Pennsylvania Department of Health
RIVERSTREET MANOR
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

RIVERSTREET MANOR
Inspection Results For:

There are 123 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 August 11, 2024, it was determined 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:

483.24(a)(3) REQUIREMENT Cardio-Pulmonary Resuscitation (CPR):

This is a less serious (but not lowest level) deficiency and is isolated to the fewest 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.

§483.24(a)(3) Personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives.

Observations:

Based on a review of clinical records and select facility policy and staff interviews it was determined that the facility failed to provide emergency care consistent with a resident's advanced directives for one resident out of 14 residents reviewed (Resident CR1).

Findings include:

According to the national library of medicine, irreversible death is classified as a person having the following: rigor mortis (stiffening of the joints and muscles of a body a few hours after death), dependent lividity (pooling of blood to dependent areas resulting in a red/purple coloration), decapitation (total separation of the head from the body), transection (cut in half), and decomposition (the state or process of rotting)

A review of Resident CR1's clinical record revealed admission to the facility on May 22, 2023, with multiple diagnoses including cancer of the right lung, type 2 diabetes, heart disease, and anxiety.

A review of Resident CR1's clinical record revealed a physician order dated May 22, 2023, identifying the resident was to receive CPR (cardio pulmonary resuscitation-emergency lifesaving procedure performed when the heart stops beating or if the resident stops breathing. Immediate CPR can double or triple chances of survival after cardiac arrest) in the event of cardiac or pulmonary arrest.

A nurse's note dated June 10, 2024, at 11:15 AM, completed by Employee 3 (LPN), indicated that Resident CR1 was "declining while in wheelchair, transferred to bed. Physician Assistant (PA) notified and at bed side. Resident expired. Resident pronounced by Physician assistant".

A review of the PA's progress note dated June 10, 2024, it revealed she was called to the room to see Resident CR1. The resident had been in the dayroom asking to go back to his room. He was wheeled back to his room and according to the PA's documentation he took his last breath while being placed back in bed. The progress note indicated the resident was found lying in bed, and unresponsive to verbal or noxious (painful) stimuli. The resident's pupils were fixed and dilated (when the pupil, round black part of the eye does not respond to light or fixed, indicating the brain is not responding to send a signal back to the eye to constrict, the pupil- fixed and dilated pupils are a sign if brain death) and his heart sounds could not be heard. The resident was without a pulse or respirations.

Although the resident's physician's orders indicated that if the resident were to suffer a cardiac or respiratory event the facility was to perform CPR in order to attempt to save the resident during a cardiac arrest, the facility failed to implement CPR as ordered.

The facility failed to provide cardio-pulmonary resuscitation (CPR) to a resident who had requested this emergency care and was identified as a full code status (designation that means to intercede if a patient's heart stops beating or if the patient stops breathing).

Interview with the Director of Nursing and Nursing Home Administrator on August 11, 2024, at approximately 4:00 PM, confirmed that nursing staff failed to provide CPR according to the resident's wishes according to his advanced directive ( legal document that provide instructions for medical care and only go into effect if the resident's wishes could not be communicated) and physician order.

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services.

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

Plan of Correction - To be completed: 10/09/2024

Resident CR1 expired.

Current residents identified as a full code will have emergency care provided consistent with their Advanced Directive.

Staff Development/Designee will re-inservice Licensed Nurses on the Emergency Procedure – Cardiopulmonary Resuscitation.

DON/Designee will complete an audit on residents that were a full code and in need of emergency care to ensure their Advanced Directive was followed appropriately weekly for 4 weeks.

Results of audits will be reviewed at monthly QAPI meeting for review and/or recommendations.

483.20(f)(5), 483.70(h)(1)-(5) REQUIREMENT Resident Records - Identifiable Information:

§483.20(f)(5) Resident-identifiable information.
(i) A facility may not release information that is resident-identifiable to the public.
(ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so.

§483.70(h) Medical records.
§483.70(h)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are-
(i) Complete;
(ii) Accurately documented;
(iii) Readily accessible; and
(iv) Systematically organized

§483.70(h)(2) The facility must keep confidential all information contained in the resident's records,
regardless of the form or storage method of the records, except when release is-
(i) To the individual, or their resident representative where permitted by applicable law;
(ii) Required by Law;
(iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506;
(iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

§483.70(h)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use.

§483.70(h)(4) Medical records must be retained for-
(i) The period of time required by State law; or
(ii) Five years from the date of discharge when there is no requirement in State law; or
(iii) For a minor, 3 years after a resident reaches legal age under State law.

§483.70(h)(5) The medical record must contain-
(i) Sufficient information to identify the resident;
(ii) A record of the resident's assessments;
(iii) The comprehensive plan of care and services provided;
(iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State;
(v) Physician's, nurse's, and other licensed professional's progress notes; and
(vi) Laboratory, radiology and other diagnostic services reports as required under §483.50.

Observations:

Based on review of clinical records, observation and staff interview it was determined the facility failed to maintain accurate and complete clinical records for three out of 14 residents reviewed. (Residents 7, 11, and 14)

Findings included:

The Pennsylvania Code, Title 49, Professional and Vocational Standards, State Board of Nursing, 21.145 Functions of the Licensed Practical Nurse (LPN) (a) The LPN is prepared to function as a member of the health-care team by exercising sound judgement based on preparation, knowledge, skills, understandings, and past experiences in nursing situations. The LPN participates in the planning, implementation, and evaluation of nursing care in settings where nursing takes place. 21.148 Standards of nursing conduct (a) A licensed practical nurse shall: (5) Document and maintain accurate records.

According to the American Nurses Association Principles for Nursing Documentation, nurses document their work and outcomes and provide an integrated, real-time method of informing the health care team about the patient status. Timely documentation of the following types of information should be made and maintained in a patient's EHR (electronic health record) to support the ability of the health care team to ensure informed decisions and high-quality care in the continuity of patient care:
problems
with other health care professionals regarding the patient
with and education of the patient, family, and the patient ' s designated support person and other third parties.

A review of Resident 7's clinical record revealed that on July 18, 2024, treatments scheduled for the 3:00 PM to 11:00 PM shift were signed out as completed by Employee 4, the facility's licensed practical nurse who functioned as a unit secretary. According to the treatment record, Employee 4 documented that she completed the following scheduled treatments for Resident 7 at 2:50 PM:
Tabs alarm (resident safety alarm to notify staff of a resident fall) checked on the resident's chair and ensure placement and function on every shift,
Tabs alarm on the resident's bed, ensure placement and function every shift,
check placement of dressing to left buttock every shift, and , check inflation and settings every shift of the mattress.

A review of Resident 11's clinical record revealed that on July 18, 2024, the following treatments scheduled for the 3:00 PM to 11:00 PM shift were signed out as completed by Employee 4 at 3:01 PM:
apply zinc oxide to scabbed MASD (moisture associated skin damage) of the left buttock and cover with foam dressing every evening shift,
check placement of dressing to left buttock every shift,
apply skin prep to bilateral heels and ensure that heels are off loaded,
monitor skin for any changes every shift,
check dialysis access site dressing every shift and reinforce as needed, notify physician as needed, and dialysis on hold until further notice.

A review of Resident 14's clinical record revealed that on July 18, 2024, the following treatments scheduled for the 3:00 PM to 11:00 PM shift were signed out as completed by Employee 4 at 2:47 PM:
apply skin prep to bilateral heels and ensure that heels are off loaded every shift,
apply skin prep to Stage 1 pressure ulcers and bilateral heels every shift,
apply zinc oxide barrier cream for MASD to bilateral groins/scrotum cleanse with soap and water and pat dry,
check placement of dressing to right medial malleolus (inner ankle) every shift,
keep heels off of bed with heels up device every shift,
apply skin prep to stage 1 pressure ulcer right lateral foot beneath 5th toe every shift,
apply zinc oxide to MASD on sacrum every shift,
apply zinc oxide to MASD left buttock every shift,
Tabs alarm to bed, check placement and function every shift, and Tabs alarm to wheelchair, check placement and function every shift.

Review of nurse staffing schedule for July 18, 2024, failed to provide evidence that Employee 4 was scheduled to work as an assigned nurse in the facility on that date.

Interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON) on August 11, 2024, at approximately 12:00 PM revealed that Employee 4 is hired as an LPN Unit Secretary and will at times assist on the floor with duties of the LPN in addition to secretarial duties. The NHA and DON confirmed there was no evidence that Employee 4 was scheduled to work as an LPN on July 18, 2024 therefore there was no reason as to why Employee 4 documented that she completed the aformentioned treatments for the residents .

The NHA and DON further confirmed the treatments signed out as completed by Employee 4 were signed out prior to the start of the 3:00 PM to 11:00 PM shift.

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

28 Pa. Code 211.5 (f) Medical records

Plan of Correction - To be completed: 10/09/2024

Employee 4 has been added to the Direct Care Staffing Sheet for July 18, 2024.

Current employees that provide direct care will be placed on the Direct Care Staffing Sheet reflecting the hours they provided direct care to residents.

Staff Development/Designee will re-inservice Licensed Nurses on Charting and Documentation Policy.

DON/Designee will complete audits on TAR's for random residents to ensure the nurse completing is listed on the Direct Care Staffing Sheet weekly for 4 weeks.

Results of audits will be reviewed at monthly QAPI Meeting for review and/or recommendations.

483.45(g)(h)(1)(2) REQUIREMENT Label/Store Drugs and Biologicals:

§483.45(g) Labeling of Drugs and Biologicals
Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable.

§483.45(h) Storage of Drugs and Biologicals

§483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys.

§483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Observations:

Based on observation, review of select facility policy and staff interview, it was determined the facility failed to implement procedures to ensure acceptable storage for medications on one of two nursing units observed (Station 1).

Findings include:

A review of facility policy titled "Discontinued Medications", provided by the facility on August 11, 2024, revealed that discontinued medications are destroyed or returned to the issuing pharmacy in accordance with facility policy and state regulations. This policy refers to the policy entitled "Discarding and Destroying Medications".

A review of facility policy titled "Discarding and Destroying Medications" provided by the facility on August 11, 2024, revealed that individual resident medications supplied in sealed unopened containers may be returned to the issuing pharmacy for disposition provided that all such medications are identified as to lot or control number and the receiving pharmacist and a registered nurse employed by the facility sign a separate log that lists the resident's name; the name, strength, prescription number, and amount of the medication returned; and the date the medication was returned. The medication disposition record contains, at a minimum, the following information: resident's name, name and strength of the medication, the prescription number, the name of the dispensing pharmacy, date medications destroyed, the quantity destroyed, method of destruction, reason for destruction, and signature of witnesses.

Observation of the Station One medication room on August 11, 2024, at 8:53 AM, in the presence of Employee 2, a licensed practical nurse (LPN), revealed a mauve wash basin on the counter labeled "Return to Rx [pharmacy]". The basin contained 16 medication cards that needed to be returned to the pharmacy.

Interview with Employee 2 indicated that it is the responsibility of the registered nurse supervisor to inventory the medications, complete disposition paperwork, and return the medications to pharmacy. Employee 2 stated the medication nurse removes any medications from their cart that are no longer in use due to a resident's discharge, death, or discontinuation. The medications are removed from the cart and placed in the bin in the medication room. The medication nurse does not complete disposition of medication paperwork when the medication is removed from the cart.

Observation of the basin revealed that medications prescribed for Resident CR4 who was discharged on August 5, 2024, remained in the medication room, awaiting return to the pharmacy. There was no evidence that a medication disposition form had been completed at time of survey ending August 11, 2024.

Observation of an unlocked drawer located at the nurse's station on August 11, 2024, at 9:00 AM, in the presence of Employee 2, LPN, revealed a blue zipper pouch filled with numerous single use vials of medications.
The zipper pouch contained;
(17) 2ml vials of Methylprednisolone 20mg,
(7) 2ml vials of Lidocaine 1%,
(3) vials of Methylprednisolone 40mg,
(1) vial of Vancomycin 1 gm labeled for intravenous use only, and
(2) vials of Piperacillin & Tazobactam 4.5 gm labeled for intravenous use only.
None of the medications within the zipper pouch were labeled as prescribed for any resident residing in the facility.

Further review of the drawer revealed;
(1) bottle of SPS (Sodium polystyrene sulfonate) 15 gm/60 mL suspension (medication to treat high potassium in blood stream). The medication label indicated it was prescribed for Resident 19,
(5) single pill packets of Fluconazole 150mg prescribed for Resident 11,
(3) full tubes of Santyl ointment prescribed for Resident 10,
a box containing a full tube of Triamcinolone 0.5% cream prescribed for Resident 13,
(3) boxes of Narcan nasal spray 4mg, and
(1)box of Scopolamine transdermal patches.

Employee 2 confirmed at time of observation the medications were not stored properly. Employee 2 stated the Station 1 registered nurse unit manager keeps the medications on hand in the event pharmacy can't deliver timely and that some medications the unit manager keeps due to "theft". According to Employee 2, the drawer at the nurse's station is usually locked.

Interview with the Nursing Home Administrator and Director of Nursing on August 11, 2024, at approximately 10:00 AM confirmed the medications at the nurse's station were not stored accordingly, labeled accordingly, and/or returned to pharmacy according to policy.

28 Pa. Code 211.9 (a)(1)(j.1)(1)(2)(3)(4)(5)(k) Pharmacy Services

28 Pa. Code 211.12 (d)(3)(5) Nursing services

Plan of Correction - To be completed: 10/09/2024

Discontinued medication located in the medication room and in the drawer of the nursing station on Station 1 has been returned to pharmacy/destroyed as appropriate.

Current discontinued medication located on Station 1 and Station 2 has been returned to pharmacy/destroyed as appropriate.

Staff Development/Designee will re-inservice Licensed Nursing Staff on Discarding and Destroying Medication Policy and Discontinued Medication Policy.

DON/Designee will complete an audit on random discontinued medications to ensure they were returned to pharmacy/destroyed as appropriate weekly for 4 weeks. DON/Designee will complete an audit on random drawers on nursing stations to ensure staff are not keeping resident medications stored in them weekly for 4 weeks.

Results of audits will be reviewed at monthly QAPI Meeting for review and/or recommendations.

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices:

§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Observations:

Based on observation and staff interview, it was determined the facility failed to maintain an environment free of potential accident hazards and obstacles for safe mobility and use of mobility assistance devices on one of two resident units (Station 2).

Findings include:

An observation on August 11, 2024, at 8:50 AM of the hallway leading to the therapy department from the main entrance of the facility revealed 4 large reclining/wheelchairs lined up against the right-hand side of the wall.

The hallway leading down the resident care area revealed multiple high back chairs setting outside of resident rooms, causing congestion in the hallways.

These items obstructed continued access to the handrails which are to be used for resident ambulation or mobility assistance and did not create a homelike environment. .

During an interview August 11, 2024, the Nursing Home Administrator stated that resident care areas should be maintained in a clean and orderly manner.

28 Pa. Code 201.18 (e)(2.1) Management

28 Pa. Code 205.9 (c) Corridors

Plan of Correction - To be completed: 10/09/2024

Recliners/Wheelchairs identified outside the therapy department have been removed. Station 2 Hallways will be clear of congestion to allow for access to the handrail.

Station 1 Hallways will be clear of congestion to allow for access to the handrail.

Staff Development/Designee will re-inservice current staff on the Homelike Environment Policy.

NHA/Designee will complete an audit on random Nursing Station and Therapy Hallways to ensure they remain free of congestion to ensure residents have access to a handrail for 4 weeks.

Results of audits will be reviewed at monthly QAPI meeting for review and/or recommendations.

483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

§483.35(g) Nurse Staffing Information.
§483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

§483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

§483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

§483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.

Observations:

Based on observation and staff interview, it was determined that the facility failed to post nurse staffing information.

Findings include:

During an observation on August 11, 2024, at approximately 8:15 AM the facility's current posted nursing hours were not observed.

Interview with Employee 1, a registered nurse supervisor, on August 11, 2024, at 8:46 AM, indicated she did not know what posted nursing time was.

Interview with the facility's Assistant Director of Nursing on August 11, 2024, at approximately 9:45 AM confirmed the facility failed to post the daily nurse staffing data as required

28 Pa. Code 211.12 (d)(1)(3)(5) Nursing services

28 Pa. Code 201.18 (b)(1)(3) Management

Plan of Correction - To be completed: 10/09/2024

Nurse Staffing information will be posted in the facility daily.

Staff Development/Designee will re-inservice the Center Scheduling Manager and Nursing Supervisors on the Policy for Posting Direct Care Daily Staffing Numbers.

NHA/Designee will complete a weekly audit to ensure Direct Care Daily Staffing Numbers are posted daily for 4 weeks.

Results of audits will be reviewed at monthly QAPI meeting for review and/or recommendations.

§ 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Plan of Correction - To be completed: 10/09/2024

The facility will provide nurse aide staff ratios at a minimum of 1:10 on the day shift, 1:11 on the evening shift, and 1:15 on the night shift based on facility's census to meet the needs of the residents. The nursing schedule and ratios will be reviewed daily Monday through Friday to include projected weekend ratios by the Administrator, Director of Nursing, and Center Scheduling Manager to validate nurse aide staff ratios are being met and adjustments will be made as necessary.

Facility residents have the potential to be affected by this practice.

The Administrator, Nursing Team Management, and Center Scheduling Manager will be re-educated concerning minimum nurse aide ratios and the appropriate response to unplanned variation in ratios.

NHA/Designee will complete random audits to ensure ratios are being met weekly for 4 weeks.

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

§ 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 3.2 hours of direct resident care for each resident.

Plan of Correction - To be completed: 10/09/2024

The facility will provide a minimum of 3.2 hours of direct resident care for each resident. The nursing schedule and HPPD will be reviewed daily Monday through Friday to include projected weekend HPPD by the Administrator, Director of Nursing, and Center Scheduling Manager to validate the hours of direct care for each resident being met and adjustments will be made as necessary.

Facility residents have the potential to be affected by this practice.

The Administrator, Nursing Team Management, and Center Scheduling Manager will be re-educated concerning the minimum 3.2 hours of direct resident care for each resident and the appropriate response to unplanned variation below that number.

NHA/Designee will complete random audits to ensure 3.2 hours or greater are being met weekly for 4 weeks.

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

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