River City Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to follow the posted menu for the lunch meal on 04/26/21. This failure has the potential to affect 133 of 134 residents living at the facility, there was one resident requiring tube feedings. Findings include: During the lunch meal observation on the East Short Hallway and the Solona Unit, on 04/26/21 at 12:20 PM, nine residents were served chicken alfredo and green peas. Observation on 04/26/21 at 1:20 PM revealed Resident Identifier (RI) #80 was served a plain hot dog on a bun and mashed potatoes. On 04/26/21 at 1:20 PM, RI #48 was served a plain hot dog on a bun and mashed potatoes. On 04/26/21 at 01:20 PM an interview with Employee Identifier (EI) #10, Assistant Director of Nursing (ADON) confirmed RI #80 and RI #48 were served hot dogs for lunch. On 04/26/21 at 1:40 PM, EI #17, a dietary staff member acknowledged that chicken alfredo was served for lunch today and the change was not updated and posted on the menu. On 04/26/21 at 2:00…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure the proper handling of clean dishes and silverware. This failure has the potential to affect 133 of 134 residents living at the facility, there was one resident requiring tube feedings. Findings include: 1. On 04/26/21 at 9:38 AM an observation of Employee Identifier #18, Dietary Aide (DA) revealed EI #18 was cleaning off dishes, pots, pans, and glasses from breakfast preparing them for the dishwasher wearing gloves. EI #18 was observed spraying/rinsing off dirty dishes and placing them on trays and into the dishwasher and then moving to the clean side of the dishwasher and handling the clean trays of dishes wearing the same gloves. EI #18 never removed the gloves or performed hand hygiene. On 04/26/21 at 09:40 AM an interview with EI #18 was conducted. When questioned what actions she had just performed she stated, I went from handling dirty dishes to handling clean dishes and did not change gloves and perform hand hygiene. A review of the facility's policy titled, Warewashing (sic), dated 09/2017,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure garbage was properly disposed of and contained. This failure has the potential to affect all 134 residents who resided at the facility. Findings include: On 04/26/21 at 9:43 AM an observation of the area behind the building with Employee Identifier #17, a dietary staff member, revealed four dumpsters used for collecting garbage at the facility. One of four dumpsters was left open; multiple bags of garbage and boxes were noted inside. During an interview on 04/26/21 at 9:43 AM an interview with EI #17, EI #17 stated, the door should be closed. She confirmed one of four trash dumpsters had a door open and the dumpster contained a mixture of cardboard boxes and miscellaneous trash. A review of the facility's policy titled, Dispose of Garbage and Refuse, dated 08/2017, indicated, Policy Statement: All garbage and refuse will be collected and disposed of in a safe and efficient manner. Procedures: 1. The Dining Services Director coordinates with the Director of Maintenance to ensure that the area…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, review of the facility's document, and facility policy review, it was determined the facility failed to ensure a clean and comfortable environment free of the growth of a black substance on three air conditioning units: six overbed tables missing vinyl covering. All located in nine of 39 rooms located on the Solona unit and the East hallway (short hall). Findings include: On 04/29/21 at 09:00 AM a tour was performed, with Employee Identifier (EI) #21, the Maintenance Supervisor (MS). Observations of the East Hall and the Solana Unit revealed the following: 1. room [ROOM NUMBER], the overhead air conditioning (AC) unit was found to have dirt, dust, and a black substance covering the air vent. 2. room [ROOM NUMBER], the overhead AC unit was found to have dirt, dust, and a black substance covering the air vent. 3. room [ROOM NUMBER], the overbed table was found to have multiple tears in the vinyl covering with some vinyl missing. 4. room [ROOM NUMBER], the overhead AC unit was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview, the facility failed to provide breakfast or a nourishing snack to residents who dialyze on the first/early shift three times a week. This failure affected two of nine residents identified by the facility as receiving dialysis. Findings include: During an interview with Resident (RI) #62 on 04/27/21 at 2:00 PM, during a Resident Council Meeting, stated I don't get no breakfast before dialysis and I am a diabetic. RI #62 said that he/she undergoes dialysis three times a week on the first shift (6:30 AM to 10:30 AM). During an interview with RI #120 on 04/27/21 at 11:05 AM, he/she stated he/she was not provided anything to eat prior to going to dialysis. During an interview with RI #120 on 04/28/21 at 5:46 AM, in his/her room just prior to his/her being placed on the transport gurney, RI#120 stated he/she had not received anything to eat this morning. During an interview with EI #25, Registered Nurse (RN), on 04/28/21 at 6:56 AM, at the medication cart in the TCU hallway, when questioned about RI #120 not receiving breakfast this…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and review of a facility policy titled, NSG305 Medication Administration: General and [NAME] and Perry's FUNDAMENTALS OF NURSING, the facility failed to ensure a Licensed Practical Nurse (LPN) did not leave an insulin pen on top the medication cart, out of her sight, when she entered a resident's room during medication administration on 3/12/19. This had the potential to affect one of 27 residents who received medications from cart one on the East wing. Findings Include: A review of a facility policy titled . Medication Administration: General with a Revised date of 7/24/18, revealed the following: POLICY . Accepted standards of practice will be followed . A review of [NAME] and Perry's FUNDAMENTALS OF NURSING, NINTH EDITION, with a Copyright of 2017, Chapter 32, page 683, revealed the following: .prepared medications are never left unattended . On 03/12/19 at 11:15 AM, Employee Identifier (EI) #1, a Registered Nurse (RN), was observed preparing medication. EI #1 removed an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and review of a facility policy titled, . Storage and Expiration Dating of Medications ., the facility failed to ensure an opened vial of Influenza Vaccine was marked with the date it was opened and the date to be used by. This deficient practice affected one of two medication rooms observed. Findings include: Review of a facility policy titled, . Storage and Expiration Dating of Medications . with a revision date of 10/31/16, revealed the following: . 5. Once any medication .package is opened .Facility staff should record the date opened on the medication container .5.1 Facility staff may record the calculated expiration date based on date opened on the medication container . On 03/12/19 at 3:07 PM, during the observation of the medication refrigerator on the Rehabilitation Unit, the surveyor observed an open vial of Influenza Vaccine with no open date or expiration date recorded on the medication. On 03/12/19 at 3:20 PM, during an interview with Employee Identifier (EI) #2, (Licensed Practical Nurse) LPN, the surveyor asked was there a date on the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and review of facility policy titled Food and Nutrition Services Use By Dating Guidelines, the facility failed to ensure the following unopened food items in the walk-in refrigerator were discarded after the best before date: thirteen boxes of thickened dairy drink honey consistency with a best before date of 6/2/18; twenty-four boxes of thickened dairy drink honey consistency with a best before date of 12/5/17; thirty-eight boxes of Sysco Imperial thickened dairy drink nectar consistency with a best before date of 12/11/17; and one unopened box of hashbrowns with a best before date of 5/24/18. This deficient had the potential to affect 10 of 10 residents receiving thickened liquids and all residents receiving meals from dietary: Findings include: A review of a facility policy titled, Food and Nutrition Services Use By Dating Guidelines, with a revision date of 12/1/15, revealed: The following is a guide to use when establishing a use by date for food items. * The manufacturer's expiration date, when available, is the use by for unopened items. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview, review of the facility's online reports to the state agency, and review of the facility's policy titled, OPS 300 Abuse Prohibition, the facility failed to ensure allegations of verbal and physical abuse were timely reported to the state agency. This deficient practice involved nine residents (Resident Identifier (RI) #9, RI #42, RI #69, RI #70,RI #161, RI #172, RI #178, RI #229 and RI #230) and five of 12 abuse allegations reviewed. Findings include: The facility policy titled, OPS 300 Abuse Prohibition, with a revision date of 11/28/2017, revealed the following: . PROCESS . 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED (Center Executive Director) or designee will perform the following. 6.2 Report allegations involving abuse (physical, verbal, . mental) not later than two hours after the allegation is made . 1) Review of the facility's online report to the state agency revealed an allegation of verbal abuse was reported to EI #11, Social Services, by RI #9's spouse. RI #9's spouse alleged the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and interview, the facility failed to ensure a Significant Change Minimum Data Set (MDS) was completed within fourteen days when Resident Identifier (RI) #10 elected to receive Hospice services. This affected one of six residents reviewed for Hospice. Findings include: RI #10 was admitted to the facility on [DATE]. RI #10's Physician's Orders dated 7/1/18 documented . admitted to . Hospice on 5/15/17 for heart disease . RI #10's medical record revealed a Significant Change MDS was completed on 9/28/17. On 7/12/18 at 6:20 PM, an interview was completed with Employee Identifier (EI) #13, the MDS Coordinator. EI #13 stated RI #10 was admitted to Hospice on 5/15/17. EI #13 stated a Significant Change MDS should have been completed when RI #10 was admitted to Hospice. EI #13 further stated the Significant Change MDS was overlooked when RI #10 was admitted to Hospice and was completed and submitted late on 9/28/17.