Riverwalk Village

In the surveyor’s words

From the most serious findings on record at Riverwalk Village, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF838Aug 29, 2022

  Based on record review and interview, the facility failed to comprehensively complete and implement a facility assessment to accurately determine the care and resources needed for resident care. Findings include: Review of the Facility Assessment, dated 2/25/22 and provided with Entrance Conference documents on 8/22/22, indicated it had been reviewed only by the former Administrator. There were an average of 85 residents on the long term care unit, 36 residents on the secured units, and 42 residents on the short-term/rehabilitation unit. The facility employed 35 CNAs at the time of the assessment. The assessment indicated there were mechanical lifts used in the facility and prompted an evaluation of staff in sufficient number to operate the lifts per policy. […]

• No harm, potential for more than minimal, patternF755Oct 30, 2024

  Based on record review and interview, the facility failed to ensure shift-to-shift narcotic count and reconciliation was completed for 6 of 7 medication carts reviewed for medication reconciliation. (Carts HI, [NAME], [NAME], C, D, and Cottage 2) Findings include: 1. During a medication storage observation of the HI medication cart, on 10/25/24 at 11:27 a.m., accompanied by LPN 7, the Narcotic Count Sheet was reviewed and the following dates lacked shift-to-shift count and reconciliation signatures of controlled medications: October 2024- lacked a narcotic card count: 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 8th, 9th, 10th, 11th, and 12th. October 2024- lacked shift-to-shift narcotic reconciliation signatures: 10/2: 6:00 a.m. - 2:00 p.m., 10/5: 6:00 a.m. - 2:00 p.m. and 2:00 p.m. […]

• No harm, potential for more than minimal, patternF880Oct 30, 2024

  Based on observation, interview, and record review, the facility failed to implement enhanced barrier precautions (EBP) during high contact care for 3 of 6 residents reviewed for infection control. (Residents 41, 2, and 79) Findings include: 1. During an observation on 10/23/24 at 11:16 a.m., there was no indication of EBP outside of Resident 41's room. A Resident Matrix document, provided by the facility on 10/23/24, indicated Resident 41 had a Stage III (full-thickness skin loss, exposing fat tissue but not muscle, tendon, or bone) pressure ulcer. During an observation on 10/24/24 at 4:29 p.m., the resident was in bed on a low air loss mattress. There was no indication of EBP outside or inside the resident's room. Resident 41's clinical record was reviewed on 10/25/24 at 10:22 a.m. […]

• No harm, potential for more than minimal, patternF565Oct 10, 2023

  Based on interview and record review, the facility failed to resolve resident council concerns related to long call light wait times and missing clothing items. (Residents 5, 47, 4, 87, 59) Findings include: 1. During the Resident Council meeting on 10/4/23 at 11:00 a.m., residents present indicated there were long call light wait times, especially on second shift, and the wait was approximately an hour. There were times when staff members would wear ear buds/headphones while on duty, or turn off the call light without completing care, and this caused continued waiting. Resident 5 indicated during an incident last week, he was left on the toilet for 40 minutes. He could see the clock from the bathroom, since the door was left open. […]

• No harm, potential for more than minimal, patternF623Oct 10, 2023

  Based on record review and interview, the facility failed to provide notice of transfer/discharge to a representative of the Office of the State Long-Term Care Ombudsman for 4 of 4 residents reviewed for hospitalization . (Residents 92, 22, 77, and 27) Findings include: 1. The clinical record for Resident 92 was reviewed on 10/3/23 at 3:02 p.m., Diagnoses included chronic respiratory failure, uropathy, chronic pain and abnormal weight loss. The resident was transferred to the hospital on 8/8/23 and returned to the facility on [DATE]. The clinical record lacked documentation of the Ombudsman notification for the transfer/discharge. 42685 2. Resident 22's clinical record was reviewed on 10/3/23 at 3:58 p.m. […]