for the medication’s continued use. Staff did not ensure the resident did not receive unnecessary [MEDICAL CONDITION] medications. 6. During an interview on 4/18/19 at 9:58 A.M., Certified Medication Technician (CMT) D said the pharmacy consultant comes once per month and is responsible for tracking the medications for gradual dosage reductions and the Director of Nursing sends those recommendations to the physician for review. During an interview on 4/18/19 at 12:01 P.M., Licensed Practical Nurse (LPN) A said the pharmacy consultant is responsible for GDR recommendations once per month. LPN A said he/she and the Director of Nursing are responsible to take off the new orders. He/She said if they aren’t addressed by the physician, staff are expected to send them back to him/her. During an interview on 4/18/19 at 1:07 P.M., the Director of Nursing said he/she is now responsible for monitoring and ensuring the GDR’s are completed from the pharmacy consultant. He/she said the pharmacy consultant is responsible for monitoring when the GDR’s are due, and the physician is to document a rationale or contraindication if the medication is not reduced. | |
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Provide and implement an infection prevention and control program. Based on observation, interview, and record review facility staff failed to change gloves, |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 22) residents (Residents #37, #23, and #9). Facility staff also failed to provide a barrier for the glucometer in a manner to prevent the spread of infection during blood sample collection for two residents (Resident #26 and #41). The facility census was 40. 1. Review of the facility’s Perineal Care Policy, dated (MONTH) 2010, showed staff are directed as follows: The following equipment and supplies will be necessary when performing this procedure: 1. Wash basin; 2. Washcloth; 3. Soap; 4. Personal protective equipment. Steps in the Procedure for a female resident: 1. Wet washcloth and apply soap or skin cleansing agent 2. Wash perineal area, wiping front to back; 3. Do not reuse the same washcloth or water to clean the urethra or labia. 2. Review of the facility’s implementing the Body Substance Precautions System, not dated, showed staff are directed as follows: Wear gloves when it can be reasonably anticipated that hands will be in contact with mucous membranes, non-intact skin, any moist body substances and/or persons with a rash. Gloves must be changed between residents and between contacts with different body sites of the same resident. 3. Observation on 4/15/19 at 12:49 P.M., showed Certified Nursing Assistant (CNA) H and CNA I entered Resident #37’s room to provide perineal care. CNA I washed the resident’s front perinal area, and swiped multiple times with same portion of the wash cloth. Further observation showed CNA H cleansed the resident’s bottom and swiped multiple times using the same, already used, portion of the washcloth. Additional observation showed CNA H did not remove his/her soiled gloves prior to touching the resident’s legs, the hoyer sling, the resident’s sheet, blankets, and other assistive devices in the resident’s room. 4. Observation on 4/16/19 at 10:30 A.M., showed CNA H and CNA J entered Resident #23’s room to provide perineal care. Both CNA H and CNA J washed their hands in the resident’s sink, then afterwards CNA H placed several washcloths into the sink under the running water and sprayed them with a cleansing agent. CNA H wrung out the washcloths and placed them in a bag next to the bed and used the cloths to clean the resident. 5. Observation on 4/17/19 at 2:45 P.M., showed CNA K and CNA H entered Resident #9’s room to provide perineal care. Both CNA K and CNA H washed their hands in the resident’s sink, then afterwards CNA H placed several washcloths into the sink under the running water and sprayed them with a cleansing agent. CNA H wrung out the washcloths and placed them in a bag next to the bed and used the cloths to clean the resident. 6. During an interview on 4/15/19 at 1:14 P.M., CNA H said staff are directed to use different parts of the washcloth with every swipe while cleansing a resident. Furthermore, he/she said staff are directed to change their gloves and wash their hands from dirty to clean tasks. During an interview on 4/17/19 at 4:00 P.M., CNA L said when staff provide care for a resident they are expected to wash hands then glove, wet the washcloths by holding them under the running water, and spray with cleansing soap. During an interview on 4/18/19 at 11:49 A.M., LPN A said he/she expects staff to use a different part of the washcloth with each swipe while performing perineal care, or use a new wipe each time. He/She also said staff are directed to change their gloves from dirty to clean tasks, and he/she expects staff to change their gloves before touching anything in a resident’s room if they had just provided perineal care. |
| DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES | PRINTED: 9/3/2019 FORM APPROVED OMB NO. 0938-0391 | |||||||||
| STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION | (X1) PROVIDER/SUPPLIER/CLIA IDENNTIFICATION NUMBER: 265434 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW NURSING CENTER | STREET ADDRESS, CITY, STATE, ZIP 10303 STATE ROAD C | |||||||||
| For information on the nursing home’s plan to correct this deficiency, please contact the nursing home or the state survey agency. | ||||||||||
| (X4) ID PREFIX TAG | SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | |
|---|---|---|
| F 0880 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 23) During an interview on 4/18/19 at 12:30 P.M., Licensed Practical Nurse (LPN) A said during perineal staff are to use clean rags and either get a clean basin to put water in or hold the washcloths under the running water to get them wet. The washcloths should not touch the sink. 7. Review of the facility’s undated, Blood Glucose Monitoring Policy, showed it did not direct the staff on how to handle the glucometer in a manner to prevent the spread of infection once the blood sample had been collected. Observation on 4/19/19 at 11:29 A.M., showed Licensed Practical Nurse (LPN) A obtained Resident #26’s blood sample with a glucometer. Further observation showed he/she placed the glucometer on the top of the open MAR indicated [REDACTED]. 8. Observation on 4/19/19at 11:41 A.M., showed LPN A obtained Resident #41’s blood sample with a glucometer. Further observation showed he/she placed the glucometer on the resident’s bed without a barrier. During an interview on 4/16/19 at 11:45 A.M., LPN A said, I shouldn’t have laid the glucometer down on the bed, I should have held it or put a barrier down. I always do, I don’t know why I didn’t this time. 9. During an interview on 4/18/19 at 1:12 P.M., the Director of Nursing (DON) said he/she expects staff to use a different portion of the wipe for each swipe during perineal care, and that he/she expects the staff to change their gloves from dirty to clean tasks. Furthermore, he/she said he/she expects staff to wash their hands or use hand sanitizer between glove changes. Additionally, he/she said staff are expected to barrier between washcloths and the sink and when moisten washcloths for care. Also, he/she said during glucometer checks he/she would expect staff to place a barrier on any surface before placing a clean or dirty glucometer on it. | |
