Riverdell Care Center

Based on observation, interview and record review, facility staff failed to ensure the dish washer machine operated according to manufacturer's instructions in a manner adequate to prevent cross contamination of kitchen wares. The facility census was 46. 1. Review of the facility's Sanitization policy, revised November 2022, showed dishwashing machines are operated according to manufacturer's instructions. General recommendations for low temperature dishwashers (chemical sanitization) are wash temperature of 120 degrees Fahrenheit (F) and final rinse with 50 parts per million (ppm) hypochlorite (chlorine). Review of the facility's Dish Machine - PPM Sanitizer Record Logs for the period of 10/01/24 through 12/12/24 showed staff documented morning and afternoon machine temperatures of 98 degrees F on all days. Observation on 12/10/24 at 10:20 A.M., showed the front of the dish machine contained a label which indicated minimum wash and rinse temperatures of 120 degrees F. Observation on 12/10/24 at 11:06 A.M., showed Dietary Dish Aide M ran a food processor bowl, lid, and blade through…

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 record review, facility staff failed to develop and implement complete policies and procedures for the inspection, testing and maintenance of the facility's water systems to inhibit the growth of waterborne pathogens and reduce the risk of an outbreak of Legionnaire's Disease (LD- a serious type of pneumonia (lung infection) caused by Legionella bacteria, which places all residents of the facility at risk of exposure which could lead to illness. Facility staff failed to use appropriate infection control procedures to prevent the spread of bacteria or other infectious causing contaminants when staff failed to position an indwelling catheter of one resident (Resident #11) out of two sampled residents off the floor. The facility census was 46 1. Review of the Centers for Medicare and Medicaid Services (CMS) Quality, Safety and Oversight (QSO) 17-30, dated 06/02/17 and revised on 07/06/18, showed: The bacterium Legionella can cause a serious type of pneumonia called LD in persons…

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, interviews, and record review, the facility staff failed to propell two residents (Resident #7, and #44) when staff did not use wheelchair footrests. Facility staff failed to provide safe mechanical lift transfers for three residents (Resident #15, #21, and #33), and failed to store hazardous materials in a safe manner in one shower room, one dining room and one storage cabinet. The facility census was 46. 1. The facility did not provide a policy for wheelchair safety. 2. Review of Resident #7's Annual Minimum Data Set (MDS), a federally mandated assessment tool, dated [DATE], showed staff assessed the resident as: -Cognitively intact; -Independent wheelchair; -Diagnosis of cerebrovascular accident, bipolar, schizophrenia, and macular degeneration. Observation on [DATE] at 2:59 P.M., showed Certified Nurse Aid (CNA) E propelled the resident in a wheelchair from the nurses desk to the Physical Therapy room. Observation showed the wheelchair did not contain foot rests and the residents feet…

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 record review, facility staff failed to provide a comfortable and homelike environment for residents, when staff failed to maintain walls, ceilings, and floors. The facility census was 46. 1. Review of the facility's Homelike Environment policy, date February 2021, showed residents are provided with a safe, clean, comfortable and homelike environment and encouraged to use their personal belongings to the extent possible. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting to include a clean, sanitary, and orderly environment. 2. Observation on 12/10/24 at 10:30 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in the tile around the toilet. Observation showed the tiles lifted from the floor. Observation on 12/10/24 at 11:10 A.M., showed resident occupied room [ROOM NUMBER]'s bathroom contained multiple areas of black stains in…

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, facility staff failed to store medications in one out of two medication storage rooms in a safe and effective manner. The facility census was 46. 1. Review of the facility's policy titled Medication Labeling and Storage, dated February 2023, showed if the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items. The nursing staff is responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner. 2. Observation on 12/11/24 at 10:17 A.M., showed the 100 hall medication storage room contained the following: -One bottle of Aspirin 325 milligram (mg) with an expiration date of 09/24; -One bottle of Magnesium Oxide 400 mg with an expiration date of 09/24; -Three bottles of Vitamin D 10 mg with an expiration date of 09/24; -One Diclofenac Sodium topical Gel 100 gram tube with an expiration date of 04/24. During an interview on 12/13/24 at 8:16 A.M., Certified 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, facility staff failed to develop a comprehensive person-centered care plan for eleven residents (Resident #3, #25, #35, #37, #44, #45, #47, #23, #28, #31, #38) to ensure their medical and nursing needs were met. The facility census was 49. 1. Review of the facility's Care Planning - Interdisciplinary Team policy, dated September 2013, showed: -The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team; -The resident, the resident's family and/or the resident's legal representative/guardian or surrogate are encouraged to participate in the development of and revisions to the residents care plan. Review showed it did not contain direction for staff in regard to when the care plan should be updated when the resident's needs changed. 2. Review of Resident #3's Quarterly Minimum Data Set (MDS), a federally mandated assessment tool, dated 9/24/22 showed staff assessed the resident as: -Severe Cognitive…

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 record review, facility staff failed to meet professional standards of quality and practice when they failed to provide consistent documentation in regard to residents' Advance Directives (a written statement of a person's wishes regarding medical treatment, often including a living will, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) for four residents (Resident #3, #7, #30, and #43). Additionally, staff failed to obtain physician orders for dialysis (purification of blood, as a substitute for normal kidney function) for two residents (Resident #27 and #38), failed to follow physician orders for oxygen for one resident (Resident #47) and failed to provide consistent documentation in regard to diet orders for one resident (Resident #31). The facility census was 49. 1. Review of the facility's Do Not Resuscitate Order (DNR), (a type of advance directive in which a person states that healthcare providers should not…

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 record review, facility staff failed to provide appropriate care and services to assist residents with Activities of Daily Living (ADLs) (everyday tasks), for four residents (Resident #33, #35, #37, and #45). The facility census was 49. 1. Review of the facility's Activities of Daily Living (ADLs), Supporting policy, dated [DATE], showed: -Residents will be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out activities of daily living (ADLs); -Resident who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene; -Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming and oral care); -If residents…

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 record review, facility staff failed to ensure the residents' environment remained free of accident hazards when staff failed to properly store environmental hazards in the shower rooms and failed to properly propel seven residents (Resident #1, #23, # 28, #31, #39, #42 and #45) in wheelchairs in a manner to prevent accidents. The facility census was 49. 1. Review of the facility's Safety and Supervision of Residents Policy, dated July 2017, showed the care team shall target interventions to reduce individual risks related to hazards in the environment, including adequate supervision and assistive devices. 2. Observation on 8/9/22 at 11:06 A.M., showed the 100 hall shower room unlocked and unattended. Further observation, showed an open and undated container of skin protectant sat on the back of the toilet. Additional observation, showed an open bottle of cleaner with bleach in an unlocked cabinet, with two unopened bottles, and a razor in an unlocked drawer. During 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 record review, facility staff failed to use hand hygiene and provide perineal care in a manner to reduce the risk of infection for two residents (Resident #19 and #40) and failed to provide wound care in a manner to reduce the risk of infection for one resident (Resident #47). The facility census was 49. 1. Review of the facility's Hand Hygiene Policy, revised August 2019, directed staff to: -Wash hands with soap (antimicrobial or non-antimicrobial) and water for the following situations: -When hands are visibly soiled; -Use an Alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -Before and after direct contact with residents; -Before handling clean or soiled dressings, gauze pads, etc.; -Before moving from a contaminated body site to a clean body site during resident care; -After contact with blood or bodily fluids; -After handling used dressings, contaminated equipment, etc.; -After removing gloves. Review of the facility's Perineal Care…

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.