Rivercrest Long Term Care

In the surveyor’s words

From the most serious findings on record at Rivercrest Long Term Care, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF656Nov 14, 2024

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was assessed by nursing as being at high risk for falls, and whose comprehensive plan of care indicated the call bell was to be within his/her reach when he/she was in his/her room, the Facility failed to ensure staff consistently implemented and followed this intervention, when on 10/15/24, Certified Nurse Aide (CNA) #1 left Resident #1 alone in his/her room without a call bell within reach, Resident #1 fell , later complained of pain, and was diagnosed several days later with a fractured finger. […]

• No harm, potential for more than minimal, isolatedF689Sep 5, 2024

  Based on interview and record review the facility failed to ensure fall interventions were implemented for one Resident (#20) out of a total sample of 12 residents. Specifically, for Resident #20 the facility failed to ensure he/she was wearing non-skid socks and had a bed alarm in place, as indicated in the falls plan of care. Findings include: The facility policy titled Fall Prevention and Management, dated 11/2/18, indicated the following: -The Center assesses each resident for his or her risk for falls, designs a plan of care, and implements procedures to minimize falls and/or injury. B. Prevention. 1. General safety precautions and interventions may include: e. Promoting resident use of non-slip footwear/proper shoes when ambulating. 3. […]

• No harm, potential for more than minimal, isolatedF761Sep 27, 2023

  Based on observation, record review and interview the facility failed to ensure medications were properly labeled, topical medications were stored separately from oral medications in one of one medication carts and eye drops were properly labeled in one out of one medication rooms observed. Findings include: Review of the facility policy titled Medication Administration General Guidelines, not dated, indicated the following: *Do not store treatment preparations in the medication cart. *Do not pre-pour medications. Once medications are poured for administration, they are not to be stored in the medication cart. 1. On 9/26/23, at 2:00 P.M., the surveyor observed a medication cup in the top drawer of a medication cart containing 6 pills. The pills were not labeled. […]

• No harm, potential for more than minimal, isolatedF812Sep 27, 2023

  Based on observation and interview, the facility failed to perform hand hygiene to prevent cross contamination during observations of the breakfast meal. Findings include: During observations of breakfast service on 9/27/23 at 8:08 A.M. the cook was wearing gloves which he contaminated by touching a thermometer while taking the temperatures of the food items, and by touching the tops of food covers. With the same contaminated gloved hands the cook opened a package of bread and placed four slices of bread in the toaster. The cook then began plating foods with the same contaminated gloved hands touching utensils for items such as hot cereal or eggs, and with the same contaminated gloved hands, picked up ready to eat pieces of toast and scones to be served to the residents. […]

• No harm, potential for more than minimal, isolatedF842Sep 27, 2023

  Based on record review and interview the facility failed to accurately transcribe a physician's order related to the treatment of a pressure ulcer for one Resident (#7) out of a total of 12 sampled Residents. Findings include: Resident #7 was admitted to the facility in August 2021 with diagnoses including peripheral venous insufficiency and glaucoma. Review of his/her Minimum Data Set assessment dated [DATE] indicated Resident #7 scored 15 out of a possible 15 on the Brief Interview for Mental Status Exam indicating he/she is cognitively intact and requires assistance with ambulation, transfers and personal hygiene. Review of the clinical record indicated Resident #7 had developed a pressure ulcer on his/her sacrum on 8/13/23 measuring 1 centimeter (CM) X .3 CM X .4 CM. […]