Rivercrest Post Acute

In the surveyor’s words

From the most serious findings on record at Rivercrest Post Acute, in the surveyor’s own words.

• Actual harm, isolatedF658May 11, 2022

  Based on interview and record review it was determined the facility failed to ensure staff adhered to professional standards of care for 1 of 3 sampled residents (#1) reviewed for change in condition. This failure resulted in delayed activation of the emergency medical system while the resident suffered from difficulty breathing. Findings include: Resident 1 was readmitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 12/5/21 by Staff 3 (RN) indicated Resident 1 complained of shortness of breath and requested to be sent to the hospital. […]

• Actual harm, isolatedF684May 11, 2022

  Based on interview and record review it was determined the facility failed to provide necessary care and services related to a resident who complained of difficulty breathing for 1 of 3 sampled residents (#1) reviewed for change in condition. This failure resulted in delayed activation of the emergency medical system (EMS) while the resident suffered from difficulty breathing. Findings include: Resident 1 was readmitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . A Progress Note dated 12/5/21 by Staff 3 (RN) indicated Resident 1 complained of shortness of breath and requested to be sent to the hospital. […]

• Actual harm, isolatedF690May 11, 2022

  Based on interview and record review it was determined the facility failed to provide care and services to prevent a [CONDITION(S)] for 1 of 3 sampled residents (#3) reviewed for urinary catheter care. This failure resulted in Resident 3 being transferred to the hospital due to a [CONDITION(S)] with [CONDITION(S)] (a potentially life-threatening condition related to an infection). Findings include: Resident 3 was admitted to the facility in 2021 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 3's Care Plan included an intervention for staff to monitor, record and report to the physician signs and symptoms of a [CONDITION(S)] including cloudiness, no output and altered mental status. […]

• No harm, potential for more than minimal, widespreadF868Oct 11, 2024

  Based on interview and record review it was determined the facility failed to have the Medical Director attend the Quality Assessment and Assurance and Quality Assurance Performance Improvement (QAA/QAPI) committee meetings. This placed residents at risk for unidentified needs. Findings include: Documentation of QAA/QAPI meeting minutes were requested from 4/2024 through 9/2024 which revealed Staff 23 (Former Medical Director) did not attend any of the QAA/QAPI meetings. On 10/8/24 at 9:59 AM, and on 10/11/24 at 1:51 PM, Staff 1 (Administrator) stated Staff 23 the Former Medical Director refused to attend the QAA/QAPI meetings in person or via skype.

• No harm, potential for more than minimal, patternF565Feb 13, 2026

  Based on observation and interview it was determined the facility failed to provide a private space for resident council meetings for 1 of 1 resident council group reviewed for privacy. This placed residents at risk for a lack of participation in group discussions regarding facility policies, procedures and resident rights. Findings include:On 2/11/26 at 12:35 PM a resident council meeting was held in the facility dining room with state surveyors and eleven residents. The dining room was located next to the therapy gym with only a thin plastic room divider between the two rooms. […]