| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0577 Level of harm – Minimal harm or potential for actual harm Residents Affected – Many | Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies. Based on observation and interview, the facility failed to ensure the most recent survey | |
| F 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Honor the resident’s right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0578 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 1) -No signed code status sheet as late as 12/3/18 at 2:00 P.M. 4. Review of Resident #137’s medical record, showed: -An electronic admission face sheet, showed an admission date of [DATE]; -An ePOS, dated 11/23/18, did not show any code status for the resident as late as 12/3/18; -No signed code status sheet provided as late as 12/3/18. 5. During an interview on 12/3/18 at 9:00 A.M., the Director of Nursing (DON) said Social Services and the nursing staff are responsible for getting the code status sheet signed on admission. The original is placed in a binder on the floor and a copy is placed in a master binder in the main office. She would expect the nursing staff to obtain an order for [REDACTED]. | |
| F 0637 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Assess the resident when there is a significant change in condition **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 – Few | (continued… from page 2) -All present were: Resident’s family member, Social Services Director (SSD), Nursing, and Activities; -Resident’s family member stated that the resident has been losing weight and having a lot of swallowing issues so he/she wanted to have hospice come out and assess resident; -SSD contacted hospice with referral information; -SSD will follow up with family after hospice meets with the resident. Review of the resident’s progress note, dated 10/26/18 at 1:02 P.M., showed the resident admitted to hospice for advanced dysphagia. Review of the resident’s e-chart, showed the resident admitted to hospice on 10/26/18 and again on 11/1/18. Review of the resident’s MDS transmissions, showed no significant change MDS in progress or completed after the resident’s admission to hospice on 10/26/18 or 11/1/18. Observation and interview on 11/28/18 at 10:01 A.M., showed the resident sat in his/her wheelchair in his/her room and watched television. He/she said that staff has to help him/her transfer, get dressed, shower and toilet. He/she cannot perform any ADL’s by himself/herself anymore. He/she was receiving hospice services. During an interview on 12/3/18 at 9:02 A.M., the Director of Nursing (DON) said: -He/she expected a significant change MDS to be performed when a resident has two or more changes in ADL’s; -A significant change MDS should have been completed for this resident when he/she had a decline in ADLs and increase in the care provided; -The resident should have had a significant change MDS when he/she was admitted to hospice. | |
| F 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0640 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 3) -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -No discharge or admission assessment in progress or submitted for the resident. 4. Review of Resident #45’s medical record, showed: -admitted to the facility on [DATE]; -Quarterly MDS dated [DATE], submitted and accepted; -discharged to the hospital on [DATE]; -Returned to the facility from the hospital on [DATE]; -Discharge – return anticipated MDS, dated [DATE], export ready; -Entry MDS, dated [DATE], export ready. 5. Record review of Resident #72’s medical record, showed: -admitted to the facility on [DATE]; -Quarterly MDS target completion date 7/16/18, submitted 10/29/18; -Discharge MDS target completion date 8/26/18, submitted 10/29/18; -Entry MDS target completion date 8/27/18, submitted 10/29/18; -Discharge MDS target completion date 9/18/18, submitted 10/29/18; -Entry MDS target completion date 9/11/18, submitted 10/29/18. 6. Review of Resident #62’s medical record, showed: -admitted to facility on 6/13/18; -Entry MDS completed 6/13/18; -No quarterly assessment in progress or submitted for the resident. 7. Review of Resident #5’s medical record, showed: -admitted to facility on 3/9/15; -Annual MDS target completion date 5/1/18, accepted 10/7/18; -Quarterly MDS target completion date 8/1/18, accepted 10/7/18. 8. Review of Resident #17’s medical record, showed: -admitted to facility on 7/21/17; -Annual MDS done on 7/31/18; -Significant change MDS dated [DATE], showed in progress. 9. Review of Resident #32’s medical record, showed: -admitted to facility on 10/10/17; -Quarterly MDS done on 7/26/18; -Annual MDS dated [DATE], showed in progress. 10. Review of Resident #15’s medical record, showed: -Quarterly MDS, dated [DATE], submitted and accepted; -Quarterly MDS, dated [DATE], export ready, had not been locked or submitted as of 11/29/18 at 11:36 A.M. 11. During an interview on 11/29/18 at 12:10 P.M., the MDS Coordinator said he is the only person at the facility that does the MDSs and reviewed the resident’s MDSs. He said export ready means they are ready to be submitted to the state but have not been submitted yet. | |
| F 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Create and put into place a plan for meeting the resident’s most immediate needs within 48 hours of being admitted **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 4) Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan consistent with the resident’s specific conditions, needs, and risks within 48 hours of admission to properly care for one of three newly admitted sampled residents (Resident #355). The sample was 18. The facility census was 87. Review of Resident #355’s electronic and paper medical record, during time of the survey, showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -Morse fall scale assessment (a test used to determine a resident’s likelihood to fall) dated 11/26/18, showed the resident has a high risk of falling; -A wandering risk assessment, dated 11/26/18, showed moderate risk for wandering. Review of the resident’s electronic physician’s orders [REDACTED]. -An order dated 11/26/18, [MEDICATION NAME] (antibiotic used to treat infections) tablet 875-125 milligram (mg), give 1 tablet two times a day related to [MEDICAL CONDITION]; -An order dated 11/26/18, [MEDICATION NAME] HCL (narcotic pain medication) capsule 5 mg, give 1 capsule by mouth every 4 hours as needed for moderate to severe pain; -An order dated 11/26/18, [MEDICATION NAME] ER (extended release narcotic pain medication) tablet 20 mg, give 1 tablet every 12 hours for pain; -An order dated 11/26/18, [MEDICATION NAME] (used to treat anxiety) tablet 0.5 mg, give 1 tablet by mouth every 12 hours for anxiety. Review of the resident’s Baseline Care Plan, dated 11/21/18, showed: -admission date of [DATE]; -Initial goals: remain in long term facility (LTC), followed by hospice; -Discharge goal: home to the community with hospice; -Cognitively intact and alert; -Safety: history of falls not selected, history of fall-related injuries not selected; -medications: [REDACTED] -Equipment: Miami J-Collar (a neck brace used to prevent head and neck movement after a spinal cord injury); -Resident’s life history, daily routines and preferences, and cultural and ethnic preferences were not noted; -There were no goals identified for infection resolution, anxiety reduction, or pain management; -Resident’s psychosocial goals: nothing listed; -Social services/psychosocial interventions: nothing listed; -Mental health needs: nothing listed; Observation on 11/27/18 at 8:26 A.M., showed the resident lay in bed on his/her back. His/her extremities appeared ridged and the resident lay very straight in the bed. The resident was not wearing a neck stabilizing collar. The resident’s call light on. At 8:27 A.M., Certified Nursing Assistant (CNA) E entered the resident’s room. The resident told CNA E he/she was in severe pain. CNA E said he/she will go tell the nurse and left the room. The resident lay in bed. Tears ran down his/her face and he/she moaned out loud. At 8:37 A.M., CNA E entered the resident’s room with his/her breakfast tray. The resident continued to have tears run down his/her face and said he/she had pain. As CNA E elevated the head of the bed, the resident yelled out in pain. CNA E told the resident that he/she would go tell the CMT that he/she needed pain medication and left the room. The resident had a visible mass on the right side of his face and he/she reached up and held onto the mass as he/she moaned. At 9:34 A.M., no pain medication had been provided. Observation on 11/29/18 at 8:02 A.M., showed the resident lay in bed on his/her back. 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0655 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 5) resident lay with his/her extremities outstretched and was very still. The resident not wearing a neck stabilizing collar. The resident stated he/she was in severe pain. The pain was located in his/her face, neck, back, and thighs. He/she tells staff every time they come into his/her room that he/she is in severe pain and staff won’t do anything about it. The resident said staff told him/her they do not have anything to give to him/her for the pain. The resident had tears in his/her eyes. During an interview on 11/27/18 at 10:04 A.M., a visitor stated the resident had fallen at home and was taken to the hospital. The resident suffered from a broken neck and his/her jaw was swollen with extensive pain. The resident found out while in the hospital he/she [MEDICAL CONDITION]. All of the changes in the resident’s health were new and the resident’s place of employment did not know of the change of condition and were waiting for him/her to return to his/her job. The visitor further stated that the resident, before admittance to the facility, was very independent who liked to read and watch TV. During an interview on 11/29/18 at 12:07 P.M., with the Minimum Data Set (MDS) coordinator, administrator and DON, they said the MDS coordinator and nursing staff are responsible to create and update the baseline care plans. They would expect a resident admitted with orders for pain medications to have goals related to pain on the baseline care plan. For this resident, goals include overall, having no pain. They would expect a resident admitted with orders for medications to treat anxiety have goals related to anxiety on the baseline care plan. For this resident, goals include a decrease in anxiety. They would expect a resident admitted with orders for antibiotics to treat [MEDICAL CONDITION] to have goals related to the need for the antibiotic on the baseline care plan. For this resident goals include a resolution of the infection. Staff should monitor signs and symptoms of infection and for adverse events related to antibiotic use. This should be on the baseline care plan. The facility currently does not have a social worker. Nursing staff are responsible for providing psychosocial care, treatment and interventions for the residents. There should be psychosocial interventions related to having a new terminal diagnosis. Every resident should be considered, when newly admitted to long-term care, as having a psychosocial need due to significant life changes and this should be on the baseline care plan. If a resident is admitted after a fall at home, this should be addressed on the baseline care plan. Resident’s identified as a high fall risk or a wander risk on their admission assessments should have these findings addressed on the baseline care plan. If a resident was diagnosed with [REDACTED]. The facility is looking into ordering a neck brace for the resident. | |
| F 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 6) Review of Resident #17’s annual Minimum Data Set (MDS), a federally mandated assessment instrument completed by facility staff, dated 7/31/18, showed: -[DIAGNOSES REDACTED]. -Rarely understood/understands; -Extensive assistance required for transfers, bed mobility, dressing, toileting, and hygiene; -Impairment on both sides of the lower extremity; -Ability to hear: moderate difficulty; -Speech clarity: clear speech; -Vision: Moderate impaired. Review of the resident’s care plan, revised on 10/14/18 and in use at the time of the survey, showed: -Focus: The resident does not speak in the dominant language of the facility. Spanish speaking, but he/she does understand simple English. Family visits multiple times a day and is usually there during meal times to assist him/her; -Interventions: Anticipate and meet needs; -Ensure/provide a safe environment: Call light in reach, adequate low glare light, bed in lowest position and wheels locked, avoid isolation; -Monitor effectiveness of communication strategies and assistive devices such as the communication books; -Monitor for/record confounding problems: decline in cognitive status, mood, decline in activities of daily living (ADLs), deterioration in respiratory status, oral motor function (lips, tongue, jaw, teeth, hard and soft palate), and hearing impairment; -Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed; -Resident is able to communicate by: writing, using communication board, gestures, sign language, and translator; -Use communication boards (a board with pictures and/or symbols used to facilitate communication), use interpreter when available, and use interpreter applications on phone or computer. Family serves as interpreter and is readily available. Review of the resident’s progress notes, dated 10/3/18, showed several attempts made in assisting the resident with eating. Food was placed into his/her mouth the resident spat the food out and began to yell no, I don’t want it. Encouraged to drink liquids and refused. Observation and interview with the resident on 11/27/18, 11/28/18, 11/29/18, 11/30/18, and 12/3/18, showed: -On 11/27/18 at 9:09 A.M., the resident was observed in his/her room. He/she sat in the wheelchair. He/she continued to say, venga (come on) continuously. He/she was heard speaking Spanish to staff in his/her room. Staff was able to say water and yes in Spanish, but no other words. The surveyor was able to communicate with the resident in Spanish. He/she was asked if he/she preferred to speak in English or Spanish. The resident said, Spanish. The resident said he/she was doing well, but had a little leg pain. The resident was asked if there were staff that spoke Spanish and he/she said no. There was a communication board on the closet with showed facial pictures and words in Spanish; -On 11/27/18 at 11:02 A.M., the resident was heard saying venga several times. Staff did not enter room. The resident was seen in his/her wheelchair with his/her head down. The surveyor entered room and the resident said he/she was feeling well, and was not in pain at that time. He/she received his/her medication every day. Teh resident was asked if staff came in the room to talk to him/her. He/she said no. The resident said he/she wanted |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 7) food and to eat; -On 11/27/18 at 12:32 P.M., the resident’s family member was in the resident’s room. The resident’s family member confirmed that the resident says venga a lot, which means come in English. The resident recently lost his/her vision and due to his/her dementia, had to be reminded every day for two months. The resident does not care for group activities, but most of the time when he/she says venga, he/she would like for someone to come and hold his/her hand; -On 11/28/18 at 9:57 A.M., the resident sat in his/her wheelchair with his/her head down and eyes closed. The television was turned on and was in English. The surveyor asked the resident if he/she could speak English, but the resident continued to respond in Spanish. The resident continued to say venga and asked the surveyor to hold his/her hand in Spanish. The resident was asked if he/she enjoyed listening to music and watching television. He/she said yes and likes to listen to Latin music and music from Bolivia; -On 11/28/18 at 10:14 A.M., the resident sat in his/her room. He/she continued to say, venga several times; -On 11/28/18 at 10:21 A.M., the resident said he/she would prefer to listen to television in Spanish; -On 11/28/18 at 10:28 A.M., the resident was heard in his/her room saying, venga, no tengo comida (Come, I don’t have food). Staff did not enter the resident’s room. The resident was easily heard in the hallway. the surveyor entered room and asked the resident if he/she wanted to eat. He/she said yes; -On 11/28/18 at 12:48 P.M., the resident was observed in the dining room. He/she continued to say venga. The resident’s head was down and his/her eyes were closed. At 12:56 P.M., the resident was served a pureed meal with ice cream, juice, and coffee. The resident did not eat or drink, but continued to reach around the table for his/her juice. At 1:15 P.M., staff sat next to the resident and spoke to the resident in English. The resident was asked if he/she wanted coffee. Staff placed the coffee to the resident’s mouth and he/she began to drink it. The resident said, no, too hot in Spanish. Staff asked the resident if he/she wanted ice cream, but the resident continued to reach for the cup of juice. Staff opened the cup of ice cream and began to feed the resident chocolate ice cream. The resident said, no, no quiero (No, I don’t want). The resident continued to reach for the juice and staff continued to feed the resident another spoonful of chocolate ice cream, and he/she ate it. Staff left the table and Certified Nurse Aide (CNA) J sat next to the resident and began to assist him/her. CNA J assisted the resident with the coffee cup by placing it to his/her mouth. The resident drank the coffee. CNA J said coffee and the resident said yes in English and Spanish. The resident started to drink the coffee. The resident said, comida, yo quiero comida (food, I want food), and CNA J began to feed the resident chocolate ice cream and the resident said no. The resident continued to drink the coffee. CNA J began to feed the resident mashed potatoes. The resident consumed three spoonful’s of mashed potatoes. The resident was fed another bite and he/she said, no mas (no more). CNA J continued to feed mashed potatoes to the resident and he/she continued to say, no quiero (I don’t want) and spit the mashed potatoes out onto his/her own shirt. CNA J attempted to feed the resident chocolate ice cream and resident said, no. CNA J tried to feed the resident mashed potatoes and the resident said, no and pushed the spoon away. CNA J tried to feed the resident ice cream and resident said no and pushed it away, and said, no quiero comida (I don’t want food). CNA J continued to feed the resident mashed potatoes and ice cream and did not attempt to feed the resident the pureed mixed vegetables or pureed country fried steak. CNA J said, coffee and the resident said yes. The resident continued to drink the coffee; |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0676 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 8) -On 11/29/18 at 1:32 P.M., the resident sat in his/her room with his/her family member. The resident said he/she was doing well in Spanish. The resident’s family member said he/she was doing well and had just eaten he/she drinks more than he/she eats at this point. The resident asked him/her to play Argentine tango music and he/she did. The resident does not have a radio, but he/she likes to listen to music; -On 11/30/18 at 2:19 P.M., the resident was in bed with his/her eyes closed. The resident softly said, venga several times. The resident said he/she was doing fine; -On 12/3/18 at 8:32 A.M., the resident was in his/her room. He/she sat in his/her wheelchair with the television on in English. The resident’s head was down and his/her eyes closed. The resident continued to say, venga. During an interview on 12/3/18 at 8:45 A.M., CNA G said he/she was not aware if there were staff that spoke Spanish, but did confirm that the resident said, venga. CNA G did not know what venga meant. The resident usually signals to staff, so they would be able to know what he/she needed. Observations during the survey on 11/27/18 through 11/30/18 and 12/3/18, showed no staff used the communication board to communicate with the resident, nor did staff use any other assistive device to communicate with the resident. During an interview on 12/3/18 at 9:00 A.M., the administrator and Director of Nursing (DON) said the resident’s vision is impaired, but it was unknown how much the resident could or could not see. He/she has a communication board, but there were no assistive devices in place to assist the resident since he/she lost his/her vision and could not see the communication board. If staff work with the resident, he/she can use signs. The resident’s family was there every day to assist with laying him/her down and keeping him/her comfortable. Staff do not use communication/translation device in Spanish when the resident is speaking Spanish. The resident does understand English. The administrator would expect staff to observe the resident for non-verbal cues. The administrator would expect staff to use an application to translate what the resident is saying. | |
| F 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide activities to meet all resident’s needs. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 9) -Listening to music: yes; -Being around pets: yes; -Doing things with groups of people: yes; -Participating in favorite activities: yes; -Spending time outdoors: yes; -Participating in religious groups or activities; yes; -Ability to hear: moderate difficulty; -Speech clarity: clear speech; -Vision: Moderate impaired. Review of the resident’s care plans, revised on 10/14/18 and in use at the time of the survey, showed: -Focus: Resident is dependent on staff for meeting emotional, intellectual, physical, and social needs related to his/her own choices. The resident chooses what he/she does and does not want to do and his/her family supports his/her choices despite staff intervention and interaction. The resident’s family members say the resident never socialized much, mainly with family and family events; -Interventions: All staff converse with resident while providing care; -Encourage ongoing family involvement. Invite the resident’s family to attend special events, activities, and meals; -The resident prefers to socialize with family and staff; -Provide with activities calendar. Notify resident of any changes to the calendar of activities; -Review resident’s activity needs with the family/representative; -The resident needs 1:1 (one to one personal) bedside/in room visits and activities if unable to attend out of room events; -Focus: The resident does not speak in the dominant language of the facility. Spanish speaking, but he/she does understand simple English. Family visits multiple times a day and is usually there during meal times to assist him/her; -Interventions: Anticipate and meet needs; -Monitor effectiveness of communication strategies and assistive devices such as the communication books; -Monitor/document for physical/nonverbal indicators of discomfort or distress, and follow-up as needed; -Resident is able to communicate by: writing, using communication board, gestures, sign language, and translator; -Use communication boards, use interpreter when available, and use interpreter applications on phone or computer. Family serves as interpreter and is readily available. Review of the resident’s medical record, showed no documentation of activity 1:1 or an activity assessment. Review of the facility’s 1:1 activities documentation for residents at the facility, showed no documentation that staff provided 1:1 activity for the resident. Observation and interview with the resident, showed: -On 11/27/18 at 9:09 A.M., the resident was observed in his/her room. He/she sat in the wheelchair. He/she continued to say, venga (come on) continuously. He/she was heard speaking Spanish to staff in his/her room. Staff was able to say water and yes in Spanish, but no other words. The surveyor was able to communicate with the resident in Spanish. He/she was asked if he/she preferred to speak in English or Spanish. The resident said, Spanish. The resident was asked if there were staff that spoke Spanish and he/she said no. There was a communication board on the closet with showed facial pictures and words in |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 10) Spanish; -On 11/27/18 at 11:02 A.M., the resident was heard saying venga several times. Staff did not enter room. The resident was seen in his/her wheelchair with his/her head down. The surveyor entered room and the resident was asked if staff came in the room to talk to him/her. He/she said no; -On 11/27/18 at 12:32 P.M., the resident’s family member confirmed that the resident says venga a lot, which means come in English. The resident recently lost his/her vision and due to his/her dementia, had to be reminded every day for two months. The resident does not care for group activities, but most of the time when he/she says venga, he/she would like for someone to come and hold his/her hand; -On 11/28/18 at 9:57 A.M., the resident sat in his/her wheelchair with his/her head down and eyes closed. The television was turned on and was in English. The resident continued to say venga and asked the surveyor to hold his/her hand in Spanish. The resident was asked if she enjoyed listening to music and watching television. He/she said yes and likes to listen to Latin music and music from Bolivia; -On 11/28/18 at 10:14 A.M., the resident sat in his/her room. He/she continued to say, venga several times; -On 11/28/18 at 10:21 A.M., the resident said he/she would prefer to listen to television in Spanish; -On 11/28/18 at 10:28 A.M., the resident was heard in his/her room saying, venga, no tengo comida (Come, I don’t have food). Staff did not enter the resident’s room. Resident was easily heard in the hallway; -On 11/28/18 at 12:48 P.M., the resident was observed in the dining room. He/she continued to say venga. The resident’s head was down and his/her eyes were closed; -On 11/29/18 at 1:32 P.M., the resident sat in his/her room with his/her family member. The resident’s family member said the resident asked him/her to play Argentine tango music and he/she did. The resident does not have a radio, but he/she likes to listen to music; -On 11/30/18 at 2:19 P.M., the resident was in bed with eyes closed. The resident softly said, venga several times; -On 12/3/18 at 8:32 A.M., the resident was in his/her room. He/she sat in his/her wheelchair with the television on in English. The resident’s head was down and his/her eyes closed. The resident continued to say, venga. During an interview on 12/3/18 at 8:45 A.M., Certified Nursing Assistant (CNA) G said he/she was not aware if there were staff that spoke Spanish, but did confirm that he/she said, venga. CNA G did not know what venga meant. The resident usually signals to staff, so they would be able to know what he/she needed. During an interview on 12/3/18 at 9:00 A.M., the administrator and Director of Nursing (DON) said the resident has a communication board, but there were no assistive devices in place to assist the resident since he/she lost his/her vision and could not see the communication board. The resident likes to fold towels, and he/she receives visits from family daily. The administrator would expect staff to use an application to translate what the resident is saying. During an interview on 12/3/18 at 10:24 A.M., the Activity Director said the resident used to be on 1:1 activity, but he/she was on the refusal list. Staff used to take him/her out to different areas in the facility and do his/her nails, but he/she did not like that. He/she would get frustrated, start to cry, and move back in his/her wheelchair. The activity director did not know what the resident said. Most of the time the resident is sleeping. The activity director did not attempt any activities in the resident’s room such as playing music or holding his/her hand. There is no documentation of the interaction or |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0679 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 11) the one on one activities. When a resident is on the refusal list, staff revisit at a later date. At 12:46 P.M., the activity director clarified that she is able to understand the resident when residents communicates since the resident has been at the facility for the past year. For the past month, the resident has refused to participate in group and one on one activities. This is shown by the resident saying no and backing away in his/her chair. The resident’s overall decrease in participation over the past month is documented in the record. The resident used to like doing manicures and currently enjoys visits with his/her daughter. The activity director was not sure what resident’s current preferred activities were. It has been two weeks since she tried to engage the resident in activities. The resident is on the refusal list for one on one activities. The activity director said she usually leaves a resident alone for one or two weeks after they refuse one on one activities before she will try to engage them again. The activity director had not tried to play music for the resident. During an interview on 12/3/18 at 1:30 P.M., the administrator said she would expect one to one activities to be documented and for staff to know the resident’s likes. It is not appropriate for a resident to be on a refusal list. | |
| F 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Provide safe and appropriate respiratory care for a resident when needed. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0695 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 12) tubing had a date of 10/18/18. The resident said he/she turned the oxygen concentrator on and set the oxygen flow rate him/herself. Observation on 11/30/18 at 1:51 P.M., showed the resident lay in bed sleeping without any oxygen in use. The oxygen tubing, dated 10/18/18, had been hung over the undated humidifying bottle and the nasal prongs directly touched the front of the concentrator without any type of protective covering. During an interview on 11/30/18 at 2:25 P.M., the Assistant Director of Nurses (ADON) verified the resident’s oxygen tubing showed a date of 10/18/18, the humidifying bottle did not have any date and there was not any type of protective covering for the nasal cannula. She said the facility policy is to change the oxygen humidifying bottle and oxygen tubing every Sunday on the night shift and she would expect staff to date the humidifying bottle when changed. The resident puts the oxygen on and off him/herself and that is why the nasal cannula is not in any type of protective covering. 2. Review of Resident #137’s ePOS, in use during the survey, showed: -admitted to the facility on [DATE]; -[DIAGNOSES REDACTED]. -An order dated 11/23/18, for oxygen at 2 liters by nasal cannula at bedtime. Observation on 11/29/18 at 7:10 A.M., showed the resident lay in bed awake with oxygen in use at 2 liters by nasal cannula. Staff had not dated the oxygen humidifying bottle or the oxygen tubing. Staff removed the resident’s oxygen, turned off the concentrator and placed the undated tubing into a plastic bag on the back of the concentrator. Observation on 11/30/18 at 1:49 P.M., showed the resident sat in his/her wheelchair in his/her room without any oxygen in use. The oxygen concentrator sat in the corner of the room by the head of the resident’s bed. The humidifying bottle and the oxygen tubing remained undated. During an interview on 11/30/18 at 2:30 P.M., the ADON verified the oxygen tubing and the humidifying bottle had not been dated and would expect staff to date them when applied for a new admission and then weekly. 3. During an interview on 12/3/18 at 9:00 A.M., the Director of Nurses (DON) said the oxygen tubing and humidifying bottles are changed weekly on Sunday night by the night shift charge nurses and they should both be dated when changed. | |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 13) HCL (short acting narcotic pain medication) capsule 5 milligram (mg), give 1 capsule by mouth every 4 hours as needed for moderate to severe pain; -An order dated 11/26/18, [MEDICATION NAME] tablet ER (extended release, long acting narcotic pain medication) 20 mg, give 1 tablet every 12 hours for pain; Observation on 11/27/18 at 8:26 A.M., showed the resident lay in bed on his/her back. His/her extremities appeared ridged and the resident lay very straight in the bed. The resident’s call light was on. At 8:27 A.M., Certified Nursing Assistant (CNA) E entered the resident’s room. The resident told CNA E he/she was in severe pain. CNA E said he/she would tell the nurse and left the room. The resident lay in bed. Tears ran down his/her face and he/she moaned out loud. At 8:37 A.M., CNA E entered the resident’s room with his/her breakfast tray. The resident continued to have tears run down his/her face and said he/she had pain. As CNA E elevated the head of the bed, the resident yelled out. CNA E told the resident that he/she would go tell the certified medication technician (CMT) that he/she needed pain medication and CNA E left the room. The resident had a visible mass on the right side of his face and he/she reached up and held onto the mass as he/she moaned. As of 9:34 A.M., no pain medication had been provided. During an interview on 11/27/18 at 9:54 A.M., CMT D said the resident received his/her scheduled pain medication earlier and he/she does not have anything else ordered for pain that could be given at that time. The resident did tell him/her that he/she was having pain around 8:00 A.M. and one of the CNAs told him/her the resident had pain, but by that time, the resident had already received his/her routine pain medication. During an interview on 11/27/18 at 10:04 A.M., a visitor said the resident fell at home prior to admission. He/she went to the hospital and was diagnosed with [REDACTED]. The resident had been having extensive pain. Observation at that time, showed the resident yelled out, moaned and said he/she still hurt. The visitor approached CMT D and told him/her the resident had pain. CMT D acknowledged the visitor and the visitor returned to the resident’s room. Review of the resident’s progress notes and medication administration record (MAR), reviewed on 11/27/18 at 11:30 A.M., showed no documentation of the resident’s complaints of pain or documentation of pain medication given for break through pain. During an interview on 11/29/18 at 8:00 A.M., Licensed Practical Nurse (LPN) C said the [MEDICATION NAME] HCL for the resident would be on the CMT cart, not the nurse’s cart. During an interview on 11/29/18 at 8:02 A.M., the resident said he/she had severe pain that rated 10 on a scale of 1-10, (where 1 is minor pain and 10 is the worse pain imaginable). He/she tells staff every time they come into the room that he/she has pain and they will not do anything about it. Staff say they do not have anything to give him/her for the pain. The resident’s eyes were tearful. During an interview on 11/29/18 at 8:10 A.M., the Director of Nursing (DON) said she was informed of the resident’s complaints of pain and said the resident has an order for [REDACTED]. During an interview on 11/29/18 at 8:32 A.M., with the DON and LPN C, the DON said as needed pain medications are given if a resident has pain that is reported to the nurse. She would expect staff to report to the nurse if the resident had pain. LPN C said no one reported the resident had pain to him/her and he/she was not aware of the resident’s pain. Further review of the resident’s MAR, reviewed on 11/29/18 at 11:45 A.M., showed no documentation of [MEDICATION NAME] HCL 5 mg administered to the resident since admission to the facility. Review of the resident’s narcotic sign out log for the [MEDICATION NAME] 5 mg tablets, reviewed on 11/29/18 at 11:50 A.M., showed [MEDICATION NAME] 5 mg one tablet documented as |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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) administered: -On 11/27/18 at 12:00 P.M., 4:00 P.M., and 8:00 P.M.; -On 11/29/18 at 10:05 A.M.; -No documentation [MEDICATION NAME] administered prior to 12:00 P.M. on 11/27/18; -No further documentation to show the level of the resident’s pain, location or type of pain or the effectiveness of the pain medication. During an interview on 11/29/18 at 11:50 A.M., CMT J said he/she worked the day and evening shift on 11/27/18. Prior to noon, only the routine pain medication was given. There was an issue with the computers that made the order for the resident’s as needed pain medication not show up on the CMT MAR. That is why the administration of the [MEDICATION NAME] 5 mg was not documented on the MAR in the computer. During an interview on 11/29/18 at 9:53 P.M., the resident said when he/she takes pain medication, his/her pain is okay but when he/she moves, it goes up and out the window. The pain never goes away and gets worse if he/she moves. His/her pain was very bad at the moment. Further review of the resident’s progress notes, showed on 11/29/18 at 10:36 A.M., staff reported to the nurse that the resident complained of pain at 10:05 A.M. The nurse went in to assess the resident’s pain. He/she stated he/she was having pain at a 9 on a scale of 1-10, with 10 being the highest and 1 the lowest. Pain was located on the right side of the resident’s face and neck. Resident’s as needed [MEDICATION NAME] given. During an interview on 11/29/18 at 11:32 A.M., the DON said the facility staff assesses resident’s pain every shift and document it on the MAR or treatment administration record (TAR). The nurses work 12 hour shifts. The documentation on the MAR or TAR is the pain assessment tool utilized by the facility on all residents. The facility uses the number scale and/or facial pain expression scale when rating resident’s pain. The score obtained utilizing these scales is what is documented on the MAR and TAR. On newly admitted residents, the facility staff complete the admission assessments, which include the skin, fall and pain assessments. If a resident reports severe pain to a CNA, she would expect them to report to the nurse immediately. This should be documented. If a visitor reports to a CMT that a resident is having pain, she would expect the CMT to follow up and report to the nurse. The nurse should assess the resident. Medications for break through pain should be administered when a resident has reports of pain, even if the resident has orders for long-acting medications. Staff who are responsible to administer the break through pain medications should be aware of the medications the resident has available for use. If a CNA believes a resident, who has reports of pain, has no orders for breakthrough pain medication, she would expect the CMT to notify the nurse. Resident complaints of pain should be documented in progress notes or on the MAR note section. Further review of the resident’s MARs and TARs for (MONTH) (YEAR), reviewed on 11/29/18 at 1:30 P.M., showed no documentation of the pain assessment tool completed for the resident, pain rating, type of pain, location of pain or effectiveness of the pain medication. | |
| F 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 15) Based on interview and record review, the facility failed to ensure resident monthly pharmacy medication regimen review (MRR) recommendations were communicated to the physician, medical director and director of nursing (DON) and that these recommendations were acted upon timely. The facility failed to ensure physician orders [REDACTED]. In addition, the facility policy failed to require the pharmacist must report any irregularities to the attending physician, the facility’s medical director and DON and/or failed to address MRRs for resident who are anticipated to stay less than 30 days and residents who experience an acute change of condition. This affected three of 18 sampled residents (Residents #5, #68, and #62). The census was 87. Review of the facility’s Drug Regimen Review policy, undated, showed: -Facility will be given a copy of the pharmacist’s drug regimen review report within 7 days after completion of facility review; -Facility will forward the recommendation to the appropriate provider(s) within 7-14 days of receiving the report; -Providers will respond, sign and return recommendation to facility within 30 days; -Irregularities that require urgent action will be attended in the following manner unless otherwise instructed: -The consultant pharmacist will immediately inform available charge nurse and/or DON of an irregularity that requires urgent action in which immediate harm could occur. The nurse will immediately contact the provider; -An irregularity that poses significant concerns, but not immediate in nature, will be reported to charge nurse and/or DON either in writing or verbally before end of review and provider will be contacted; -The policy failed to require the pharmacist must report any irregularities to the attending physician and the facility’s medical director and DON; -The policy failed to address MRRs for a resident who is anticipated to stay less than 30 days, residents who experience an acute change of condition and for whom an immediate MMR is requested after appropriate staff have notified the resident’s physician, the medical director and the DON about the acute change. 1. Review of Resident #5’s quarterly Minimum Data Set (MDS), a federally required assessment instrument completed by facility staff, dated 8/1/18, showed: -Brief interview for mental status (BIMS) of 1, indicated severe cognitive impairment; -Resident mood interview not conducted because resident rarely/never understood; -Staff assessment of resident’s mood: Severity 0; -No [MEDICAL CONDITION], behavioral symptoms, or wandering; -Rejects care 1-3 days a week; -Received antipsychotic on routine basis; -No attempt at gradual dose reduction (GDR). Review of the resident’s electronic medical record, showed a [DIAGNOSES REDACTED]. Review of the resident’s MRR for recommendations, between 7/1/18 and 7/16/18, showed: -This resident is receiving the following antipsychotic order: [MEDICATION NAME] 12.5 milligram (mg) twice daily for dementia related behavioral disturbances. Centers for Medicare and Medicaid services (CMS) guidelines state that GDR must be attempted twice in two separate quarters the first year the medication is initiated unless clinically contraindicated; -If a GDR is appropriate at this time, please write new order below; -Staff documented follow-through as, Note written to secondary physician; -No documentation of a rationale to continue the medication as ordered. Review of the resident’s physician order [REDACTED]. |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 16) Review of the resident’s Medication Administration Record [REDACTED] -An order, dated 10/8/18 and discontinued 11/30/18, for [MEDICATION NAME] 25 mg given by mouth at bedtime for dementia, administered 11/1/18 through 11/29/18; -An order, dated 11/30/18, for [MEDICATION NAME] 25 mg, given at bedtime for dementia, administered 11/30/18. Review of the resident’s MRR, dated 11/19/18, showed: This resident is receiving the following antipsychotic order: [MEDICATION NAME] 25 mg at bed time for dementia related to behavioral disturbances; -If a GDR is appropriate at this time, please write new order below; -Physician response: Disagree; -Staff documented, keep same order; -No documentation of a rationale to continue the medication as ordered or documentation the GDR was clinically contraindicated. 2. Review of Resident #68’s quarterly MDS, dated [DATE], showed: -BIMS of 6, indicating severe cognitive impairment; -No [MEDICAL CONDITION] or behavioral symptoms; -Wanders 1-3 days, rejects care 4-6 days but less than daily; -Receives antipsychotic, antidepressant, and antianxiety medication 7 days a week; -No attempt at GDR for antipsychotic medication, not documented by physician as clinically contraindicated. Review of the resident’s MRR for recommendations between 7/1/18 and 7/16/18, showed: -This resident is receiving the following antipsychotic order: [MEDICATION NAME] (brand name for [MEDICATION NAME], antipsychotic) 0.25 mg at night for dementia related behaviors that has been in place since last successful GDR 3/20/18. CMS guidelines state that a GDR must be attempted twice in two separate quarters the first year medication is initiated unless clinically contraindicated. Must be evaluated quarterly for dementia related behaviors; -If a GDR is appropriate at this time, please write new order below; -Staff documented follow-through as, Note written to secondary physician; -No documentation of a rationale to continue the medication as ordered, documentation the GDR clinically contraindicated or physician response. On 11/28/18, the resident’s MMR for 10/19/18 requested. Review of the resident’s MRR, dated 10/19/18, showed: Second request: This resident is receiving the following antipsychotic order: [MEDICATION NAME] 0.25 mg at bed time for dementia related behaviors that has been in place since last successful GDR 3/20/18. CMS Guidelines state that a GDR must be attempted twice in two separate quarters the first year medication is initiated unless clinically contraindicated. Must be evaluated quarterly for dementia related behaviors; -If a GDR is appropriate at this time, please write new order below; -Staff documented, discontinue [MEDICATION NAME] per nurse practitioner. Review of the MAR for (MONTH) (YEAR), showed an order, starting 6/11/18 and discontinued 11/30/18, for [MEDICATION NAME] 0.5 mg (give half tablet at bedtime), administered 11/1/18 through 11/29/18. 3. Review of Resident #62’s annual MDS, dated [DATE], showed: -Rarely/never understood; -Exhibits verbal behavioral symptoms without impacting resident or others; -No [MEDICAL CONDITION], physical behaviors, or wandering; -Receives antipsychotic on routine basis; -GDR not attempted, last documented by physician as clinically contraindicated on 3/1/17. |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0756 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 17) Review of the resident’s electronic medical record, showed: -Diagnosis, dated 6/11/18, of dementia with behavioral disturbance; -An order, dated 6/11/18, for [MEDICATION NAME] 50 mg, 1.5 tab by mouth three times daily for dementia with behavioral disturbance; -Pharmacist MRRs completed 1/10/18, 2/14/18, 3/14/18, and 5/10/18, directed staff to see the consultation for recommendations or irregularities. Review of the resident’s monthly pharmacist consultations, showed missing documentation from the MRRs completed on 1/10/18, 2/14/18, 3/14/18, and 5/10/18. On 11/28/18, the resident’s MMR consultation for recommendation or irregularities documentation requested. During an interview on 11/30/18 at 1:07 P.M., the administrator said several pharmacist consults could not be located at the facility. 4. During an interview on 12/3/18 at 9:04 A.M., the DON said the recommendations provided in pharmacy consultations should be submitted to the primary physician for review. If the physician declines the pharmacist’s recommendation to discontinue an order for [REDACTED]. | |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 18) -Has a gradual dose reduction (GDR) been attempted: Blank. Review of the resident’s medical record, showed: -An electronic physician order [REDACTED]. -An order, dated 6/11/18, for [MEDICATION NAME] (anti-depressant) 50 milligram (mg), give 0.25 tablet by mouth three times a day for anxiety (0.25 Tablet = 12.5 mg); -An order, dated 6/11/18, for [MEDICATION NAME] ([MEDICATION NAME], medication used to treat anxiety) 0.25 mg, give one tablet by mouth two times a day for anxiety; -Review of the Medication Administration Record [REDACTED] -An order, dated 6/11/18, for [MEDICATION NAME] 50 mg, 0.25 mg tablet administered three times a day for anxiety; -An order, dated 6/11/18, for [MEDICATION NAME] 0.25 mg, one tablet administered two times day for anxiety; -No documentation of assessing or monitoring for anxiety and behaviors and/or documentation of behavioral intervention; -No documentation of a GDR since the 6/11/18 order date or physician documentation to show that at GDR was contraindicated. Review of the resident’s care plan, revised on 10/14/18 and in use at the time of the survey, showed: -Focus: Resident has a mood problem related to disease process. He/she has anxiety, dementia, and a mood disorder along with [MEDICAL CONDITION] (difficulty sleeping). He/she takes [MEDICATION NAME] (medication used to treat [MEDICAL CONDITION]), [MEDICATION NAME] (anti-depressant) as ordered; -Interventions: Administer medications as ordered. Monitor/document for side effects and effectiveness; -Behavioral health consults as needed; -Monitor/record mood to determine if problem seems to be related to external causes; -Monitor/record/report to physician as needed for harming others: increased anger, labile mood or agitation, feel threatened by others or thoughts of harming someone, possession of weapons or objects that could be used as weapons; -Observe for signs and symptoms [MEDICAL CONDITION](high energy) or hypomania (low energy), racing thoughts or euphoria, increased irritability, frequent mood changes, pressured speech, flight of ideas, marked change in need for sleep, or [MEDICAL CONDITION]. Observation of the resident, showed: -On 11/27/18 at 12:32 P.M. and 9:57 A.M., the resident sat in his/her wheelchair in his/her room with his/her head down. He/she said, venga (come on, in Spanish), and asked the surveyor to hold his/her hand; -On 11/28/18 at 10:14 A.M., the resident was observed in his/her room. He/she sat in his/her wheelchair with his/her head down. He/she was heard saying, venga several times. No staff responded; -On 11/28/18 at 12:48 P.M., he/she was in the dining room. He/she continued to say, venga several times. No staff responded; -On 11/29/18 at 4:48 P.M., 5:15 P.M., and 6:00 P.M., the resident sat at the dining table with his/her eyes closed; -On 11/30/18 at 2:19 P.M., the resident lay in bed with his/her eyes closed; -On 12/03/18 at 8:01 A.M., the resident was in the dining room with his/her head down. Observation and interview on 12/3/18 at 8:32 A.M., showed the resident sat in his/her room. He/she continued to say venga. Certified Nurse Aide (CNA) G said the resident has a little anxiety and confirmed that it occurred when the resident continued to say, venga. |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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) During an interview on 12/3/18 at 9:00 A.M., the Administrator and Director of Nursing (DON) said they would not call the resident’s behavior, anxiety. The resident likes to fold towels. He/she does not have a lot of behaviors. The administrator would expect staff to provide non-pharmological interventions and document episodes of anxiety. Resident’s should have appropriate [DIAGNOSES REDACTED]. 2. Review of Resident #32’s quarterly MDS, dated [DATE], showed: -A brief interview of mental status (BIMS) score of 6 out of 15, showed the resident cognitively impaired; -[DIAGNOSES REDACTED]. -Extensive assistance required for transfers, dressing, and hygiene; -Antipsychotic medications administered in the last 7 days; -Antipsychotic medications used on a routine basis; -No gradual dose reduction (GDR) attempts. Review of the resident’s medical record, showed: -[DIAGNOSES REDACTED].>-An order, dated ordered 6/11/18, for [MEDICATION NAME] (anti-psychotic) 25 mg, give one tablet by mouth at bedtime for dementia; -The MAR for (MONTH) (YEAR) and (MONTH) (YEAR), showed an order, dated 6/11/18, for [MEDICATION NAME] 25 mg given at bedtime for dementia. The MAR indicated [REDACTED] Review of the resident’s care plan, revised on 7/26/18 and in use at the time of the survey, showed: -Focus: The resident has potential to be verbally aggressive related to dementia. On [MEDICATION NAME]; -Interventions: Analyze of key times, places, circumstances, triggers, and what de-escalates behaviors and document; -Give the resident as many choices as possible about care and activities; -Monitor effects of [MEDICATION NAME], monitor for side effects. Pharmacy to review monthly and to keep on lowest effective dose; -When the resident becomes agitated: Intervene before agitation escalates, guide away from source of distress, and engage calmly in conversation. If response is aggressive, staff to walk calmly away, and approach later. Review of the resident’s medication regimen review, dated 10/23/18, showed: -Second request: Resident is receiving the following antipsychotic order: [MEDICATION NAME] 25 mg by mouth at bedtime, since 1/18. Centers for Medicare and Medicaid services (CMS) guidelines states that a gradual dose reduction must be attempted twice in separate quarters the first year medication is initiated unless clinically contraindicated; -If a GDR is appropriate at this time, please write new order below; -Physician response: Disagree; -Staff documented, per physician, do not change; -Further review showed no documentation of a rationale to continue the medication as ordered or documentation the GDR is clinically contraindicated. Observation of the resident, showed: -On 11/28/18 at 12:54 P.M., the resident sat in the dining room. The resident engaged in friendly conversation with staff; -On 11/29/18 at 4:45 P.M., the resident sat in his/her room. He/she sat in his/her wheelchair and watched television; -On 12/3/18 at 8:00 A.M., the resident sat in the dining room eating his/her meal. He/she engaged in a friendly conversation with surveyor. During an interview on 11/28/18 at 11:30 A.M., CNA J said the resident mostly relaxes in his/her room. He/she did not display behaviors. |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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) During an interview on 12/3/18 at 9:00 A.M., the Administrator and DON said residents should have appropriate [DIAGNOSES REDACTED]. If the physician declines the pharmacist’s recommendation to discontinue an order for [REDACTED]. 3. Review of Resident #5’s quarterly MDS, dated [DATE], showed: -BIMS of 1, indicated severe cognitive impairment; -Resident mood interview not conducted because resident rarely/never understood; -Staff assessment of resident’s mood: Severity 0; -No [MEDICAL CONDITION], behavioral symptoms, or wandering; -Rejects care 1-3 days a week; -Receives antipsychotic and antidepressant medication; -No attempted GDR. Review of the resident’s care plan, undated and in use at the time of survey, showed the following: -Focus: Resident is at risk for displaying behaviors such as hitting, kicking and has a history of exit seeking at times. He/she can be combative with staff during care; -Interventions: -Attempt non-pharmacological interventions such as engaging in conversation about family, work history, hobbies, etc.; -Maintain a calm approach to resident; -Monitor for drug use effectiveness and adverse consequences; -Monitor resident’s mood and response to medication; -Pharmacy consult review; -Quantitatively and objectively document the resident’s behavior/mood; -Resident often gets agitated when family leaves from visiting. He/she can become combative with staff during periods of agitation; -When resident becomes physically abusive, stop and try task later. Do not force tasks. Make sure he/she is safe before leaving. Review of the resident’s electronic POS, for (MONTH) (YEAR), showed: -Principal diagnosis, dated 5/30/18, of unspecified dementia with behavioral disturbance; -An order, dated 10/8/18, for [MEDICATION NAME] 25 mg by mouth at bedtime for dementia. Review of the resident’s progress notes, from 7/16/18 through 11/28/18, showed: -On 9/20/18, staff noted the resident refused to shower; -On 11/3/18, staff noted the resident refused to participate in activities three times on that date; -No documentation of the resident exhibiting agitation or combative behavior; -No documentation to provide rationale for continued use of antipsychotic medication. Review of the MAR, for (MONTH) (YEAR), showed: -An order, dated 10/8/18 and discontinued 11/30/18, for [MEDICATION NAME] 25 mg given at bedtime for dementia; -[MEDICATION NAME] 25 mg administered as ordered 11/1/18 through 11/29/18; -An order, dated 11/30/18, for [MEDICATION NAME] 25 mg given at bedtime for dementia. Observations on 11/29/18 at 1:16 P.M., 11/30/18 at 6:45 A.M., 11/30/18 at 2:40 P.M., 12/3/18 at 7:19 A.M., and 12/3/18 at 8:30 A.M., showed the resident sat in his/her wheelchair. He/she sat quietly and calmly, and spoke to others in a quiet, pleasant tone. During an interview on 11/29/18 at 1:16 P.M., CNA F said sometimes when the resident is startled, he/she will swing or kick at staff. If staff backs away and calmly talks to the resident, he/she will be fine. The resident is easily calmed and no other interventions are required. The resident does not exhibit any other behavioral symptoms. During an interview on 12/3/18 at 8:36 A.M., CNA G said the resident wanders and yells out |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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) at times, but he/she is easily redirected if staff sit and talks to him/her, or walks around with him/her. The resident’s behaviors do not interfere with staff’s ability to provide care. During an interview on 12/3/18 at 9:00 A.M., the Administrator and DON said residents should have appropriate [DIAGNOSES REDACTED]. 4. Review of Resident #62’s annual MDS, dated [DATE], showed: -Resident rarely/never understood; -Exhibits verbal behavioral symptoms without impacting resident or others; -No [MEDICAL CONDITION], physical behaviors, or wandering; -Received antipsychotic on routine basis; -GDR not attempted, last documented by physician as clinically contraindicated on 3/1/17. Review of the resident’s care plan, undated and in use at the time of survey, showed: -Focus: Resident received antipsychotic medication due to senile dementia with depressive features; -Interventions: -Assess if resident’s behavioral symptoms present danger to resident and/or others. Intervene as needed; -Monitor resident’s behavior and response to medication; -Focus: Resident has physically and verbally abusive symptoms. Resident hollers out for no apparent reason. No matter how the staff try to resolve what is causing resident to holler, he/she continued to holler out; -Interventions: -Assess whether the behavior endangers resident and/or others, intervene if necessary; -Resident curses while hitting him/herself in the head, has conversations with him/herself as if he/she is talking to another person whom he/she is fighting; -Resident often hits himself/herself in his/her head during moments of delusion; -If resident delusions/hallucinations, do not try to reason with or confront, offer reassurance; -Maintain a calm environment and approach to resident; -Maintain a calm, slow, understandable approach with resident; -Rub resident’s hand or back when he/she begins hitting himself/herself; -When resident becomes physically abusive, keep distance between him/her and others. Review of the resident’s POS, for (MONTH) (YEAR), showed: -Diagnosis, dated 6/11/18, of unspecified dementia with behavioral disturbance; -An order, dated 6/11/18, for [MEDICATION NAME] 50 mg, 1.5 tab by mouth three times daily for dementia with behavioral disturbance. Review of the resident’s progress notes from 7/16/18 through 11/29/18, showed the following: -On 8/1/18, staff noted the resident hit him/herself in the head and yelled expletives. Staff moved the resident to a quiet area; -On 8/3/18, staff noted the resident hit him/herself in the head. Staff moved the resident to a quiet area and noted no further yelling; -No further documentation to provide rationale for continued use of antipsychotic medication. Observation on 11/28/18 at 12:47 P.M. and 11/29/18 at 7:18 A.M., showed the resident sat quietly in his/her chair, during meal service. Review of the residents MAR for (MONTH) (YEAR), reviewed on 11/29/18, showed: -An order, dated 6/11/18 for [MEDICATION NAME] 50 mg, 1.5 mg tab by mouth three times daily for dementia with behavioral disturbance (1.5 = 75 mg); |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 22) -[MEDICATION NAME] administered as ordered at 9:00 A.M., 1:00 P.M., and 5:00 P.M., from 11/1/18 through 11/28/18. Observation on 11/30/18 at 2:33 P.M., showed the resident lay in bed, calm and quiet. Observation on 12/3/18 at 7:20 A.M. showed the resident sat quietly in his/her chair during meal service. At approximately 8:30 A.M., CNA I moved the resident from the dining room into the main hall. During an interview on 12/3/18 at 8:36 A.M., CNA G said the resident yells out on occasion, which includes cursing. His/her yelling does not interfere with staff’s ability to provide care to the resident. The resident does not demonstrate any other behavioral symptoms, such as hitting staff. During an interview on 12/3/18 at 9:00 A.M., the Administrator and DON said residents should have appropriate [DIAGNOSES REDACTED]. 5. During an interview on 12/3/18 at 9:04 A.M., the DON said before resorting to pharmacological interventions to address dementia related behaviors, staff is expected to redirect the resident’s behaviors. If the physician declines the pharmacist’s recommendation to discontinue an order for [REDACTED]. | |
| F 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure medication error rates are not 5 percent or greater. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 23) [DEVICE]; -LPN C failed to hold the tube feeding by at least 1 hour before and/or 1 hour after administering the [MEDICATION NAME] suspension to the resident; -LPN C failed to stagger administration of the [MEDICATION NAME] from the other medications for at least 1 hour before and 1 hour after the administration of other medications. During an interview with Director of Nursing (DON) on 11/27/18 at 2:42 P.M., the DON stated: -Nursing staff should draw up medications with a syringe to get accurate measurements; -[MEDICATION NAME] should not be administered with other medications; -Tube feedings should be held before administering [MEDICATION NAME]; -She expects a physician’s orders [REDACTED]. According to WebMD, nutritional tube-feeding (enteral) products may decrease the absorption of [MEDICATION NAME]. Do not take these products at the same time as your [MEDICATION NAME] dose. Separate liquid nutritional products at least 1 hour before and 1 hour after your [MEDICATION NAME] dose, or as directed by your doctor. 2. Review of Resident #10’s electronic medical record (e-chart), showed the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident’s pain care plan, in use at the time of survey, showed: -The resident had chronic pain related to his/her [MEDICAL CONDITION]’s disease diagnosis; -Interventions included: -Administer [MEDICATION NAME] (pain medication) per order; -Monitor, record, and report to the nurse any resident complaints of pain or requests for pain treatment. Review of the resident’s ePOS, showed: -[MEDICATION NAME] HCL (narcotic pain pill) tablet 50 mg give 1 tablet by mouth every 6 hours as needed for pain, order dated 7/10/18; -[MEDICATION NAME] (narcotic pain pill) tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain, order dated 7/10/18; -Tylenol 325 mg, give two tablets by mouth every four hours as needed for pain. Observation of medication administration on 11/29/18 at 4:54 P.M., showed Certified Medication Technician (CMT) H: -Told the resident to remain in his/her room because he/she was gathering the resident’s medication for administration; -The resident complained of lower back pain with a pain rating of 10/10 and requested pain medication; -CMT H said the resident liked [MEDICATION NAME] in the morning and [MEDICATION NAME] in the evening; -He/she signed out the [MEDICATION NAME] then looked in the medication cart and said no [MEDICATION NAME] available; -CMT H looked in the medication cart for [MEDICATION NAME] and said no [MEDICATION NAME] available; -He/she told the resident that he/she did not have any pain medication in the cart and the only thing he/she could offer was Tylenol; -CMT H administered Tylenol 325 mg two tablets at 5:03 P.M.; -He/she did not look in the Emergency Medication Kit (e-kit) for the unavailable pain medication; -CMT H did not notify the nurse the resident was in pain, requesting pain medication, and that the [MEDICATION NAME] and [MEDICATION NAME] were not available; |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0759 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 24) -CMT H said that narcotics are delivered from the pharmacy on Fridays. Since it was Thursday evening, there would be none available until after the delivery on Friday. Review of the resident’s Medication Administration Record, [REDACTED] -[MEDICATION NAME] HCL tablet 50 mg give 1 tablet by mouth every 6 hours as needed for pain. As of 11/29/18, the last documented [MEDICATION NAME] 50 mg dose administered documented on 11/10/18 at 8:40 A.M.; -[MEDICATION NAME] tablet 5-325 mg give 1 tablet by mouth every 6 hours as needed for pain. [MEDICATION NAME] 5-325 mg administered on 11/29/18 at 4:58 P.M. and was effective; -Tylenol 325 mg give two tablets by mouth every four hours as needed for pain. Tylenol 325 mg two tablets administered on 11/29/18 at 5:00 P.M. and was effective. During an interview on 11/29/18 at 5:17 P.M., LPN C said: -CMTs cannot access the e-kit, they need to let the nurse know, and the nurse can look for the medication; -He/she expected CMTs to notify him/her any time a resident complains of pain or requests pain medication so he/she can monitor the resident’s pain; -He/she expected CMTs to notify him/her if any medications are not available so he/she can look in the e-kit. If the medication is not in the e-kit, he/she can call the physician for a one time order. During an interview on 12/3/18 at 9:02 A.M., the DON said: -If a medication is unavailable during medication pass, he/she expected the CMT to notify the nurse; -The nurse will check the e-kit. CMTs do not have access to the e-kit; -Residents should never go without pain medication because it can be pulled from the e-kit and if it’s not in the e-kit, the pharmacy will deliver pain medications outside of the normal delivery day. | |
| F 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | Ensure that residents are free from significant medication errors. **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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 25) records (MARs), showed the resident received [MEDICATION NAME] 0.125 mg every day instead of the ordered dose of [MEDICATION NAME] 0.125 mg every other day, for a total of 28 extra doses. Review of the resident’s (MONTH) (YEAR) MAR, showed the resident received [MEDICATION NAME] 0.125 mg daily on 9/1/18 through 9/25/18, instead of the ordered dose of [MEDICATION NAME] 0.125 mg every other day, for a total of 12 extra doses. Review of the resident’s progress note, dated 9/25/18 at 11:52 A.M., showed: -Per pharmacy recommendation review [MEDICATION NAME] changed to 0.125 mg every other day; -No documentation noted that a [MEDICATION NAME] level was requested. Review of the resident’s ePOS, at the time of survey, showed: -An order dated 9/26/18, for [MEDICATION NAME] 125 mcg every other day; -No order for a [MEDICATION NAME] level lab at the time the error was noted or since. During an interview on 11/29/18 at 5:17 P.M., Licensed Practical Nurse (LPN) C said he/she did not know what happened with the [MEDICATION NAME] order but it should have remained the same if there was not an order to change it. During an interview on 12/3/18 at 9:02 A.M., the Director of Nursing (DON) said: -Pharmacy pulled over all orders from the prior medical record system into the current; -The assistant DON was responsible to make sure orders where correct; -He/she would have expected staff to have caught the error sooner than three months after the change; -He/she expected the resident to receive the correct dose per physician order; -He/she would have expected a [MEDICATION NAME] level to have been obtained at the time of the error; -He/she was ordering a level be drawn that day; -He/she would expect a nurse’s note showing the physician had been notified and the orders that were received. 2. Review of Resident #64’s ePOS, showed: -An order dated 11/16/18, for [MEDICATION NAME] 1.5 Cal Liquid (Nutritional Supplements), give 50 milliliters (ml) per hour via gastrostomy tube ([DEVICE], a tube placed through the abdomen into the stomach to provide nutrition, hydration and medication); -An order dated 11/15/18, for [MEDICATION NAME] Tablet ([MEDICATION NAME], used to treat irritable bowel syndrome), give 0.125 mg via [DEVICE] three times a day; -An order dated 6/11/18, for [MEDICATION NAME] (Tylenol) liquid 160 mg per 5 ml. Give 20.3 ml by mouth four times a day for pain (20.3 ml = 650 mg); -An order dated 7/12/18, for [MEDICATION NAME] suspension (used to treat [MEDICAL CONDITION]) 125 mg per 5 ml, give 4 ml via [DEVICE] three times a day (4 ml = 100 mg). During a medication administration observation via [DEVICE] on 11/27/18 at 12:26 P.M., showed LPN C prepared the following medications for administration: -[MEDICATION NAME] 160 mg per 5 ml = 20 ml; -[MEDICATION NAME] tablet 0.125 mg, 1 tablet, crushed into a medication cup; -[MEDICATION NAME] suspension 125 mg per 5 ml. The medication cup used by LPN C only had lines delineated for 2.5 ml and 5.0 ml. LPN C poured the [MEDICATION NAME] suspension to just under the 5.0 ml line and stated it was 4.0 ml; -LPN C entered the resident’s room with the prepared medications. The resident’s [MEDICATION NAME] 1.5 Cal Liquid tube feeding was connected to his/her [DEVICE] and the feeding machine was on. LPN C turned off the feeding tube machine and disconnected the resident’s [DEVICE] from the feeding tube. LPN C gave the resident his/her medications, separating each medication by pouring approximately 5 ml to 10 ml of water into the [DEVICE]; |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0760 Level of harm – Minimal harm or potential for actual harm Residents Affected – Few | (continued… from page 26) -LPN C failed to hold the tube feeding by at least 1 hour before and/or after administering the [MEDICATION NAME] suspension to the resident; -LPN C failed to stagger administration of the [MEDICATION NAME] from the other medications by at least 1 hour before and 1 hour after the administration of other medications. During an interview with DON on 11/27/18 at 2:42 P.M., the DON stated: -Nursing staff should draw up medications with a syringe to get accurate measurements; -[MEDICATION NAME] should not be administered with other medications; -Tube feedings should be held before administering [MEDICATION NAME]; -She expects a physician’s orders [REDACTED]. According to WebMD, nutritional tube-feeding (enteral) products may decrease the absorption of [MEDICATION NAME]. Do not take these products at the same time as your [MEDICATION NAME] dose. Separate liquid nutritional products at least 1 hour before and 1 hour after your [MEDICATION NAME] dose, or as directed by your doctor. | |
| F 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Based on observation and interview, the facility failed to maintain an effective pest |
| 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: 265751 |
| (X3) DATE SURVEY COMPLETED | |||||||
| NAME OF PROVIDER OF SUPPLIER RIVERVIEW, THE | STREET ADDRESS, CITY, STATE, ZIP 5500 SOUTH BROADWAY | |||||||||
| 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 0925 Level of harm – Minimal harm or potential for actual harm Residents Affected – Some | (continued… from page 27) pests in the kitchen had just been brought to her attention that day. During an interview on 11/28/18 at 12:24 P.M., Exterminator N said the facility’s kitchen had an infestation of silverfish or earwigs. The exterminator sprayed the kitchen. Observation of the kitchen on 11/29/18 at 10:30 A.M., showed: -Two dead insects lay on the middle of the floor by the dish line; -One live bug crawled on the floor by the beverage counter; -The DM stepped on the bug, killed it, continued to work on lunch preparation, and left the dead insect on the floor. During an interview on 12/3/18 at 10:00 A.M., the administrator said all dietary staff is expected to notify the administrator if they notice insects in the kitchen. The administrator and maintenance staff are responsible for contacting the pest control company. It is inappropriate for staff to kill bugs and leave the dead insects on the floor. | |
