Riverview Post Acute

Based on policy review, employee list review, and interview, the facility failed to offer COVID-19 vaccinations to employees after February 2025, which had the potential to affect 76 of 76 residents that were residing in the facility. The findings include: Review of the facility policy titled, Employee Immunization and Vaccination Status, dated January 2024, revealed .Employees are offered or provided with immunization/vaccinations per state or local agency policies/regulations. Review of the employee list dated 1/14/2026 revealed 45 employees were hired from 2/2025 to 1/14/2026. The facility was unable to provide documentation that employees hired from 2/2025 to 1/14/2026 were offered the COVID vaccine. During an interview on 1/14/2026 at 8:30 AM, the Infection Control Preventionist (ICP) was asked if the COVID vaccine was offered to staff. The ICP stated, We do not offer the COVID vaccine to employees. We only educate them if a new vaccine is available .the vaccine was no longer offered to staff beginning in February 2025 .

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on facility policy review, medical record review, and interview, the facility failed to provide Advance Beneficiary Notice of Medicare Non-Coverage for 3 of 3 (Resident #20, #82, and #83) sampled residents reviewed for Advanced Beneficiary Notice. The findings include: 1. Review of the facility policy titled, Medicare Advance Beneficiary and Medicare Non-Coverage Notices, dated 9/2024, revealed .A resident (who is a Medicare beneficiary) is informed in advance and in writing when Medicare payment denial or change in coverage is likely.Written notices of the likelihood of Medicare payment denial are provided to the resident/beneficiary.as soon as the facility makes the assessment that Medicare payment certainly or probably will not be made and before the item of service is furnished.far enough in advance of an event.so that the beneficiary can make a rational, informed decision without undue pressure. 2. Review of the medical record revealed Resident #20 was admitted to the facility on [DATE], with…

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 facility policy review, medical record review, observation, and interview, the facility failed to ensure 2 of 4 (Licensed Practical Nurse (LPN) B and LPN C) nurses administered medications with a medication error rate of less than 5 percent (%). A total of 2 errors were observed out of 25 opportunities, resulting in a medication error rate of 8%. The findings include: 1. Review of facility policy titled, Medication Administration, .Residents shall receive medications according to safe standards of practice.Medications are prepared and administered according to the following: right medication, right dose, right time, right person, right route, right position, right texture and right documentation.Prior to administration, the medication and dosage schedule on the resident's MAR (medication administration record) is compared with the medication label. If the label and MAR are different, stop and compare to physician's orders. Seek further clarification as needed. 2. Review of the medical record revealed…

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 facility policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured when 1 of 3 (Licensed Practical Nurse (LPN) B left a medication cart unsecured and unattended. The findings include: Review of the facility policy titled, Storage of Medications, dated 11/2020, revealed .The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Drugs and biologicals used in the facility are stored in locked compartments.Only persons authorized to prepare and administer medications have access to locked medications.Compartment (including, but not limited to, drawers, cabinets, rooms, refrigerators, carts, and boxes) containing drugs and biologicals are locked when not in use. Unlocked medication carts are not left unattended. Review of the facility policy titled, Medication Administration, dated 7/1/2025, revealed .The medication cart should always be locked when not attended by nurse. During an observation and interview on the 600 Hall on 1/13/2026 at 1:18 PM, LPN B walked away from the 600 Hall F/Bottom…

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 policy review, observation and interview, 2 of 8 staff members (Certified Nursing Assistant (CNA) #1 and #2) failed to distribute and serve food in a sanitary manner during dining when they did not perform hand hygiene between serving residents and after touching contaminated surfaces. The findings include: Review of the facility's policy titled, Hand Hygiene Policy, revised 4/14/2020, revealed .Hand washing/hand hygiene is generally considered the most important single procedure for preventing healthcare-associated infections .If hands are not visibly soiled, use an alcohol-based hand rub . Review of the facility's policy titled, Infection Prevention and Control Program, revised 4/10/2021, revealed .Hand Hygiene Protocol .All staff shall perform hand hygien [hygiene] when coming on duty, between resident contacts, after handling contaminated objects, after PPE [Personal Protective Equipment: isolation gowns, gloves, masks, shields] removal .Staff shall perform hand hygiene before and after performing resident care procedures . Observation outside of the resident's…

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 policy review, observation and interview, the facility failed to maintain or enhance resident dignity and respect when 1 of 7 staff members (Certified Nurse Assistant (CNA) #3) was standing over a resident (Resident #14) to assist with their meal. The findings include: Review of the facility's policy titled, Promoting/Maintaining Resident Dignity During Mealtimes, with an effective date of 6/16/2021, revealed that staff will be seated to assist with meals. Observation in the resident's room on 6/15/2021 at 8:12 AM, revealed CNA #3 was standing to assist Resident #14 with their meal. During an interview on 6/16/2021 at 5:48 PM, the Director of Nursing (DON) confirmed staff should be seated to assist residents with their meals.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, observation, and interview, the facility failed to ensure medications were properly stored and secured in 1 of 6 medication storage areas (A Hall Medication Cart) when a medication cart was unlocked and unattended and unattended medications were on top of the cart. The finding's include: Review of the facility's policy titled, Medication Storage, updated 6/2012, revealed .It is the responsibility of the facility to keep the medication cart locked and secure at all times when not in use .Medications .CANNOT be stored on top of the medication cart. All safety measures must be taken to protect the residents from accessing medications and other objects that could potentially harm the resident or others . Observation of the A Hall Medication Cart outside of room [ROOM NUMBER] on 6/15/2021 at 8:55 AM, revealed an unlocked and unattended medication cart. Observation of the A Hall Medication Cart outside of room [ROOM NUMBER] on 6/15/2021 at 9:03 AM, revealed umeclidinium-vilanterol aerosol…

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 policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when staff failed to ensure 1 of 1 newly admitted residents (Resident #202) was placed in isolation on admission, when 1 of 8 staff members (Certified Nursing Assistant #1) failed to properly dispose of disposable Personal Protective Equipment, and when 2 of 2 isolation rooms (Isolation room [ROOM NUMBER] and Isolation room [ROOM NUMBER]) had trash overflowing and was spilling onto the floor. The findings include: Review of the facility's undated policy titled, New Admissions/LOA [Leave of Absence] Instructions, revealed .New admissions .will be placed in yellow zone [isolation] for at least 14 days to continue to monitor for s/s [signs and symptoms] of COVID-19. However if a resident has been fully vaccinated for COVID-19 .they do not have to be placed in isolation on the yellow zone . Review of the medical record, revealed Resident #202…

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 policy review, medical record review, observation, and interview, the facility failed to notify the physician for 2 of 2 (Resident #22 and #53) sampled residents reviewed for pressure ulcers and bowel function. The findings include: 1. Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Demyelinating Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, Pressure Ulcer Left Buttock, and Retention of Urine. The Admit/Readmit Screener dated 4/30/19 documented, .Right buttock .Pressure .Left buttock .Pressure . The physician's orders dated 5/8/19 documented, .Barrier cream to BIL [bilateral] buttocks r/t [related to] pressure injury every shift for pressure injury .Order Date .4/30/2019 . Observations in Resident #22's room on 5/19/19 at 10:39 AM, revealed a half dollar size open area to her right buttock. Thyere was no documentation in the medical record th physician had been notified of this wound. Telephone interview with the Wound Care Doctor 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview the facility failed to administer treatment to restore normal bowel function for 1 of 1 (Resident #53) sampled residents reviewed for bowel function. The findings include: The facility's Bowel Policy . dated 12/30/11 documented, .beginning of the 3rd day of no B.M [bowel movement] Administer miralax 17 gram, mix with prune juice or beverage of choice, wait 4 hours, if no bowel movement repeat one time, wait 2 hours. Apply one ducalox [Dulcolax] sup [suppository] rectally, wait 2 hours. Administer fleets enema one rectally, wait 2 hours . Medical record review revealed Resident #53 was admitted to the facility on [DATE] with diagnoses of Heart Failure, Neuromuscular Dysfunction, Diabetic Mellitus, Venous Insufficiency, Chronic Pain, and Constipation. The Care Plan dated 1/29/19 documented, .Problem .I have the potential for constipation r/t [related to] Decreased mobility, Pain med [medication] use .Interventions .receive laxatives and stool softeners…

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 policy review, medical record review, observation, and interview, the facility failed to identify and assess 1 of 3 (Resident #22) sampled residents reviewed for pressure ulcers. The findings include: The facility's Wound Care policy dated 12/1/05 documented, .Document site, size, description of site, condition of skin around site, treatment started and who the pressure ulcer was reported to . The Facility's Standing Orders policy dated 5/30/18 documented, .Barrier Cream or Calmoseptine for reddened or excoriated skin .follow skin protocol for stg [stage] 1-4 pressure ulcers . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Demyelinating Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, Pressure Ulcer Left Buttock and Retention of Urine. The Admit/Readmit Screener dated 4/30/19 documented, .Right buttock .Pressure .Left buttock .Pressure . The physician's orders dated 5/8/19 documented, .Barrier cream to BIL [bilateral] buttocks r/t…

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, observation, and interview, the facility failed to follow interventions for the prevention of accidents for 1 of 2 (Resident #7) sampled residents reviewed for accidents. The findings include: Medical record review revealed Resident #7 was admitted to the facility on [DATE] with diagnoses of Immune Thrombocytopenic Purpura, Visual Loss Both Eyes, Macular Degeneration, Hearing Loss, Dementia, Hypertension, Diabetes, Depression, Anxiety, Anemia, Acquired Absence of Right Leg Above Knee, and Osteoporosis. Review of the quarterly Minimum Data Set, dated [DATE] revealed a Brief Interview for Mental Status score of 13, which indicated no cognitive impairment, no behaviors, and was totally dependent on staff for transfers. The Care Plan dated 11/13/17, and last reviewed 4/28/19, documented, .risk for weakness, fatigue, malaise, lethargy r/t [related to] Anemia .Interventions .If I experience any .bruising, or excessive bleeding alert my CN [Charge Nurse]/MD [Medical Doctor] .have…

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 policy review, medical record review, observation, and interview, the facility failed to ensure practices to prevent the potential spread of infection were maintained when 1 of 1 (Certified Nursing Assistant (CNA) #1) staff member failed to perform hand hygiene during indwelling catheter care. The findings include: The facility's undated Standard and Precaution Policy documented, .Hand Hygiene .before applying and after removing personal protective equipment, including gloves .before and after handling clean or soiled .linens . Medical record review revealed Resident #22 was admitted to the facility on [DATE] with diagnoses of Demyelinating Disease, Heart Failure, Chronic Obstructive Pulmonary Disease, Pressure Ulcer Left Buttock and Retention of Urine. The Physician's Orders dated 4/30/19 documented, .Foley cath [catheter] care q [every] shift .as needed . Observations in Resident #22's room on 5/21/19 at 9:01 AM, revealed CNA #1 gathered supplies, donned gloves, and completed indwelling catheter 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.