Rivers Edge Rehabilitation and Healthcare Center

Based on observation, interview, and facility policy review, the facility failed to store food in a sanitary manner. Specifically, the facility failed to ensure refrigerators were clean, and food items were labeled and dated prior to storage in a nutrition refrigerator located at the nurse's station. These failures had the potential to affect all residents who received meals and snacks from the facility. The findings included:Review of facility policy, Monitoring of Cooler/Freezer Temperature, revised 09/01/2024, indicated, It is the policy of this facility to maintain temperatures of coolers and freezers at the appropriate temperature to promote food safety. This policy also addresses refrigerated storage. The policy further indicated, 1. Logs for recording temperatures for each refrigerator or freezer will be posted in a visible location outside the freezer or refrigerator unit. a. Temperatures will be checked and logged at least twice per day by designated personnel. The policy continued, 11. Refrigerated food shall be labeled, dated, and monitored so that is issued by the use by…

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, record review, and facility policy review the facility failed to develop a care plan to address the tracheostomy (an opening in the neck to facilitate breathing) care for 1 (Resident #5) of 1 sampled residents reviewed for respiratory care. The findings included: Review of the facility's undated policy titled, Comprehensive Care Plans, indicated, It is the policy of this facility to develop and implement a comprehensive-person centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. The policy further indicated, 3. The comprehensive care plan will describe, at a minimum, the following: a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. and 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in 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 observation, interview, record review, and facility document and policy review, the facility failed to maintain infection control practices during tracheostomy care for 1 (Resident #5) of 1 resident observed during tracheostomy care. Specifically, staff failed to maintain a sterile field and use proper hand hygiene during tracheostomy care. The findings included: Review of facility policy titled, Tracheostomy Care, dated 12/31/2024, indicated, The facility will ensure that residents who need respiratory care, including tracheostomy care and tracheal suctioning, is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and resident goals and preferences, The Policy further indicated, 6. Procedure with Use of Reusable Cannula: a. Explain the procedure to the resident and screen for privacy. b. Perform hand hygiene per facility policy. c. Put exam gloves on both hands; masks and eye wear should be worn if there is a likelihood of splashes and splattering. d. Suction tracheostomy per facility policy. e. Remove old…

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 facility policy, it was determined the facility failed to store drugs in accordance with currently accepted professional principles for one (1) of two (2) medication carts audited out of a total of four (4) medication carts. Observation on 11/14/2024 at 11:45 AM, of the East Wing Medication cart revealed 17 cards of medications stored beyond the expiration date printed on the package labels for ten (10) of 20 residents (Resident (R) 60 (R60), R54, R69, R42, R61, R39, R86, R32, R36, and R65). The findings include: Review of the facility policies titled Medication Storage version 09/2020 and Medication Administration version 09/2020, were revealed no guidelines specified regarding the expiration dates of medications. Review of the Food and Drug Administration (FDA) website (fda.gov) with the current content date of 10/22/2022 revealed Drug Expiration dates reflect the time period which the product is known to be stable, which means it retains its strength, quality, and purity when it is stored according to its label conditions.…

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 facility policies, the facility failed to ensure staff labeled and dated food items stored in the refrigerator and food items stored in dry storage. This deficient practice has the potential to affect all residents who utilize the facility's dining services. The findings include: Review of the facility's policy, Food Storage, revised 01/23/2018, revealed all incoming foods will have a delivery date and an open date or use by date. When the foods are stored in a container other than the original container, the container will be labeled with the name of the product and an incoming wash and fill date. Further review revealed the first in, first out method will be used in all storage. New product will be stored behind the old product. Review of document labeled, Job Title: Dietary Aide, dated 07/2016 revealed major duties and responsibilities included to prepare food in accordance with sanitary regulations as well as our established policies and procedures; assist in inventorying, rotating, and storing incoming food, supplies, etc. as…

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 facility policy, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections while providing wound care for 2 of 3 residents with wounds of the 23 residents sampled (Resident (R) 12 and R343). Observation of the Treatment Nurse/Licensed Practical Nurse (LPN) 1 performing wound care revealed the nurse did not perform hand hygiene after entering the residents' room before initiating wound care and did not change non-sterile gloves or perform hand hygiene after the gloves were potentially contaminated during the dressing change procedure. The findings include: Review of the facility policy, Handwashing Policy dated 04/2023 stated personnel are required to wash their hands after each direct or indirect resident contact for which handwashing is indicated by acceptable standards of practice. Ongoing review of the policy identified before and after touching wounds. Review…

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 record review and interview the facility failed to provide residents and/or their representatives the right to formulate an advance directive for 1 of 9 sampled residents, R53. Record review revealed R53 did not have evidence of their legally appointed guardian's choice for the resident's advance directive, other than their code status. The findings include: Review of facility policy, Advanced Directives and Do Not Resuscitate (DNR) dated 08/2019 revealed the existence of any advance directive was documented in the resident's medical record by filing a copy of all directives on the chart and by making a progress note. The note should include that advance directive information was given to the resident (or the resident's representative if the resident is unable to comprehend.) Documentation of what advance directives the resident has or that they have none should be noted as well. If a resident wished to make an advance directive, they were assisted with information and with the provision of forms. Review of Resident's #53 Face Sheet revealed the facility admitted 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 observation, interview, record review, and facility policy review, it was determined the facility failed to ensure drugs or biologicals were stored in accordance with State and Federal laws. Observations revealed one (1) of four (4) medication carts was unlocked and unsupervised. Additionally, observations revealed an opened and unlabled container of insulin available for use in the refrigerator in one (1) of four (4) medication refrigerators. Furthermore, record review revealed the facility failed to routinely perform glucometer testing as recommended by the manufacturer on four (4) of four (4) medication cart glucometers. The findings include: 1. Review of facility policy Medication Storage, revised 11/01/17, revealed Controlled substances were stored under double lock and the medication cart was locked at all times, when not under the direct physical supevision of a licensed nure or medication aide. Observation of the South Hall, on 07/12/19 at 1:37 PM, revealed the medication cart was unlocked and unsupervised. Continued observation revealed the South Hall medication…

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 facility policy review it was determined the facility failed to ensure staff labeled and dated food items stored in the refrigerator and freezer. The findings include: Review of the policy Food Storage: Cold, revised May 2014, revealed the center insured all Time/Temperature Control for Safety (TCS), frozen and refrigerated food items, would be appropriately stored in accordance with guidelines of the USDA Food Code. The policy revealed the Food Services Director / Cook(s) insured all food items were stored properly in covered containers, labeled and dated, and arranged in a manner to prevent cross contamination. Review of the Food and Drug Administration (FDA) 2017 Food Code Chapter 3 Subpart 3-501.17 Paragraph (B) revealed except as specified in (E)-(G) of this section, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked at the time the original container is opened in a food establishment and if the food is held for more than twenty-four (24) hours, to…

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 facility policy review, it was determined the facility failed to maintain a safe, sanitary environment for residents. Observations revealed one (1) of four (4) medication carts contained a staff member's personal drinking container. The findings include: Review of facility policy The Infection Prevention and Control Program (IPCP), revised 01/22/18, revealed the facility established and maintained an effective program providing safe, sanitary, and comfortable environment, and attempted to prevent the development and transmission of diseases and infections. Additionally, the facility would provide hand hygiene procedures for staff to follow. Observation, on 07/11/19, at 9:25 AM, revealed a sytrofoam, capped, cup of liquid, in the third drawer of the medication cart on the South Unit. Interview with Licensed Practical Nurse (LPN) #2, on 07/11/19 at 9:25AM, revealed the drink cup in the medication cart was hers. LPN #2 stated she was aware staff should not have personal food and drinks in the medication cart as it was an infection control concern…

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 facility policy review it was determined the facility failed to ensure resident dignity during dining. Staff were observed cleaning tables during meal service while residents were seated at the table eating. The findings include: Review of facility policy, Dignity, version July 2013, revealed residents were given care and treatment in a manner that preserved their dignity, self-esteem, and self-respect. Each resident was valued as an individual. Observation during dining service, on 07/09/19 at 12:12 PM, revealed the Dietary Manager wiped down tables while residents were seated at the table. Interview with the Manager during observation revealed he would not want the table sanitized while he ate because it was rude; however, he was told to wipe them down. He stated sanitizing the table while a resident ate could make the resident feel rushed. Observation of dining, on 07/09/19 at 12:13 PM, revealed the Interim Director of Nursing (DON) removed soiled plates and sanitized tables during the meal. Further observation, on 07/09/19 at 12:20 PM,…

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, record review, and facility policy review it was determined the facility failed to ensure the environment was free from accident hazards on one (1) of four (4) nursing units. The North Hall housekeeping closet was unlocked and unsupervised and contained chemicals. The findings include: Review of the Healthcare Services Group Environmental Services Chemical Use/Dilution and Hazards In-service Training revealed staff must follow guidelines in order to help prevent accidents from occurring. The training revealed the door to the janitor's closet must be locked if staff left chemicals inside. Observation on the North Hall, on 07/09/19 at 10:16 AM, revealed the housekeeping closet was unlocked and unattended. Further observation with the Environmental Services Director revealed the following cleaning chemicals stored in the closet: five (5) two (2) liter bottles of HDQL10 disinfectant cleaner, ten (10) two (2) liter bottles of Halt disinfectant cleaner (including one (1) bottle with no cap), two (2) two (2) liter bottles of Tribase multi-purpose cleaner,…

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, record review, and facility policy review it was determined the facility failed to ensure twelve (12) hours of annual in-service training was completed for one (1) of five (5) Certified Nurse Assistants (CNA), CNA #7 The findings include: Review of the policy Inservice Training, revised 09/19/11, revealed in-service education was a necessary basis for providing residents with the best possible care. Further review revealed Nursing Assistants were required to attend at least twelve (12) hours of training per year and it was the responsibility of the Staff Development Coordinator/Designee to offer training programs during all three (3) shifts for staff convenience. The policy revealed the facility would post in-service hours accumulated per quarter for each Nursing Assistant in order to keep facility and staff current with the requirement, and mandatory in-services included Care for Residents with Dementia. Review of the facility's annual In-Service Training Records revealed CNA #7 did not attend 12 hours of training per year. Interview with the Staff Development…

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.