Riverbend Health and Rehabilitation Center

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure medical gas and vacuum systems have documented maintenance programs.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Smoke Deficiencies

Install an approved automatic sprinkler system.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have restrictions on the use of portable space heaters.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Quality of Life and Care Deficiencies

Provide routine and 24-hour emergency dental care for each resident.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Egress Deficiencies

Have exits that are accessible at all times.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Missing two (2) year smoke detector sens.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the backup emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was .. Based on observation and staff interviews during the survey, it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:The printer room has penetration i.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1. Patio exit signs.2. The patio gate.. Based on observation and staff interviews, it was determined that the facility failed to maintain a fire-safe environment within the facility Life Safety Code, Section 19.7.8Space heater in the administration office. Life.. Based on observation during the survey, it was determined that the facility failed to maintain proper gas valve protection in accordance with Life Safety Section 9.1 and NFPA 54, 7.9.2.1. This was evidenced by the following:The .. Based on observations and a review of records, it was determined that the facility did not maintain fire extinguishers in accordance with NFPA 10. 1. Dietary kitchen extinguisher to above 5 feet.2. Kitchen - extinguisher mounted above.. Based on observations and records review, it was determined that the facility did not have out-of-service guidance for the fire alarm in accordance with NFPA 101. Out-of-Service Fire Alarm Guidance was not available at the time of insp.. Based on observations and records review, it was determined that the facility did not have Sprinkler System out-of-service guidance in accordance with NFPA 101 and NFPA 25Out-of-service Sprinkler Guidance - This was unavai.. Based on observations and records review, it was determined that the facility did not maintain oxygen storage in accordance with NFPA 99. Portable concentrators are stored in an oxygen transfill room. 11.5.2.2 Transfilling Cylinde.. Based on observations during the survey, it was determined that the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. Oxygen Transfill rooms need a vent 12" off the floo.. Based on the documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continui.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied timesNFPA 101, 19.7.1.6 Drills shall b.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is a one-s.. Through observation during the documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13.1. Missing Semi-annual and quarterly reports.2. Wi..

A recertification survey with complaint #CO36415 was completed on 6/24/24 to 6/27/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 6/24/24 to 6/27/24. No deficiencies were cited. Based on interviews, record review and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture and temperature.Specifically, the facility failed to ensure the residents' food was palatable in taste, texture and temperature.Findings include:I. Facility policy and procedure The Menus policy and procedure, revised September 2017, was received from the nursing home administrator (NHA) on 6/27/24 at 12:40 p.m. It read in pertinent part, "Menus will be planned in advance to meet the nutritional needs of the residents/patients in accordance with established national guidelines. Menus will be developed to meet the criteria through the use of an approved menu-planning guide."Menu cycles will be developed .. Based on observations, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 6.25%, or two errors out of 32 opportunities for error. Findings include:I. Facility policyThe Medication Administration policy and procedure, revised 2/9/24, was received from the nursing home administrator (NHA) on 6/27/24 at 12:45 p.m. It documented in pertinent part, "Resident medications are administered in an accurate, safe, timely, and sanitary manner. Medications are administered in accordance with written orders of the attending physician or physician extender." II. Manufacturer' s recommendationsAccording to the National Library of Medicine, Levothyroxine.. Based on record review and interviews, the facility failed to ensure residents were free from abuse for one (#59) of two residents reviewed for abuse out of 35 sample residents.Specifically, the facility failed to:-Protect Resident #59 from sexual abuse by Resident #62; and,-Implement interventions for Resident #62 in order to prevent the abuse from occurring again.Findings include: I. Facility policy and procedureThe Abuse policy was requested from the nursing home administrator (NHA) on 6/25/24 at 3:30 p.m. The Abuse policy was not provided, however, the NHA provided an undated print out titled "What is Intimacy?" on 6/25/24 at 4:43 p.m. It read in pertinent part, "Intimacy can take many forms, from enjoying watching a movie together, to hand holding, to sexual intercourse. Residents ha..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 02/12/2024 and 02/18/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.