Pennsylvania Department of Health
 RIVERSTREET MANOR
Patient Care Inspection Results

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RIVERSTREET MANOR
Inspection Results For:

There are  120 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.
RIVERSTREET MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on an abbreviated complaint survey completed on April 24, 2024, it was determined that Riverstreet Manor was not in compliance with the following requirements of 42 CFR Part 483 Subpart B Requirements for Long Term Care Facilities and the 28 PA Code Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on review clinical records and resident and staff interviews it was determined that the facility failed to provide care in a manner and environment, which promotes each resident's quality of life by failing to respond timely to residents' requests for assistance, as evidenced by experiences reported by six residents out of 15 interviewed (Residents 2, 40, 54, 69, 89, and 92).

Findings include:

A review of resident clinical records, and a facility provided BIMS (brief interview mental status - to assess cognitive status) report, and random interviews conducted on April 24, 2024, with 15 alert and oriented residents, to include six residents residing on nursing station 1, and nine residents residing on the nursing station 2, revealed that 6 residents' interviewed expressed complaints regarding staff's failure to respond to their requests for assistance and provide requested and needed care and services in a timely manner.

During the random interviews, the residents stated that they feel the facility is not adequately staffed because they wait extended periods of time for staff to respond to their requests for assistance, including untimely responses to their requests via the nurse call bell system.

Of those residents interviewed, 4 of 6 residents residing on nursing station 1, and 2 of 9 residents residing on nursing station 2, expressed concerns with untimely staff response to their requests and needs as described above.

Interview with Resident 2 on April 24, 2024, at approximately 11:06 AM, revealed that she waits 30 minutes, or more for staff assistance when requested. The resident stated that the extended waits occur daily, and happen at any time of day, including all three shifts, day, evening, or night shift, and that there have been times she has soiled herself while waiting for staff to answer her call bell.

Interview with Resident 54 on April 24, 2024, at approximately 11:10 AM, revealed she waits 30 minutes for staff to answer her call bell, and these waits occur weekly, often two or three times each week. The resident stated that these waits occur on 2nd shift (evening shift) of nursing duty.

Interview with Resident 89 on April 24, 2024, at approximately 11:15 AM, revealed that she waits up to an hour for someone to answer her call bell, and these waits that long have occurred two or three times in the last month. The resident stated that there have been times she has soiled herself while waiting for staff to answer her call bell for assistance with toileting needs

Interview with Resident 40 on April 24, 2024, at approximately 11:26 AM, revealed that she waits 30 minutes for staff to answer her call bell, and these waits occur daily. The resident stated that these waits occur mostly on 3rd (night shift) of nursing duty. The resident revealed that there have been times she has soiled herself while waiting for staff to answer her call bell when she needs toileting assistance.

Interview with Resident 69 on April 24, 2024, at approximately 11:48 AM, revealed that she has waited greater than 1 hour, at least once a week, for staff to answer her call bell. The resident stated that these waits occur mostly on 2nd shift (evening shift) of nursing duty, and that there have been times she has soiled herself while waiting for the call bell to be answered to provide assistance with toileting.

Interview with Resident 92 on April 24, 2024, at approximately 11:54 AM, revealed that she can wait 1 hour, weekly, for staff to answer her call bell. The resident stated that these waits occur mostly on 2nd shift (evening shift) of nursing duty.

Interview on April 24, 2024, at approximately 2:10 PM with the Nursing Home Administrator (NHA) verified that it is her expectation that all residents be treated with dignity and respect. The NHA was unable to explain why multiple residents are reporting untimely staff response times to their requests for care and assistance, resulting in the residents' feelings that the facility is not adequately staffed, which was negatively affecting the residents' quality of life in the facility.



28 Pa. Code 201.18 (e)(1) Management.

28 Pa. Code 201.29 (a) Resident rights.

28 Pa Code 211.12 (c)(d)(5) Nursing services




 Plan of Correction - To be completed: 05/29/2024

-Residents 2, 40, 54, 69, 89, and 92 will have their requests for assistance responded to in a timely manner.

-Current residents will have their requests for assistance responded to in a timely manner.

-Staff Development Coordinator/Designee will re-inservice all current staff on Resident Rights. The focus for all staff is that everyone can see what a resident is in need of if they ring their call bell and if able to assist can do so. The nursing staff will be reminded that they need to respond timely to the needs of the resident and if unable to do so they should seek assistance from co-workers. NHA/Designee will meet with resident council monthly to discuss concerns regarding staffing and timeliness of needs being met.

-DON/Designee will complete a weekly audit for four weeks on call bell response time for random residents to ensure their requests for assistance was responded to in a timely manner.

-Results of the audit will be presented at the monthly QAPI Meeting for review and/or recommendations.

483.25(i) REQUIREMENT Respiratory/Tracheostomy Care and Suctioning:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§ 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning.
The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.
Observations:

Based on observations, a review of clinical records and select grievances/complaints lodged with the facility, resident, and staff interviews it was determined that the facility failed to consistently administer oxygen as ordered and maintain sanitary oxygen delivery systems for two out of five sampled residents (Residents 59, and 72).

Findings included:

According to the American Thoracic Society, oxygen is a medication that requires a prescription from a healthcare provider. The provider will prescribe your oxygen at a specific flow rate and a specific number of hours per day. It is very important that oxygen is used as prescribed. Using too little oxygen may put a strain on the heart and brain, causing heart failure, fatigue, or memory loss. Using too much oxygen can also be a problem. For some patients, using too much oxygen can cause them to slow their breathing to dangerously low levels. It is important to wear oxygen as your provider ordered it. If the patient starts to experience headaches, confusion, or increased sleepiness after using supplemental oxygen, the patient may be getting too much.

A review of a grievance lodged with the facility dated March 21, 2024, revealed that Resident 83's son called the facility reporting that on Wednesday, the resident's brother at the facility visiting with the resident in the resident's room and observed that the resident's portable oxygen tank was empty. The facility immediately monitored the resident's oxygen saturation and updated the order to check the resident's oxygen tank and provide in-service education of staff on placing resident back on concentrator when back in room.

A review grievance lodged with the facility dated April 12, 2024, indicated that Resident 83's son called the facility to report that his uncle was in the facility visiting the resident last evening around 6:00 PM and observed the resident's oxygen concentrator was off and her nasal canula was upside down. He said her pulse Ox was in the 80's when obtained. The facility called the resident's brother and confirmed that the resident's oxygen was off and he obtained her pulse ox with the one he brought in and she was 85%. The resident's brother stated that he got the supervisor, she went right down to check the resident. The grievance resolution was that the resident's oxygen was being checked hourly.

A review of clinical record revealed Resident 59 was admitted to the facility on April 11, 2024, with diagnoses to include chronic obstructive pulmonary disease ([COPD] chronic obstructive pulmonary disease- chronic inflammatory lung disease that causes obstructed airflow from the lungs), dependence on supplemental oxygen, and a solitary pulmonary nodule (small, round, or oval growth in the lung).

A review of a current physician order dated April 12, 2024, for continuous oxygen 2 L/min via nasal canula (NC).

A review of an admission MDS (minimum data set- a federally mandated standardized assessment conducted at specific intervals to plan resident care) dated April 17, 2024, indicated the resident was severely cognitively impaired and required assistance with activities of daily living

Resident 59's plan of care dated April 17, 2024, and revised April 22, 2024, revealed that the resident was resistive/noncompliant with treatment/care. It was noted that the resident was refusing oxygen (O2) and disconnecting wound vac, refusing breathing treatments. The interventions included to a allow for flexibility in ADL routine to accommodate mood, preferences and customary routine, elicit family input for best approaches, provide non-care related conversation proactively before attempting ADLs.

An observation on April 24, 2024, at approximately 9:15 AM, and at 9:55 AM, revealed Resident 59 sitting in bed, with his oxygen tubing, including the nasal canula lying observed on the floor next to the bed.

Another observation in the presence of Employee 1, Licensed Practical Nurse (LPN), on April 24, 2024, at approximately 10:05 AM, revealed Resident 59 sitting in bed at which time, Employee 1 confirmed the observation of the resident's oxygen tubing, including the nasal canula laying on the floor next to the bed, and that the resident was not receiving the oxygen as ordered. Resident 59 stated "he can reach it" (the nasal cannula). Employee 1 (LPN), picked up the oxygen tubing and nasal canula from the floor and placed it on the resident's lap without cleaning, or replacing the set up. Resident 59 was then observed to place the nasal cannula that had been on the floor, in his nose. Interview with Employee 1, LPN on April 24, 2024, at approximately 10:22 AM, confirmed that the resident was not receiving the oxygen as physician ordered, and that he had not adhered to infection control procedures, by picking up the oxygen tubing, including the nasal canula that was lying on the floor, and placing it on the resident's lap without cleaning, or replacing it.

Following surveyor observations and interviews with staff, the facility obtained a physician order dated April 24, 2024, for staff to monitor Resident 59's oxygen (02) and wound vac on properly, every hour, and document compliance.

A review of clinical record revealed Resident 72 was most recently admitted to the facility on April 20, 2023, with diagnoses to include chronic obstructive pulmonary disease (COPD), obstructive sleep apnea, acute and chronic respiratory failure with hypoxia, hypertensive heart and chronic kidney disease with heart failure, congestive heart failure (CHF), and morbid (severe) obesity due to excess calories.

A review of a quarterly MDS assessment dated February 1, 2024, indicated that the resident was cognitively intact.

A review of Resident 72's plan of care, dated January 17, 2024, revealed that the resident requires use of Oxygen to maintain oxygenation with interventions to check the filter and clean weekly, check oxygen tubing length and placement to avoid tripping hazard, humidifier as indicated, monitor for skin breakdown related to oxygen tubing contact with skin, oxygen therapy per physician's order and weekly change of oxygen tubing date. The resident's care plan, dated December 4, 2023, revealed that the resident was resistive/noncompliant with treatment/care interventions to allow for flexibility in ADL routine to accommodate mood, preferences and customary routine, if resisting care, leave (if safe to do so) and return later, physician to explain/reinforce need for treatment as necessary, provide education about risks of not complying with therapeutic regimen, provide non-care related conversation proactively before attempting ADLs, and psych consult as ordered.

The resident had a current physician order dated January 17, 2024, for continuous oxygen 2 L/min via nasal canula (NC), and to check the oxygen saturation every (Q) shift and as needed. (Oxygen [02] saturation is the percentage of 02 in a person's blood, normal 02 saturation levels are between 95 % and 100 %, and levels below 90% are considered low and may indicate hypoxemia, which is an abnormally low level of oxygen in the blood that could be a life - threatening condition).

Observations on April 24, 2024, at approximately 9:21 AM, and at 9:58 AM, revealed Resident 72 sitting in bed, without the nasal cannula on delivering continuous oxygen as ordered. The oxygen concentrator was turned on, but the nasal cannula was observed on the resident's lap, under her bedding (sheets/blanket).

A third observation in the presence of Employee 2, Licensed Practical Nurse (LPN), on April 24, 2024, at approximately 10:13 AM, revealed Resident 72 sitting in bed. Employee 2, LPN, confirmed that the resident's nasal cannula located was her lap, under her sheets and blankets and the resident was not not receiving the oxygen as ordered by the physician. In response, the resident stated, "I was told I can remove it" (the oxygen).

On April 24, 2024, at approximately 10:25 AM, Resident 72's oxygen saturation was measured by Employee 1, LPN and read 85 %, while wearing the oxygen nasal canula.

Interview with Resident 72 on April 24, 2024, at approximately 12:10 PM, revealed this was not the first time she had removed the nasal canula. The resident stated that she removes her oxygen daily, and that facility staff are aware. The resident stated that staff had told her she could remove it, but the resident was unable to identify which staff member had told her that.

The facility failed to consistently monitor Resident 72's compliance with oxygen use and oxygen saturation levels to timely identify the resident's oxygenation status and potential need for intervention.

Interview with the Nursing Home Administrator (NHA) on April 24, 2024, at approximately 2:10 PM, confirmed that the physician's order for supplemental oxygen was not consistently followed for Resident 59, and 72, and oxygen equipment is to be kept clean, and maintained in a sanitary manner.



28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services





 Plan of Correction - To be completed: 05/29/2024

-Residents 83 and 72 will have their oxygen saturations monitored Q4 hours to timely identify their oxygenation status and potential need for intervention due to resident exhibiting non-compliance with oxygen. Resident 59 has discharged from the facility.

-Current residents exhibiting non-compliance with oxygen will have their oxygen saturations monitored Q4 hours to timely identify their oxygenation status and potential need for intervention due to the resident exhibiting non-compliance with oxygen. Infection control practices will be maintained for current residents with oxygen when placing oxygen tubing on resident that had fallen on the floor.

-Staff Development Coordinator/Designee will re-inservice current Licensed Nursing Staff on Oxygen Administration Policy, Pulse Oximetry Policy, and Cleaning/Disinfection of Resident-Care Items and Equipment Policy.

-DON/Designee will complete a weekly audit for four weeks on random residents that are non-compliant with their oxygen to timely identify their oxygenation status and potential need for intervention. DON/Designee will complete a weekly audit for four weeks on random residents that are non-compliant with their oxygen order to ensure infection control practices are maintained.

-Results of the audit will be presented at the monthly QAPI Meeting for review and/or recommendations.

483.60(d)(4)(5) REQUIREMENT Resident Allergies, Preferences, Substitutes:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
§483.60(d) Food and drink
Each resident receives and the facility provides-

§483.60(d)(4) Food that accommodates resident allergies, intolerances, and preferences;

§483.60(d)(5) Appealing options of similar nutritive value to residents who choose not to eat food that is initially served or who request a different meal choice;
Observations:

Based on observations, a review of the the minutes from Residents' Council meetings and grievances lodged with the facility, resident and staff interviews it was determined that the facility failed to provide food that accommodates resident preferences for 26 residents of 26 resident meal trays observed and as reported by nine residents out of 15 interviewed (Residents 1, 72, 73, 87, 88, 89, 91, 92, and 94).

Findings include:

A review of the minutes from the Resident Council meeting dated March 4, 2024, revealed that Resident 93 voiced concern that there has not been a good variety of food being offered at meals.

A review of the minutes from the Resident Council meeting dated April 1, 2024, revealed that Resident 27 complained that the rice is always hard. Resident 93 voiced concern that the meat served during the St. Patrick's Day meal was tough and food is often hard or under cooked.

A review of facility grievance dated February 23, 2024, indicated that Resident 44 complained that the scrambled eggs were burnt. The facility's response to that grievance was that the employee that was cooking had resigned and other cooks will be educated regarding proper cooking procedures.

A review of facility provided BIMS (brief interview mental status - to assess cognitive status) report, and random interviews conducted on April 24, 2024, with 15 alert and oriented residents, to include six residents residing on nursing station 1, and nine residents residing on the nursing station 2, revealed that 9 residents interviewed expressed complaints/concerns regarding the preparation of the food, selection of food, and taste of food served at the facility

Of those residents interviewed, 3 of 6 residents residing on nursing station 1, and 6 of 9 residents residing on nursing station 2, expressed concerns as described above.

Interview with Resident 89 on April 24, 2024, at approximately 11:15 AM, revealed that it is her experience that the "food is over cooked a lot." According to the resident, she has made this known to the kitchen/dietary staff.

Interview with Resident 88 on April 24, 2024, at approximately 11:18 AM, revealed that the food "tastes lousy", and is "over cooked quite a bit".

Interview with Resident 94 on April 24, 2024, at approximately 11:24 AM, revealed that it is his experience that the food served "does not taste good", and that additional items like condiments and butter, are missing from his meal tray. The resident stated "you never get it" (butter and condiments).

During an interview with Resident 87 on April 24, 2024, at approximately 11:51 AM, the resident stated that she is not happy with some of the meals served and that her preferences are not accommodated. She stated that dietary staff documented her dislikes and preferences, but then she is not offered the food she likes, such as tacos and spaghetti. The resident stated that she has expressed this complaint to the facility's dietary staff in the recent past, without any changes in food service.

Interview with Resident 92 on April 24, 2024, at approximately 11:54 AM, revealed that it is her experience that "sometimes the food is good, but mostly not."

Interview with Resident 73 on April 24, 2024, at approximately 11:57 AM, revealed that the food "is not edible."

Interview with Resident 1 on April 24, 2024, at approximately 12:07 PM, revealed that the food served is "bland", and that additional items, like condiments and butter, are missing from her meal tray. The resident stated that "butter is very scarce."

Interview with Resident 72 on April 24, 2024, at approximately 12:10 PM, revealed that the food served is often "salty, and that the vegetables are frequently overcooked."

Interview with Resident 91 on April 24, 2024, at approximately 12:15 PM, revealed that it is her experience that the food is "not too good."

An observation of the lunch meal in the presence of Employee 3, Registered Nurse (RN) Unit Manager, on April 24, 2024, at approximately 12:31 PM, on nursing station 2, revealed 17 of 17 food trays observed had no butter on the resident meal trays (resident room 57 A/B, 58 B, 42 B, 43 A, 56 A/B, 44 A, 54 B, 53 B, 46 A, 47 A, 52 A, 48 B, 49 A/B, and 50 A), as confirmed by Employee 3 RN, Unit Manager.

An observation of the lunch meal trays in the presence of Employee 1, Licensed Practical Nurse (LPN), on April 24, 2024, at approximately 12:40 PM, nursing station 1, revealed 13 of 13 food trays observed had no butter (resident room P 3, 17 A/B, 4, 5 A, 6 A, 7 B, 10 A, 15 A, 29 B, 28 A, 27 B, and 24 B), as confirmed by Employee 1 LPN.

During an observation of the kitchen, on April 24, 2024, at approximately 12:50 PM, in the presence of the Employee 4, Dietary Manager, revealed 1 box of whipped spread, 900 count of individual packets, located in the walk-in cooler. A further observation of the box revealed it open and half empty. Employee 4, Dietary Manager stated there was approximately 500 individual packets left. The facility census on April 24, 2024, was 101. Employee 4, Dietary Manager acknowledged there were no butter packets on the resident food trays at today's lunch meal, and stated that butter (whipped spread) are only provided with certain food items such as "dinner rolls, baked potatoes." Employee 4 stated that should a resident request butter, the staff would need to contact the kitchen and one packet would be provided because the butter packets (whipped spread) stay in the cooler at all times.

Interview with the Nursing Home Administrator (NHA) on April 24, 2024, at approximately 2:05 PM, indicated the reason for the lack of butter observed was because today's meal did not call for butter, but when asked who decides whether a meal or food items calls for butter, the NHA responded "the resident."

Interview with the NHA on April 24, 2024, at approximately 2:10 PM, confirmed the facility failed to consider individual food preferences, to increase resident satisfaction with meals, and failed to accommodate individual food preferences, to the extent possible, to increase resident satisfaction with meals.




28 Pa. Code 211.6 (a) Dietary services

28 Pa. Code 201.18 (a) Resident rights



 Plan of Correction - To be completed: 05/29/2024

-Residents 1, 72, 73, 87, 88, 89, 91, 92, and 94 will have their preferences reviewed with Food Service Director/Designee to update likes/dislikes.

-Current residents will have their preferences reviewed by the Food Service Director/Designee to update likes/dislikes

-Staff Development Coordinator/Designee will re-inservice Dietary Staff on Resident Food Preferences Policy, Food and Nutrition Services (with focus on preparation and serving meals), and placing additional condiments on the food carts so that they are readily accessible if a resident should want a condiment that is not on their tray.

-Food Service Director/Designee will complete a weekly audit for four weeks on random residents to ensure their food preferences are up to date, to ensure they are satisfied with their meals, and to ensure additional condiments are available to them when they asked for same.

-Results of the audits will be presented at the monthly QAPI Meeting for further review and recommendations.


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