Riverside Nursing Centre

In the surveyor’s words

From the most serious findings on record at Riverside Nursing Centre, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 23, 2022

  This citation pertains to intake MI00- 4 Past non-compliance was accepted for this citation. Plan identified below. Based on observation, interview, and record review the facility failed to prevent the elopement of 1 of 3 residents reviewed for elopement (Resident #102) from a total of 3 sampled residents, resulting in an Immediate Jeopardy when (Resident #102) who had been assessed as an elopement risk and was observed attempting to exit the facility, eloped from the facility, unbeknownst to staff, on 06/10/22 at 7:00 PM and was brought back to the facility when a visitor notified facility staff and made them aware that the resident had eloped. […]

• Immediate jeopardy, isolatedF678Oct 29, 2021

  Based on interview and record review, the facility failed to immediately initiate CPR (cardiopulmonary resuscitation) for one pulseless resident (Resident #129) and failed to verify a code status and then initiate CPR for another pulseless resident (Resident #336), resulting in an immediate jeopardy when beginning on [DATE], the facility failed to initiate CPR for 2 residents who were found without a pulse and who were documented to be full code status. This deficient practice led to the death of 2 residents and placed all residents who were full code status at risk for not receiving CPR, if needed to sustain life. Findings: Resident #129 (R129) Review of a facility Face Sheet reflected R129 admitted to the facility on [DATE]. […]

• Immediate jeopardy, isolatedF686Oct 29, 2021

  This citation pertains to intake # MI00- 3, #MI00- 7, MI00- 9 Based on interview and record review, the facility failed to assess, monitor, and prevent a pressure wound for one resident (Resident #29), resulting in an Immediate Jeopardy when beginning on 08/07/21, the facility failed to prevent a stage 4 pressure wound for Resident #29. This deficient practice led to Resident #29 being found unresponsive, in septic shock, requiring emergency medical intervention. Findings: Resident #29 (R29) Review of a Face Sheet revealed R29 was an [AGE] year-old male, originally admitted on [DATE], with pertinent diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• Immediate jeopardy, isolatedF726Oct 29, 2021

  Based on observations, interviews, and record reviews, the facility failed to monitor and assess for changes in condition for 2 residents (Resident #8 and Resident #26), resulting in an Immediate Jeopardy beginning on 9/17/21 when Resident #26 was hospitalized , and no assessments or physician notifications were documented; and on 10/26/21 Resident #8 was sent to the hospital after staff failed to competently assess, identify and report a change in condition to the physician. This deficient practice resulted in potentially avoidable hospitalization s and has the high likelihood to cause serious harm, injury and death for any residents who may experience a change in condition. […]

• Actual harm, widespreadF867Oct 29, 2021

  Based on observation, interview and record review, the facility failed to ensure its Quality Assessment Process Improvement (QAPI) committee addressed known, self-identified deficiencies meaningfully and effectively, resulting in repeated failings related to the delivery of care and services at the facility that caused serious harm, serious injury and death and has the potential to impact all residents at the facility. Findings: Review of a facility policy QAPI Policy/Procedure last reviewed ,d+[DATE] reflected Each facility will ensure development of a plan that describes the process for conducting QAPI activities, such as identifying and correcting quality deficiencies as well as opportunities for improvement, which will lead to improvement in the lives of their residents, through… […]