River Crossing Rehab and Healthcare Center

In the surveyor’s words

From the most serious findings on record at River Crossing Rehab and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF689Feb 3, 2023

  Based on interview and record review, the facility failed to provide care in a manner which prevented or minimized the possibility of accidental injury to one of three sampled residents (Resident#1) by performing transfers inconsistent with the resident's care plan. Staff also failed to report a fall promptly to the nurse, in accordance with the facility's policy, so the resident could be assessed and the incident reported to the physician. Resident #1 sustained a fracture. The census was 98. Review of the facility's policy titled Standards and Guidelines: SG Mechanical Lifts revised 3/27/21, showed it was the standard of the facility to provide a safe environment for residents and staff. […]

• Actual harm, isolatedF692Nov 29, 2022

  Based on observation, interview and record review, the facility failed to maintain acceptable parameters of nutritional status by not providing diets and supplements as ordered and not providing feeding assistance for one resident who experienced a significant weight loss (Resident #7). The sample size was seven. The census was 93. Review of the facility's Standards and Guidelines for Weighing/Weight Loss Protocol, revised on 3/5/21, showed: -Standard: It will be the practice of this facility to implement the following systems regarding weight documentation; -Guidelines: New admits and readmissions will be weighed upon admission, monthly and/or as ordered by the physician; -Staff will be responsible for obtaining weights for these admits and will have this information available for morning… […]

• No harm, potential for more than minimal, widespreadF727Jan 24, 2025

  Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week. The RN working on the hall was serving as the acting Director of Nursing (DON). This deficiency had the potential to affect all residents. The census was 87. Review of the nursing schedules provided by the facility, dated 12/30/24 through 1/23/25, showed: -On 1/3, 1/4, 1/5, 1/6, 1/8, 1/12, 1/13, 1/20 and 1/22, there was no RN; -On 12/31/24, 1/1, 1 /2, 1/7, 1/9, 1/10, 1/11, 1/14, 1/16, 1/17, 1/18, 1/21 and 1/23/25 the only RN scheduled was the DON. During interviews on 1/22/25 at 3:30 P.M. and at 4:13 P.M., the Administrator said the facility missed having RN coverage for four out of 30 days. […]

• No harm, potential for more than minimal, widespreadF812Jan 24, 2025

  Based on observation and interview, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety by failing to label, date and cover food. The facility also failed to ensure kitchen equipment and the floor was kept clean during three of four days of observation, in addition to ensuring that staff followed sanitary conditions when staff used their bare hands to clean out a mixing bowl and failed to ensure the mixing bowl was properly clean before preparing the next pureed dish. These deficient practices had the potential to affect all residents who consumed food from the facility kitchen. The census was 87. 1. Observation on 1/21/25 at 9:35 A.M., 1/22/25 at 4:06 P.M., and 1/23/25 at 11:38 A.M. […]

• No harm, potential for more than minimal, widespreadF730Aug 29, 2023

  Based on interview and record review, the facility failed to ensure 10 out of 10 Certified Nurse Aides (CNAs) received the required annual 12 hour resident care training. The census was 92. Review of the CNA Individual Service Records, showed the following: -CNA V hired 6/1/21, with no identified number of hours of in-service education; -CNA W hired 7/22/22, with no identified number of hours of in-service education; -CNA X hired 6/10/22, with no identified number of hours of in-service education; -CNA Y hired 12/1/21, with no identified number of hours of in-service education; -CNA Z hired 7/22/22, with no identified number of hours of in-service education; -CNA AA hired 4/20/22, with no identified number of hours of in-service education; -CNA BB hired 6/27/22, with no identified number… […]