River Valley Health and Rehabilitation Center LLC

In the surveyor’s words

From the most serious findings on record at River Valley Health and Rehabilitation Center LLC, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jan 27, 2025

  Based on interview and document review the facility failed to comprehensively assess proper full body mechanical lift sling type and size according to manufacturer recommendations to ensure safety for 1 of 1 residents (R1). This resulted in immediate jeopardy (IJ) for R1 who had a history of behaviors during lift transfers, fell from the lift and suffered a shoulder fracture. The immediate jeopardy began on 1/19/25, when staff used a hygiene (toileting) sling that was too large causing R1 to experience pain resulted in behaviors and fell through the lift sling to the floor. The administrator, director of nursing, corporate nurse, and regional director of operations were notified of the IJ at 5:00 p.m. on 1/27/25. […]

• No harm, potential for more than minimal, widespreadF727May 13, 2025

  Based on interview and document review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of eight consecutive hours per day for four of 30 days reviewed for RN coverage. This had the potential to affect all 35 residents residing at the facility. Findings include: Review of the nursing staff schedules from 4/13/25-5/13/25, identified there was no RN that worked for a minimum of eight hours per day. During an interview on 5/13/25 at 12:35 p.m., scheduling coordinator (SC)-A stated the facility was supposed to have an RN scheduled eight hours per day. It had been difficult lately, but she tried her best to fill the gaps utilizing facility staff, corporate agency staff, and outside staffing agencies. There had been gaps with RN coverage on the weekends recently. […]

• No harm, potential for more than minimal, widespreadF727Feb 5, 2025

  Based on interview and record review, the facility failed to ensure a registered nurse (RN) was on duty a minimum of 8 consecutive hours per day for 5 of 7 days reviewed. This had the potential to affect all 32 residents living in the facility. Findings include: Review of the nursing staff schedules and time punches for 8/29/24, 9/8/24, 9/28/24, 9/29/24 and 1/11/25 identified there was no evidence an RN had worked for a minimum of 8 hours per day. Interview on 2/5/25 at 11:23 a.m., with RN-B identified the facility was short on RN coverage and either she or the director of nursing (DON) would attempt to cover those shifts as charge nurse or floor nurse, however some days no replacements could be assigned. She confirmed for the above dates, there was no RN working. […]

• No harm, potential for more than minimal, widespreadF851Feb 5, 2025

  Based on interview and document review, the facility failed to submit accurate staffing data based on payroll and other verifiable, auditable data during 1 of 1 quarter reviewed (Quarter 4), to the Centers for Medicare and Medicaid Services (CMS), according to specifications established by CMS. This had the potential to affect all 32 residents living in the facility. Findings include: Review of the July 2024, Electronic Staffing Data Submission Payroll-Based Journal (PBJ) Frequently Asked Questions, located at https://www.cms.gov/medicare/quality-initiatives-patient-assessment-instruments/nursinghomequalityinits/downloads/pbj-policy-manual-faq-11-19-2018.pdf, identified reporting shall be based on the employee ' s primary role. […]

• No harm, potential for more than minimal, widespreadF867Feb 7, 2024

  Based on interview and document review, the facility failed to have evidence of a Performance Improvement Project (PIP) which focused on high risk or problem-prone areas identified thorough and appropriate data collection and analysis and evaluation of the identified concern(s) during QAPI. This had the potential to affect all 35 residents. Interview on 2/7/24 at 1:56 p.m., with registered nurse (RN)-A identified she has heard of a PIP before, and thinks maybe some staff are watching for urinary tract infections, but was unsure what the PIP was or what her role in the PIP project could be. RN-A thought if there was a PIP there may be signage in the staff breakroom. RN-A received online general QAPI training but had not received training specific for the facilities QAPI plan. […]