River City Nursing And Rehab Center

Based on kitchen food service observations, staff interviews, facility document review, and facility policy and procedure review, the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness, with the potential to affect all residents who consumed foods from the facility, by failing to label and date mark an open beverage found in the 400 hallways nourishment room. Additionally observed were open bundles of bread in the cook area storage bin. Food handling and sanitation are important in health care settings serving nursing home residents. Unsafe food handling practices represent a potential source of pathogen exposure.The findings include:During an observation of the 400 hallways nourishment room on 2/25/26 at 12:53 PM, an open 1.18-liter bottle of Starbucks Vanilla Latte with no date marking was observed. Licensed Practical Nurse (LPN) L was immediately notified and instructed to remove or properly label the item. (Photographic evidence obtained)On 2/26/26 at 1:02 PM, a re-inspection of the 400 hallways nourishment room…

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, record reviews and interviews, the facility failed to implement interventions identified in the comprehensive care plan for two (Residents #31 and #3) of 32 residents in the total survey sample. Resident #31 had no floor mat at bedside as per the physician's order and her care plan. Resident #3 had no pillow supporting her left elbow as per the physician's order and her care plan. Failing to follow these residents' care plans could result in falls with injuries, worsening of pressure areas, increased pain, and overall functional decline. The findings include:1.A review of Resident #31's medical record revealed that she was admitted to the facility on [DATE]. Her diagnoses included spinal stenosis (narrowing of the spinal column spaces placing pressure on the nerves that travel through it), hemiplegia (paralysis of one vertical side of the body often causing trunk muscle control loss, including limpness or spasticity), polyneuropathy (widespread, simultaneous dysfunction of multiple…

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 and record review, the facility failed to ensure dignity while dining for two (Residents #94 and 54) of two residents reviewed for dignity. The findings include: 1. On 04/24/24 at 8:18 AM, an observation was made of Resident #94 during her breakfast meal. She was lying in bed with her plate uncovered and the plate cloche cover lying on her bed. She was unable to eat her meal without staff assistance. Further observation revealed Certified Nursing Assistant (CNA) D entering the resident's room at 8:43 AM to assist her with eating. CNA D was observed standing over Resident #94 while assisting her with her meal. Resident #94's tray sat uncovered for 25 minutes before she was assisted by staff. A review of Resident #94's medical record revealed an admission date of 07/10/23 and a medical history significant for stroke, right-sided paralysis, difficulty swallowing, and weakness. A review of the Quarterly Minimum Data Set (MDS) assessment, completed on 01/16/24, revealed the resident had a Brief Interview for Mental Status (BIMS) score of one out of 15 possible…

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, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as body weight, by failing to provide nutritional interventions in a timely manner for two (Residents #54 and #94) of two residents reviewed for nutritional status, resulting in significant weight loss. The findings include: 1. During a tour of the facility on 04/23/24 at 8:59 AM, Resident #54 was observed eating her breakfast while lying in bed. She had difficulty holding her spoon while eating her pureed food. A moderate amount of food was present on the cloth clothing protector which was worn over her shirt. She also had a Mighty Shake nutritional supplement on her tray which was untouched. Resident #54 consumed approximately 15% of her meal tray. A review of Resident #54's medical record revealed an admission on [DATE] and a medical history significant for stroke, right-sided paralysis, Parkinson's disease, difficulty swallowing, and weakness. An admission…

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 that all drugs and biologicals were stored in locked compartments with access granted only to authorized personnel for one (Resident #45) of one resident reviewed for medication storage. The findings include: During a tour of the facility on 04/22/24 at 1:00 PM, Resident #45's room was entered and a medication cup containing seven (7) medication tablets was observed sitting unattended on the bedside table. (Photographic evidence obtained) Further observation revealed an individual entering Resident #45's room. An interview was conducted with this individual on 04/22/24 at 1:37 PM. She stated she was Resident #45's private duty aide. She further stated the nurse brought the observed medications into Resident #45's room around breakfast time, and that this was not the first time the nursing staff had left medications for her to administer to Resident #45. When asked, the private duty aide stated she was not a certified medication technician, she was a certified nursing assistant. When asked to clarify…

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, staff interview, and facility policy review, the facility failed to ensure safe and secure storage (including limited access and mechanisms to minimize loss or diversion) of all medications, with the potential of affecting all residents, related to staff not ensuring one (St. [NAME] nursing unit (rooms 300/400) of two treatment carts containing medications was locked when not in use and unattended. The findings include: On 4/10/22 at 12:10 p.m., an observation was made of an unlocked and unattended treatment cart on the St. [NAME] nursing unit (rooms 300/400). The same cart was observed unlocked and unattended at 1:53 p.m. The second drawer was opened, and multiple bags of medications with resident labels were observed. There was no staff observed in the area. (Photographic evidence obtained) On 4/11/22 at 11:15 a.m. and at 4:38 p.m., this same treatment cart on the St. [NAME] nursing unit (rooms 300/400) was observed unlocked and unattended. (Photographic evidence obtained at 4:38 p.m.)…

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 interviews and record review, the facility failed to ensure that each resident had the right to participate in the development and implementation of his or her person-centered plan of care for one (Resident #23) of 42 residents sampled. The findings include: A review of Resident #23's record revealed he was initially admitted on [DATE]. After being transferred to the hospital on 4/6/2022, he was last readmitted on [DATE]. His diagnoses included atherosclerosis of native arteries of extremities with gangrene, acquired absence of left leg above knee, acquired absence of right leg above knee, polyneuropathy, congestive heart failure, malignant neoplasm of the colon, and memory deficit following cerebral infarction. A review of the Progress Notes in the electronic medical record (EMR) revealed that Resident #23 was alert and oriented with some confusion but was able to make his needs known. A review of the Minimum Data Set (MDS) assessment completed on 1/26/2022, Resident #23 scored 9 out of a possible 15…

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, staff and resident interviews, medical record review, and facility policy review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for one (Resident #86) of a sample of 42 residents. The findings include: On 04/10/22 at 12:56 p.m., two bottles of Systane eye drops were observed on Resident #86's bedside table. The resident was asked if she administered the eye drops herself. She stated yes. She stated, I have my family buy them for me because it's a larger bottle and I am able to use it, even with my arthritis. She was asked when she used the eye drops. She stated, I use them when my eyes are itchy and scratchy, and then I don't have to wait for the nurse. She was asked if staff were aware that she had the eye drops on her bedside table. She stated yes. She was asked how long she had kept the eye drops at her bedside. She stated, As long as I've been here. She was asked again whether she kept the eye drops on her bedside table and…

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 and record review, the facility failed to ensure that one (Resident #251) of three residents with an indwelling catheter, from a total of 42 sampled residents, received appropriate care and services to prevent urinary tract infections (UTI). The findings include: On 4/10/22 at 2:35 PM, cloudy urine in a urinary catheter bag dated 1/18/22 was observed. Resident #251 could not recall when it was last changed. During another observation of Resident #251 on 4/12/22 at 12:30 PM, cloudy urine was observed in his urinary catheter bag dated 1/18/22. A review of the clinical record revealed that Resident #251 was admitted to the facility on [DATE] with a primary diagnosis of hydrocephalus. Other diagnoses included presence of urogenital implants. A review of the active physician's orders revealed an order for Suprapubic catheter - change as needed as a whole system with drainage bag French (Fr) 20 balloon 10 ml (milliliters). Suprapubic catheter care: Cleanse stoma with soap and water,…

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, and record reviews, the facility failed to ensure that two (Resident #72 and Resident #43) of 16 residents receiving respiratory care, for a total sample of 42 residents, received oxygen as ordered. The findings include: 1. On 4/10/22 at 1:20 PM, Resident #72's oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained) On 4/12/22 at 9:26 AM, an observation of Resident #72 revealed her oxygen canula was dated 4/11/22 and her oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained) On 4/13/22 at 9:03 AM, Resident #72's oxygen flow rate was set at 3 Liters per minute (L/min). (Photographic evidence obtained) A review of the medical record revealed that Resident #72 was admitted on [DATE]. Her diagnoses included Chronic Obstructive Pulmonary Disease (COPD), unspecified; bilateral; generalized anxiety disorder; and polyneuropathy, unspecified. Active physician's orders included: Oxygen via nasal cannula continuous at 2…

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.