Riverside

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility did not ensure that all residents are clinically appropriate to self-administer medications for 1 of 25 sampled residents (R49).R49 was observed to have a cup of medications left on her bedside table for her to take independently. R49 does not have an assessment for self-administration of medications indicating that she is safe to administer medications independently.Evidenced by:The facility policy titled, Self-Administration of Medication states, in part, Facility, in conjunction with the interdisciplinary care team, should assess and determine with respect to each resident whether self-administration of medications is safe and appropriate .to ensure safe and appropriate self administration, facility should educate residents to ensure that resident is able to: a) state the name, dose, strength, frequency, time, and purpose for use of his/her medications; b) understand the possible side effects of his/her medications and the he/she should notify…

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 interview and record review, the facility did not immediately notify and consult with the resident's physician when a change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 25 sampled residents (R94). R94 was sent to the ED (Emergency Department) with a change in condition. The facility did not consult with PA E (Physician Assistant) or any provider regarding R94's abnormal lab results. As evidenced by The facility policy, Change of Condition Notification, updated 1/2026, documents, in part, as follows: Purpose: Notification of a provider and family/POA (Power of Attorney) of changes in a resident's condition or health status.Procedure for Provider NotificationBetween the hours of 8:00 AM to 5:00 PM, 7 days a week, attending provider or on-call provider is to be notified of all condition or health status changes.Between the hours of 5:00 PM - 8:00 AM…

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 and record review, the facility did not recognize, evaluate and address the nutritional and hydration needs of 1 of 3 Residents (R50) to reduce the risk of continued weight loss. R50 did not have appropriate interventions put into place to prevent continued weight loss. R50 had an unintentional weight loss of 8.4 pounds/5.77% over 1 month, indicating a severe weight loss. This is evidenced by: Facility policy titled, Identification of Residents at Nutritional Risk, undated, states in part, Policy: Nutrition risk is determined by the presence of characteristics that are associated with an increased likelihood of poor nutritional status. This includes various non-acute or chronic diseases and conditions, unintended weight change, inadequate or inappropriate food/fluid intake, dependence, disability. Procedure: A. Special nutritional needs will be identified by the following criteria: 1. Weight status; unplanned loss or gain a. >5% WT (weight) change in 30 days. 2. Oral/nutrition intake; food: a. Leaves 25% or more at most meals. Facility policy titled, Immediate…

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, the facility did not ensure that all drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This affected 2 of 3 medication carts.Surveyor observed R2's latanoprost eye drops on the medication cart with no open date during medication storage task.Surveyor observed R47's brimonidine eye drops on the medication cart with no open date during medication storage task.Evidenced by:The facility policy entitled Medication Administration, dated 1/2026, states, in part: . Purpose: The following guidelines have been established for the staff to assure the safe administration of all medications, without jeopardizing the health and safety of all residents.Procedure: Medication therapy at Riverside is administered only in accordance with written orders of the resident's attending physician or designee, consulting physicians or Riverside's Medical Director. Telephone orders may be obtained from these physicians 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility did not ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 13 resident (R6) reviewed for hospice. R6 was receiving hospice services, and the facility failed to obtain hospice documentation. Evidenced by: The facility policy titled Hospice Plan of Care, dated 7/1/96, with last review date of 1/2026, states, in part: Purpose: Hospice Staff and the nursing home staff will establish one individualized Plan of Care for the Hospice resident/family in the nursing home setting. The Plan of Care will be developed by both staff - Hospice and nursing home. Procedure:. 1. Nursing home resident becomes Hospice. a. Hospice will meet with family and resident for admission assessment and collaborate with nursing home staff. R6 was admitted to the facility on [DATE] with diagnoses that include, in part: Acute kidney failure, Type 2 diabetes mellitus, and Chronic Obstructive Pulmonary Disease. R6's most recent MDS…

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, the facility did not ensure that 4 of 6 residents (R) reviewed for pressure injuries (PI) (R58, R89, R9, and R28) received care consistent with professional standards of practice to prevent the development of a new pressure injury and promote healing of existing PIs. R58 was admitted with multiple PIs and was at risk for PI development. R58 developed an unstageable PI. The facility did not reposition R58 for several hours. R89 was at risk for PI development. The facility failed to evaluate the effectiveness of current interventions R89 had in place. The facility did not reposition R89 for several hours and did not off-load heels and coccyx. R9 and R28 have existing PIs. R9 and R28 were not repositioned to promote healing of existing PIs or prevent pressure injuries from developing. Findings include: Example 1 R58 was admitted to facility on 01/30/24 with diagnoses which included in part: hypertension, hyponatremia, pressure injury to the right ankle stage 3,…

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, the facility did not prepare, distribute, and serve food in accordance with professional standards for food service safety. Staff touched ready to eat foods with contaminated gloves when preparing and serving toast to two residents (R66 and R57). Staff carried uncovered food trays in the hallway for R62, R393, R43, R20, R42, R392 and R73. Findings include: Example 1 Facility policy and procedure entitled, Bare Hand Contact with Food and Use of Plastic Gloves, stated in part, .3. Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation. 4. Hands are to be washed when entering the kitchen and before putting on the single-use gloves (before beginning to work with food) 6. Gloves are just like hands. They…

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, the facility did not 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. During the 4-day survey Surveyors had multiple observations of staff not following the Centers for Disease Control (CDC) guidance for Personal Protective Equipment (PPE) use during a COVID-19 outbreak. This had the potential to affect all 18 residents residing on the dementia unit. Surveyor observed staff not performing hand hygiene after changing soiled gloves during cares for R64. Findings include: According to CDC Infection Control Guidance: SARS-CoV-2 [COVID-19] last updated 06/24/24, in reference to use of masks or respirators, .If they are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE) (e.g., NIOSH Approved particulate respirators with N95…

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, the facility did not maintain confidentiality of resident medical record information for 12 of 12 sampled and supplemental residents reviewed. Surveyor observed resident (R79, R142, R83, R33, R45, R54, R15, R20, R73 and R39) dietary information on index cards in plastic upright holders on tables in the [NAME] dining room. The resident information was easily read by the Surveyor when passing by the tables in the dining room. During the three-day survey, Surveyors had three observations of computer screens left open and unattended on medication carts with resident (R) identifiable information visible. (R23, R1.) This is evidenced by: Example 1 Surveyor requested and reviewed the facility policy titled HIPPA Privacy Rule dated December 2019. The policy in part reads: ~Employees only have the right to see and read residents' confidential/health information on a need to know basis in order to perform their duties. ~Medical charts and confidential/health information…

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 interview and record review, the facility did not ensure each residents' drug regimen was free of unnecessary medications for 1 (R23) of 3 sampled residents reviewed for unnecessary medications related to monitoring of prophylactic antibiotic use. R23 has been on a prophylactic antibiotic for an excessive duration without adequate assessments/monitoring for continued use. This is evidenced by: R23 was admitted to the facility on [DATE] and has diagnoses that include, in part: Alzheimer's disease, dementia and history of recurrent urinary tract infections (UTI). On 08/08/23, at 10:00 AM, Surveyor reviewed R23's Electronic Health Record (EHR). Review of EHR shows R23 has a physician's order for cephalexin capsule 250 mg with instructions to give 250 mg (1 capsule) daily for prophylaxis related to prevention of UTI with start date of 05/27/21. Review of nurses' notes in EHR shows that facility nurses are not documenting or monitoring R23's ordered antibiotic. Review of care plan for R23 shows that there is…

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 and interview, the facility did not ensure all drugs and biologicals were stored in locked compartments and did not ensure only authorized personnel had access to the keys. This occurred for 1 of 6 medication carts observed. During the three-day survey, observations were made of medication carts left unlocked with the keys on top of the cart when unattended and out of view of staff. One observation was made of resident medications left on top of the medication cart when the cart was unattended and out of view of staff. Findings include: Example 1 On 08/08/23 at 7:32 AM, Surveyor observed a medication cart on the 400 unit unattended in the hallway. The cart was unlocked, and the nurse keys were on top of the cart. There was a tube of Diclofenac gel and a bottle of refresh artificial tears labeled with a resident's name sitting on top of the unattended cart. At 7:40 AM, Surveyor observed Nurse Tech (NT) F return to the medication cart and place the medications back in a drawer on the cart. NT F began preparing medications for another resident. On 08/08/23 at 8:17…

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, staff did not perform hand hygiene when warranted during cares for 3 (R79, R58, R67) of 7 residents observed for cares. Certified Nursing Assistants (CNA) I and J did not perform hand hygiene when warranted during R79's morning cares. CNA D did not perform hand hygiene before putting on gloves to empty a catheter for R67. This is evidenced by: Surveyor requested and received the facility policy titled Standard Precautions with most recent date of 4/26/23. The policy in part reads: Purpose: Standard precautions are designed to reduce the risk of transmission of microorganisms from both recognized and unrecognized sources of infection and are to be used to care for all residents regardless of diagnosis or presumed infection status. Hand Hygiene: Employees must wash their hands for at least 20 seconds .under the following conditions: ~After contact with resident mucous membranes and body fluids or excretions. ~After handling soiled or used linens . ~After removing gloves. Example 1 On 8/08/23 at 8:06 AM, Surveyor observed CNA I and CNA…

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.