Inspection Reports for River Towne Center – Genesis
5131 Warm Springs Rd, Columbus, GA 31909, United States, GA, 31909
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 9, 2025, identified deficiencies related to failure to maintain the fire alarm system and smoke barrier doors. Prior inspections showed a pattern of deficiencies in care planning, infection control, medication management, and safety, including multiple citations for inadequate care plan implementation, expired medication storage, and fire safety issues. Several complaint investigations were substantiated, particularly involving wound care, medication diversion, and abuse, while many complaints were unsubstantiated. Enforcement actions included an Immediate Jeopardy finding in 2023 related to infection control during a COVID-19 outbreak and another in 2020 involving fall monitoring and care planning, both of which were resolved after corrective actions. The facility’s record shows ongoing challenges with regulatory compliance, especially in infection control and safety systems, with some corrections verified but recent inspections indicating persistent issues.
Deficiencies (last 9 years)
Deficiencies (over 9 years)
25 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
410% worse than Georgia average
Georgia average: 4.9 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
139 residents
Based on a April 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Census over time
Inspection Report
Follow-Up
Deficiencies: 2
Date: Jun 9, 2025
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies at River Towne Center.
Findings
The facility failed to maintain the fire alarm system and smoke barrier doors. The fire alarm panel displayed a trouble alarm light due to a blown fuse that was not yet repaired. Smoke barrier doors near room 505 failed to close properly, affecting residents and staff.
Deficiencies (2)
Failure to maintain the fire alarm system, with a trouble alarm light displayed and unresolved blown fuse.
Failure to maintain smoke barrier doors in the hall corridor near room 505, which failed to close properly.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed findings regarding fire alarm system trouble and smoke door deficiencies during the tour on 6/9/2025. |
Inspection Report
Routine
Deficiencies: 9
Date: Apr 24, 2025
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication management, infection control, safety, and food handling at River Towne Center.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive, person-centered care plans for residents, inadequate assistance with activities of daily living, unsafe medication storage and disposal practices, failure to discard expired medications and food items, improper pain management, and lapses in infection control related to respiratory therapy equipment and feeding tube care.
Deficiencies (9)
Failed to develop a comprehensive, person-centered care plan for two of 49 sampled residents, risking unmet needs and diminished quality of life.
Failed to ensure two residents received scheduled showers and adequate personal hygiene care.
Medication cart contained an unpackaged syringe with uncapped needle posing a potential injury risk.
Hazardous chemicals including aerosol disinfecting spray and multi-purpose cleanser were accessible to residents in their rooms.
Failed to provide appropriate pain management for a resident due to missing medication orders and lack of physician notification.
Expired medications were stored with unexpired medications in medication rooms.
Expired food items were found in the kitchen and walk-in cooler, risking foodborne illness.
Nebulizer and BiPAP masks were not stored in protective bags, risking contamination and infection.
Feeding tube site dressing was soiled and not changed as ordered, risking infection.
Report Facts
Residents sampled: 49
Residents affected: 2
Residents affected: 2
Medication rooms inspected: 2
Residents receiving oral diet: 110
Residents reviewed for respiratory care: 5
Residents reviewed for feeding tube care: 31
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS DD | Verified respiratory needs and pain management issues in care plans | |
| Director of Nursing | DON | Provided multiple interviews confirming expectations for care plans, pain management, infection control, and shower schedules |
| Certified Nursing Assistant UU | CNA | Confirmed nebulizer mask storage and shower documentation |
| Licensed Practical Nurse LL | LPN | Confirmed nebulizer mask storage and shower expectations |
| Registered Nurse MM | RN | Verified unsafe syringe disposal |
| Unit Manager CC | UM | Discussed syringe disposal expectations |
| Certified Nursing Assistant HH | CNA | Verified hazardous chemicals in resident room |
| Registered Nurse ZZ | RN | Acknowledged presence of hazardous chemicals brought by family |
| Licensed Practical Nurse JJ | LPN | Unaware of chemicals in resident room |
| Admissions Director RR | Explained opioid medication ordering process | |
| Registered Nurse SS | RN/Hospital Liaison | Explained opioid medication ordering process |
| Registered Nurse CC | RN | Verified expired medication storage |
| Dietary Manager | DM | Confirmed expired food items found in kitchen |
| Licensed Practical Nurse AA | LPN | Confirmed feeding tube dressing condition |
Inspection Report
Annual Inspection
Deficiencies: 9
Date: Apr 24, 2025
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication management, infection control, and facility safety.
Findings
The facility was found deficient in multiple areas including failure to develop comprehensive, person-centered care plans for residents, inadequate assistance with activities of daily living, unsafe medication storage and disposal practices, failure to discard expired food and medications, improper storage and handling of respiratory therapy equipment, and failure to provide appropriate pain management and feeding tube care.
Deficiencies (9)
Failed to develop a comprehensive, person-centered care plan for two of 49 sampled residents, risking unmet needs and diminished quality of life.
Failed to ensure two residents received scheduled showers and adequate personal hygiene care.
Medication cart contained an unpackaged syringe with uncapped needle, posing a risk of injury.
Hazardous chemicals such as aerosol disinfecting spray and multi-purpose cleansers were accessible to residents in their rooms.
Failed to provide appropriate pain management for a resident due to missing physician order and lack of medication administration.
Expired medications were stored with unexpired medications in medication rooms.
Expired food items were found in the kitchen and walk-in cooler, risking foodborne illness.
Nebulizer and BiPAP masks were not stored in protective bags, increasing risk of contamination and infection.
Feeding tube site dressing was soiled and not changed as ordered, risking infection.
Report Facts
Residents sampled: 49
Residents affected: 2
Residents affected: 2
Medication rooms inspected: 2
Residents affected: 1
Residents affected: 3
Residents affected: 110
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Provided statements confirming expectations for care plans, shower schedules, medication disposal, and infection control practices |
| Certified Nursing Assistant UU | Certified Nursing Assistant (CNA) | Confirmed nebulizer mask storage practices and shower documentation |
| Licensed Practical Nurse LL | Licensed Practical Nurse (LPN) | Confirmed nebulizer mask storage and shower scheduling practices |
| Registered Nurse MM | Registered Nurse (RN) | Verified unsafe syringe disposal on medication cart |
| Unit Manager CC | Unit Manager (UM) | Discussed proper syringe disposal procedures |
| Administrator | Facility Administrator | Confirmed expectations for shower schedules and chemical storage |
| Certified Nursing Assistant HH | Certified Nursing Assistant (CNA) | Verified presence of hazardous chemicals in resident room |
| Registered Nurse TT | Registered Nurse (RN) | Confirmed aerosol disinfectant should not be left at resident bedside |
| Licensed Practical Nurse JJ | Licensed Practical Nurse (LPN) | Stated staff were supposed to remove chemicals from resident rooms |
| Registered Nurse ZZ | Registered Nurse (RN) | Acknowledged knowledge of hazardous chemical presence in resident room |
| Admissions Director RR | Admissions Director | Described process for opioid pain medication orders |
| Registered Nurse SS | Registered Nurse (RN)/Hospital Liaison | Described process for opioid pain medication orders |
| Registered Nurse CC | Registered Nurse (RN) | Verified expired medication storage |
| Dietary Manager | Dietary Manager (DM) | Confirmed expired food items found in kitchen and walk-in cooler |
| Licensed Practical Nurse AA | Licensed Practical Nurse (LPN) | Confirmed soiled feeding tube dressing and BiPAP mask storage |
Inspection Report
Routine
Census: 139
Deficiencies: 11
Date: Apr 24, 2025
Visit Reason
A standard survey was conducted at River Towne Center from April 22, 2025, through April 24, 2025, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake Numbers GA00254631, GA00253726, GA00254195, GA00254660, GA00254541, and GA00254699 were investigated. GA00254699 and GA00254631 were unsubstantiated. GA00254195 and GA00254660 were substantiated without deficiency. GA00253726 and GA00254541 were substantiated with deficiency.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to care planning, pain management, restorative services, communication services, medication storage, infection control, dental services, ADL support, and safety hazards.
Deficiencies (11)
Failure to ensure comprehensive, person-centered care plans for multiple residents including pain management, restorative services, communication, dental, and respiratory needs.
Failure to provide scheduled showers and ADL care for dependent residents.
Failure to discard expired medications and food items in storage.
Failure to ensure safe handling, labeling, and storage of nebulizer equipment to prevent contamination.
Failure to provide pain management timely due to missing narcotic medication orders from hospital transfer.
Failure to ensure medications were discarded after expiration date in medication rooms.
Failure to provide sanitary storage for BPAP mask and tubing, risking respiratory infections.
Failure to provide dressing changes according to physician orders for gastrostomy site, risking infection.
Failure to maintain necessary vision equipment for resident, resulting in unmet vision needs.
Failure to ensure hazardous chemicals were not accessible to residents.
Failure to ensure safe disposal of syringes in sharps containers.
Report Facts
Residents sampled: 49
Residents with BPAP: 3
Medication carts: 7
Residents with oral diet: 110
Residents with GT: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DD LPN | MDS Coordinator | Named in care planning and pain management deficiencies. |
| DON | Director of Nursing | Named in multiple interviews regarding care plan expectations and deficiencies. |
| RN CC | Unit Manager | Named in medication storage and safety interviews. |
| LPN LL | Licensed Practical Nurse | Named in nebulizer equipment handling deficiency. |
| RN MM | Registered Nurse | Named in safe syringe disposal deficiency. |
| AA LPN | Licensed Practical Nurse | Named in pain medication process deficiency. |
| PP LPN | Licensed Practical Nurse | Named in pain medication process deficiency. |
| QQ RN | Registered Nurse | Named in pain medication process deficiency. |
Inspection Report
Life Safety
Census: 140
Capacity: 210
Deficiencies: 9
Date: Apr 23, 2025
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with several life safety code requirements including enclosure of vertical openings, hazardous area protections, door closing devices, cooking facility separation, fire alarm system maintenance, sprinkler head clearance, smoke compartment doors, electrical panel clearance, fire drills, and smoking regulations.
Deficiencies (9)
Failed to maintain ceiling tiles that prevent the spread of smoke; several ceiling tiles were broken, damaged, or missing in kitchen and storage areas.
Failed to maintain door closing devices on exit doors from the kitchen; one door closer dismantled and another propped open.
Failed to maintain deep fryer separation; deep fryer was less than 18 inches from gas stove fire source.
Failed to maintain fire alarm system; fire alarm control panel emitting audible trouble alarm.
Failed to maintain sprinkler head clearance; boxes stored within 18 inches of sprinkler head in kitchen storage room.
Failed to maintain smoke corridor doors near room 505; doors failed to close within 1/8 inch gap.
Failed to maintain clear workspace in front of electrical panels; items blocking access to two electrical panels.
Failed to conduct fire drills for each shift per quarter; no fire drills conducted during second shift in second quarter of 2024.
Failed to provide documentation of the no-smoking policy covering rules and requirements.
Report Facts
Census: 140
Total Capacity: 210
Distance: 18
Distance: 18
Gap: 0.125
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Confirmed multiple findings during facility tour and interviews |
Inspection Report
Abbreviated Survey
Census: 128
Deficiencies: 0
Date: Oct 31, 2024
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints on behalf of the Georgia Department of Community Health.
Complaint Details
Complaints #GA00250955, #GA00250854, and #GA00249681 were substantiated. Other complaints listed were unsubstantiated.
Findings
Complaints #GA00250955, #GA00250854, and #GA00249681 were substantiated, while numerous other complaints were unsubstantiated. No deficiencies were cited during the survey.
Report Facts
Complaints investigated: 24
Census: 128
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 04/01/2024 and 04/07/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 8, 2024
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 04/01/2024 and 04/07/2024 as required by regulation, potentially causing more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for River Towne Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 140
Deficiencies: 0
Date: Mar 27, 2024
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during a February 14, 2024 complaint survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on February 14, 2024; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the February 14, 2024 complaint survey were found to be corrected.
Report Facts
Census: 140
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 03/04/2024 and 03/10/2024 as required by CMS and CDC regulations, potentially causing more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 11, 2024
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 03/04/2024 and 03/10/2024 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 3
Date: Feb 14, 2024
Visit Reason
The inspection was conducted to assess the facility's compliance with care plan implementation and treatment of pressure ulcers and venous stasis ulcers for sampled residents.
Findings
The facility failed to implement care plan interventions and provide timely and descriptive wound treatment documentation for pressure ulcers and venous stasis ulcers for several residents, increasing the potential for inadequate care.
Deficiencies (3)
Failed to implement care plan interventions for pressure ulcer treatments and provide descriptive wound documentation for two residents (R2 and R6).
Failed to provide treatment timely for one resident (R10) with a venous stasis ulcer.
Failed to assess pressure ulcers and initiate pressure ulcer treatments timely for three residents (R2, R6, and R10).
Report Facts
Residents sampled: 12
Residents affected: 3
Wound measurements: 7.1
Wound measurements: 8.5
Wound measurements: 0.1
Wound measurements: 12.6
Wound measurements: 11.2
Wound measurements: 0.1
Wound measurements: 0.4
Wound measurements: 0.5
Wound measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Interviewed on 2/13/2024 regarding failure to provide wound treatment documentation for R2 and R6 | |
| Treatment Nurse | Interviewed on 2/14/2024 regarding lack of documentation for treatment of R10 | |
| Administrator | Interviewed on 2/14/2024 regarding staffing issues affecting wound treatment on 2/10/2024 and 2/11/2024 |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Feb 14, 2024
Visit Reason
The inspection was a State Licensure survey conducted to determine compliance with the State Long Term Care Requirements at River Towne Center.
Findings
The facility failed to implement care plan interventions and provide descriptive wound documentation for pressure ulcer treatments for several residents. There were delays in assessing pressure ulcers and initiating treatments as ordered, with missing treatment documentation for multiple residents.
Deficiencies (2)
Failed to implement care plan interventions for pressure ulcer treatments and provide descriptive wound documentation for two of 12 sampled residents (R2 and R6).
Failed to assess pressure ulcers and initiate pressure ulcer treatments timely for three of 12 sampled residents (R2, R6, and R10).
Report Facts
Residents sampled: 12
Pressure ulcer measurements: 7.1
Pressure ulcer measurements: 8.5
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 12.6
Pressure ulcer measurements: 11.2
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Treatment Nurse | Interviewed on 2/13/2024 regarding failure to provide wound documentation and treatment records | |
| Administrator | Interviewed on 2/14/2024 regarding staffing issues affecting treatment administration |
Inspection Report
Complaint Investigation
Census: 127
Deficiencies: 3
Date: Feb 14, 2024
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint intake numbers between February 5, 2024 and February 14, 2024.
Complaint Details
The investigation involved multiple complaint intake numbers. Some complaints were unsubstantiated with no deficiencies, some were substantiated with no deficiencies, and others were substantiated with deficiencies related to wound care and treatment documentation.
Findings
The facility failed to implement care plan interventions and provide descriptive wound documentation for pressure ulcer treatments for several residents, resulting in delayed or undocumented treatments. Some complaints were substantiated with deficiencies, including failure to timely assess and treat pressure ulcers and venous stasis ulcers.
Deficiencies (3)
Failed to implement care plan interventions for pressure ulcer treatments and provide descriptive wound documentation for two residents (R2 and R6).
Failed to provide treatment timely for one resident (R10) with a venous stasis ulcer.
Failed to assess pressure ulcers and initiate pressure ulcer treatments timely for three residents (R2, R6, and R10).
Report Facts
Complaint Intake Numbers: 7
Residents sampled: 12
Resident census: 127
Pressure ulcer measurements: 7.1
Pressure ulcer measurements: 8.5
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 12.6
Pressure ulcer measurements: 11.2
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 0.4
Pressure ulcer measurements: 0.5
Pressure ulcer measurements: 0.1
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
The inspection was conducted to review the facility's compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 02/05/2024 and 02/11/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Feb 12, 2024
Visit Reason
The facility was reviewed for compliance with reporting requirements to the CDC's National Healthcare Safety Network (NHSN) regarding COVID-19 data during a required seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the NHSN between 02/05/2024 and 02/11/2024 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 12, 2023
Visit Reason
A Follow-Up Survey was conducted to verify correction of previously cited deficiencies.
Findings
All previously cited survey tags have been corrected as noted during the follow-up survey.
Inspection Report
Deficiencies: 0
Date: Dec 8, 2023
Visit Reason
The document is a statement of deficiencies and plan of correction for River Towne Center, indicating a regulatory inspection was conducted.
Findings
The report contains an initial comment section but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 149
Deficiencies: 0
Date: Dec 8, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the October 12, 2023 Recertification with Complaint Survey.
Findings
All deficiencies cited in the prior October 12, 2023 survey were found to be corrected during this revisit survey.
Inspection Report
Routine
Census: 131
Deficiencies: 9
Date: Oct 12, 2023
Visit Reason
The inspection was conducted as a routine regulatory survey of River Towne Center to assess compliance with healthcare facility regulations, including resident rights, care plans, medication administration, infection control, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to promote resident self-determination regarding bathing preferences, incomplete baseline care plans for fall risk, inadequate assistance with activities of daily living, failure to administer medications as ordered, failure to provide appropriate respiratory care, failure to discard expired medications and supplies, failure to provide timely laboratory services, and significant deficiencies in infection prevention and control resulting in an Immediate Jeopardy related to COVID-19 outbreak management.
Deficiencies (9)
Failed to provide care in a manner that maintained or enhanced a resident's dignity for one resident.
Failed to promote and facilitate resident self-determination through support of resident choice for bathing for four residents.
Failed to ensure baseline care plan included goals and interventions for fall risk for one resident.
Failed to provide activities of daily living related to bathing for one resident.
Failed to administer medication as ordered for two residents, including missed doses of Ozempic and unavailable neuropathy medication.
Failed to provide safe and appropriate respiratory care for one resident, including incorrect oxygen flow and unbagged BiPAP tubing.
Failed to discard discontinued and outdated supplements, tube feedings, and COVID-19 tests stored in medication storage area.
Failed to get labs and administer treatment for infection in a timely manner for one resident.
Failed to maintain an effective Infection Prevention Control Program, including failure to follow CDC guidelines for COVID-19 outbreak testing, cohorting, source control, and notification, resulting in Immediate Jeopardy.
Report Facts
Residents tested for COVID-19: 119
Staff tested for COVID-19: 95
Residents refused COVID-19 testing: 7
Total positive residents: 5
Total positive staff: 1
Facility census: 131
Morse Fall Scale score: 40
Medication doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA IIII | Certified Nurse Aid | Observed transferring resident R11 with mechanical lift |
| LPN CC | Licensed Practical Nurse | Named in medication administration deficiency for missed Ozempic doses |
| LPN QQ | Unit Manager | Confirmed missed Ozempic doses and medication replacement issues |
| RRT EE | Respiratory Therapist | Reported respiratory therapy monitoring practices |
| Administrator | Named in infection control deficiency and Immediate Jeopardy management | |
| Director of Nursing | DON | Named in multiple deficiencies including infection control and medication management |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Named in infection control deficiency and outbreak management |
| Medical Director | Named in medication and infection control deficiencies |
Inspection Report
Routine
Census: 131
Deficiencies: 10
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident rights, care plans, medication administration, respiratory care, infection control, and COVID-19 outbreak management at River Towne Center.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity, failure to provide resident choice in bathing, incomplete baseline care plans, inadequate assistance with activities of daily living, medication administration errors, improper respiratory care, failure to discard expired medications and supplies, delayed laboratory testing and treatment, and significant deficiencies in infection prevention and control resulting in a COVID-19 outbreak with immediate jeopardy status.
Deficiencies (10)
Failed to provide care in a manner that maintained or enhanced a resident's dignity by placing a resident in a wheelchair in the hallway instead of in his room.
Failed to promote and facilitate resident self-determination through support of resident choice related to bathing and showering.
Failed to ensure baseline care plan included goals and interventions for fall risk for one resident.
Failed to provide activities of daily living related to bathing for one resident.
Failed to administer medication as ordered for two residents, including missed doses of Ozempic and unavailable neuropathy medication.
Failed to provide oxygen therapy as ordered and failed to contain BiPAP tubing in a clean plastic bag when not in use for one resident.
Failed to discard discontinued and outdated supplements, tube feedings, and COVID-19 tests stored in medication storage areas.
Failed to get labs and administer treatment for infection in a timely manner for one resident.
Failed to maintain an effective Infection Prevention Control Program (IPCP) to prevent or reduce the spread of COVID-19, resulting in immediate jeopardy with five residents and two staff testing positive.
Failed to implement initial and ongoing testing of residents and staff as recommended by CDC, failed to ensure source control during outbreak, and failed to notify staff and family of outbreak status.
Report Facts
Residents tested for COVID-19: 119
Staff tested for COVID-19: 95
Residents refused COVID-19 testing: 7
Total positive residents: 5
Total positive staff: 2
Morse Fall Scale score: 40
Ozempic doses missed: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA IIII | Certified Nurse Aid | Observed transferring resident R11 with mechanical lift in hallway |
| LPN CC | Licensed Practical Nurse | Did not administer Ozempic injections on three dates |
| LPN QQ | Unit Manager | Confirmed missed Ozempic doses and described medication replacement process |
| DON | Director of Nursing | Provided multiple interviews regarding resident care, infection control, and medication issues |
| ADON/IP | Assistant Director of Nurses/Infection Preventionist | Responsible for contact tracing and outbreak management |
| Administrator | Facility Administrator | Responsible for infection control oversight and COVID-19 outbreak management |
| RRT EE | Respiratory Therapist | Reported respiratory therapy monitoring and BiPAP checks |
Inspection Report
Life Safety
Census: 132
Capacity: 210
Deficiencies: 8
Date: Oct 12, 2023
Visit Reason
The inspection was a Life Safety Code Survey conducted to assess compliance with fire safety regulations and related NFPA standards for participation in Medicare/Medicaid.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including exit signage, cooking facility hood system, fire alarm system installation, corridor doors, smoke barrier doors, fire doors, fire drills, smoking regulations, and fire door maintenance and inspection. Several deficiencies posed risks to residents and staff in the event of fire.
Deficiencies (8)
Exit doors were marked but did not meet exit requirements, including a door over a non-required door that could confuse occupants.
Cooking hood suppression system was not compliant with NFPA 96; caps missing on nozzles, broken filter, and kitchen staff lacked proper training on hood extinguishment system.
Fire alarm control panel lacked power circuit (breaker) identification.
Resident corridor doors did not close properly or latch, failing to create a smoke tight seal.
Smoke barrier doors were not maintained in reliable working order; fire doors outside certain rooms did not close or lacked self-closing mechanisms.
Facility failed to conduct and document quarterly fire drills for each shift, missing documentation for second and third quarters of 2023.
Facility failed to follow smoking regulations; cigarette butts were found disposed in a trash can reserved for paper waste.
Facility failed to document annual inspections and testing of fire door assemblies within the past 12 months.
Report Facts
Residents at risk: 100
Staff at risk: 20
Residents at risk: 20
Staff at risk: 7
Residents at risk: 25
Staff at risk: 10
Residents at risk: 30
Residents at risk: 100
Residents at risk: 10
Residents at risk: 100
Staff at risk: 20
Residents at risk: 132
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff M | Staff member who confirmed multiple findings during the tour and interviews |
Inspection Report
Annual Inspection
Census: 131
Deficiencies: 4
Date: Oct 12, 2023
Visit Reason
A State Licensure survey was conducted at River Towne Center from 10/3/2023 through 10/12/2023 to assess compliance with state licensure requirements.
Findings
The facility was found not in substantial compliance due to failures in infection prevention and control related to a COVID-19 outbreak affecting five residents and two staff, improper medication storage including expired items, and failure to provide adequate bathing care to one resident. Immediate Jeopardy was identified and removed after corrective actions.
Deficiencies (4)
Failure to maintain an effective Infection Prevention Control Program (IPCP) to identify and investigate a COVID-19 outbreak, resulting in five residents and two staff testing positive.
Failure to discard discontinued and outdated supplements, tube feedings, and COVID-19 tests stored in medication storage areas.
Failure to implement initial and ongoing testing of residents and staff as recommended by CDC during COVID-19 outbreak, failure to ensure source control, and failure to notify staff and family appropriately.
Failure to provide adequate Activities of Daily Living (ADL) bathing care to one resident (R80), with documentation showing missed baths and observations of foul odor.
Report Facts
Residents tested for COVID-19: 119
Staff tested for COVID-19: 95
Residents refusing COVID-19 testing: 7
Total positive residents: 5
Total positive staff: 1
Facility census: 131
Sampled residents for bathing deficiency: 59
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CC | Licensed Practical Nurse (LPN) | Interviewed regarding medication storage and disposal practices. |
| SSS | Licensed Practical Nurse (LPN) | Interviewed about resident COVID-19 testing and mask usage. |
| ZZZ | Certified Nursing Assistant (CNA) | Interviewed about isolation room door protocols and mask usage. |
| BBBBB | Receptionist | Interviewed about knowledge of outbreak status and mask distribution. |
| NNNN | Registered Nurse/Unit Manager | Interviewed about bathing documentation and procedures. |
| DON | Director of Nursing | Interviewed regarding infection control, outbreak management, and bathing care. |
| ADON/IP | Assistant Director of Nursing/Infection Preventionist | Interviewed about outbreak contact tracing, testing, and infection control practices. |
| Administrator | Facility Administrator | Interviewed about outbreak response and infection control oversight. |
| Medical Director | Medical Director | Interviewed about resident cohorting and outbreak awareness. |
Inspection Report
Abbreviated Survey
Census: 131
Deficiencies: 11
Date: Oct 12, 2023
Visit Reason
A standard survey was conducted from 10/3/2023 through 10/12/2023, including investigation of multiple complaint intakes, to assess compliance with Medicare/Medicaid regulations and infection control related to a COVID-19 outbreak.
Complaint Details
Complaint Intake Numbers GA00237629, GA00239046, GA002329697, GA00239257, GA00237422, and GA00238223 were investigated. Complaint GA00239046 was substantiated with deficiency; others were unsubstantiated.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, including failure to implement outbreak testing and infection control measures during a COVID-19 outbreak, failure to maintain resident dignity, failure to provide choice in bathing, incomplete baseline care plans, failure to administer medications as ordered, failure to provide respiratory care as ordered, failure to discard expired medications and supplies, and failure to timely obtain and act on laboratory results. Immediate Jeopardy was identified and removed after corrective actions.
Deficiencies (11)
Failure to implement outbreak testing for residents and staff after a resident tested positive for COVID-19, resulting in five residents and two staff testing positive.
Failure to maintain resident dignity by transferring a resident in a mechanical lift in the hallway instead of in the resident's room.
Failure to allow residents the choice to take showers instead of bed baths due to staffing shortages and scheduling practices.
Failure to complete baseline care plan for one resident to include goals and interventions for fall risk.
Failure to provide Activities of Daily Living (ADL) related to bathing for one resident, with evidence of inadequate bathing and hygiene.
Failure to administer medication as ordered for two residents, including missed doses of Ozempic due to discarded medication and unavailable neuropathy medication.
Failure to provide oxygen therapy as ordered and failure to contain BiPAP tubing in a clean plastic bag when not in use for one resident.
Failure to discard discontinued and outdated supplements, tube feedings, and COVID-19 tests stored in medication storage areas.
Failure to obtain and act on laboratory tests in a timely manner for one resident with a multidrug resistant infection.
Failure to maintain an effective Infection Prevention Control Program to identify and investigate a COVID-19 outbreak, including failure to follow CDC guidelines for testing, cohorting, source control, and notification, resulting in Immediate Jeopardy.
Failure to implement initial and ongoing testing of residents and staff as recommended by CDC, failure to ensure source control during outbreak, failure to monitor and document COVID-19 symptoms, and failure to notify staff and family of outbreak status.
Report Facts
Resident census: 131
Residents tested: 119
Staff tested: 95
Positive residents: 5
Positive staff: 2
Staff in-service completion: 106
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Named in Immediate Jeopardy notification and infection control failures | |
| Director of Nursing | Named in Immediate Jeopardy notification and infection control failures | |
| Regional Vice President | Named in Immediate Jeopardy notification and infection control failures | |
| Assistant Director of Nursing/Infection Preventionist | Named in infection control findings and Immediate Jeopardy | |
| LPN CC | Licensed Practical Nurse | Named in medication administration deficiency related to missed Ozempic doses |
| RRT EE | Respiratory Therapist | Named in respiratory care deficiency |
| LPN HHHH | Licensed Practical Nurse | Named in respiratory care deficiency |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 28, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate complaints #GA00235506, #GA00235643, #GA00235773, #GA00236886, and #GA00237324 at River Towne Care and Rehabilitation Center.
Complaint Details
Complaints #GA00235506, #GA00235643, #GA00235773, #GA00236886, and #GA00237324 were unsubstantiated.
Findings
The complaints investigated were unsubstantiated and no regulatory violations were cited during the survey conducted on behalf of the Georgia Department of Community Health by Ascellon Corporation.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: May 22, 2023
Visit Reason
This document is a Statement of Deficiencies and Plan of Correction for River Towne Center, indicating a regulatory inspection was conducted and deficiencies were identified requiring correction.
Findings
The report contains a summary statement of deficiencies identified during the inspection; however, no specific deficiencies or severity levels are detailed in the provided page.
Inspection Report
Re-Inspection
Census: 138
Deficiencies: 0
Date: May 22, 2023
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the March 30, 2023 Focused Infection Control/Complaints Survey.
Findings
All deficiencies cited in the prior March 30, 2023 survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to a medication discrepancy involving a missing Tramadol pill for resident #306, which triggered drug testing of nursing staff and investigation of controlled substances management.
Complaint Details
The visit was complaint-related due to a medication discrepancy about two weeks prior involving a missing Tramadol pill for resident #306. Drug testing of nursing staff was conducted, resulting in termination of one nurse for testing positive for another drug. The resident confirmed receiving medication as requested. The facility was unable to determine what happened to the missing medication.
Findings
The facility failed to ensure that one resident's narcotic pain medication was free from diversion and failed to maintain accurate records on controlled substances across six medication carts, with multiple missing medications, missing shift counts, and missing signatures documented. Despite these issues, the resident reported receiving pain medication as requested, and one nurse was terminated after testing positive for a non-opioid drug.
Deficiencies (2)
Failed to ensure one resident's narcotic pain medication (Tramadol) was free from diversion.
Failed to maintain accurate records on controlled substances on six medication carts, including missing medications, missing shift counts, and missing signatures.
Report Facts
Medication missing dates: 15
Missing signatures: 60
Drug screens conducted: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Interviewed regarding medication cart counting procedures. |
| BB | Licensed Practical Nurse (LPN) | Interviewed regarding medication cart counting procedures. |
| Director of Nursing | Director of Nursing (DON) | Conducted drug screens, investigated medication discrepancies, and provided interviews about medication management. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 30, 2023
Visit Reason
The inspection was conducted due to a complaint regarding medication discrepancies, specifically the diversion of narcotic pain medication (Tramadol) for one resident (R#306).
Complaint Details
The complaint investigation was substantiated by findings of a missing Tramadol pill for resident R#306. Drug testing of nursing staff was conducted, resulting in one nurse's termination. The resident confirmed receiving medication as requested despite the discrepancy.
Findings
The facility failed to ensure that one resident's narcotic pain medication was free from diversion, with one Tramadol pill missing. Drug screens were conducted on nursing staff, resulting in one nurse's termination for testing positive for another drug. Additionally, the facility failed to maintain accurate records on controlled substances across six medication carts, with multiple missing medications, missing shifts, and missing signatures documented.
Deficiencies (2)
Failed to protect resident from wrongful use of belongings or money related to narcotic medication diversion for one resident (R#306).
Failed to maintain accurate records on controlled substances on six medication carts, including missing medications, missing shifts, and missing signatures.
Report Facts
Medication missing dates: 1
Controlled Drug Shift Audit missing medication dates: 15
Missing signatures: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing (DON) | Conducted drug screens on nursing staff and investigated medication discrepancies |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Described medication cart counting procedures during interview |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Confirmed two nurses are required to count medication carts each shift |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Mar 30, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints (GA00227950, GA00232296, GA00231309, GA00233743, GA00228884, GA00231353) initiated on March 27, 2023 and concluded on March 30, 2023.
Complaint Details
The survey was initiated to investigate complaints GA00227950, GA00232296, GA00231309, GA00233743, GA00228884, and GA00231353. The findings confirmed deficiencies related to controlled substance record-keeping.
Findings
The facility failed to maintain accurate records on controlled substances across six medication carts, with multiple instances of missing medication totals, incomplete shift counts, and missing signatures documented in the Controlled Drug Shift Audit Reports from January through March 2023.
Deficiencies (1)
Failure to maintain accurate records on controlled substances on six medication carts.
Report Facts
Medication totals missing: 27
Single shift counts: 70
No shifts indicated: 30
Missing signatures: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Licensed Practical Nurse (LPN) | Interviewed on 3/27/23 regarding medication cart counting procedures and discrepancy handling |
| BB | Licensed Practical Nurse (LPN) | Interviewed on 3/27/23 confirming two nurses are required to count medication carts each shift |
| Director of Nursing | Director of Nursing (DON) | Interviewed on 3/29/23 regarding pharmacy medication reviews and facility procedures |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Mar 30, 2023
Visit Reason
A Focused Infection Control Survey was conducted in conjunction with an Abbreviated/Partial Extended Survey investigating multiple complaints related to medication management and controlled substances.
Complaint Details
The investigation was initiated due to complaints GA00227950, GA00232296, GA00231309, GA00233743, GA00228884, and GA00231353. The Director of Nursing reported a medication discrepancy involving a missing Tramadol pill for resident #306, leading to drug testing of nursing staff and termination of one nurse for testing positive for another drug. Multiple discrepancies in controlled drug shift audits were found across medication carts.
Findings
The facility failed to ensure that one resident's narcotic pain medication was free from diversion and failed to maintain accurate records on controlled substances across six medication carts, with multiple discrepancies and missing medication counts documented.
Deficiencies (2)
Failed to ensure that one resident's (R#306) narcotic pain medication (Tramadol) was free from diversion.
Failed to maintain accurate records on controlled substances on six of six medication carts, including missing medication totals, missing shifts, and missing signatures.
Report Facts
Medication missing dates: 15
Medication carts with discrepancies: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Conducted drug screens on nurses after medication discrepancy; reported findings and actions taken. |
| Licensed Practical Nurse AA | Licensed Practical Nurse | Interviewed regarding medication cart counting procedures. |
| Licensed Practical Nurse BB | Licensed Practical Nurse | Interviewed regarding medication cart counting procedures. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 17, 2023
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaint allegations identified by codes GA00229297, GA00228747, GA00227952, GA00227448, GA00226347, and GA00226074.
Complaint Details
The investigation involved multiple complaint allegations identified by codes GA00229297, GA00228747, GA00227952, GA00227448, GA00226347, and GA00226074, all of which were unsubstantiated.
Findings
The investigation was conducted on behalf of the Georgia Department of Community Health by Ascellon Corporation and all complaints were found to be unsubstantiated. No deficiencies were cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 2, 2023
Visit Reason
An abbreviated survey was conducted to investigate complaint #GA00232026.
Complaint Details
Complaint #GA00232026 was investigated and found to be unsubstantiated with no deficiencies cited.
Findings
The complaint was found to be unsubstantiated and no deficiencies were cited during the survey.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Dec 22, 2022
Visit Reason
An Abbreviated Survey was conducted to investigate complaint #GA00230671.
Complaint Details
Complaint #GA00230671 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the abbreviated survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 12, 2022
Visit Reason
The facility was reviewed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 12/05/2022 and 12/11/2022 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 12, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 12/05/2022 and 12/11/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 5, 2022
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/28/2022 and 12/04/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Date range: From 2022-11-28 to 2022-12-04, incomplete COVID-19 reporting occurred
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 5, 2022
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/28/2022 and 12/04/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 28, 2022
Visit Reason
The inspection was conducted to review the facility's compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network (NHSN) during a mandated seven-day reporting period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 11/21/2022 and 11/27/2022 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 28, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/21/2022 and 11/27/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
The facility was surveyed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/14/2022 and 11/20/2022 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 21, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/14/2022 and 11/20/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 15, 2022
Visit Reason
The facility was reviewed for failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/07/2022 and 11/13/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Date range: Between 11/07/2022 and 11/13/2022
Inspection Report
Deficiencies: 1
Date: Nov 15, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 11/07/2022 and 11/13/2022 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Date range: Between 11/07/2022 and 11/13/2022
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 7, 2022
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 10/31/2022 and 11/06/2022 as required by regulation, potentially causing more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Nov 7, 2022
Visit Reason
The facility was reviewed due to failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/31/2022 and 11/06/2022 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's NHSN during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/24/2022 and 10/30/2022 as required by CMS and CDC regulations, potentially causing more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 1
Date: Oct 31, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/24/2022 and 10/30/2022 as required by CMS and CDC regulations, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Date range: 10/24/2022 to 10/30/2022
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 24, 2022
Visit Reason
The facility was reviewed for compliance with COVID-19 reporting requirements to the CDC's National Healthcare Safety Network during a seven-day period.
Findings
The facility failed to report complete COVID-19 information to the CDC's NHSN between 10/17/2022 and 10/23/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Oct 24, 2022
Visit Reason
The report addresses the facility's failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Findings
The facility did not report complete COVID-19 data to the NHSN between 10/17/2022 and 10/23/2022 as required by CMS and CDC regulations, which could potentially cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 10/10/2022 and 10/16/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Oct 17, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 10/10/2022 to 10/16/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Sep 19, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 09/12/2022 and 09/18/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 19, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 09/12/2022 to 09/18/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 09/05/2022 and 09/11/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Sep 12, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 09/05/2022 to 09/11/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day period between 08/29/2022 and 09/04/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Sep 6, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 08/29/2022 and 09/04/2022, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/15/2022 to 08/21/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 22, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/15/2022 to 08/21/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
The inspection was conducted due to the facility's failure to report complete COVID-19 information to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN) as required by regulation.
Findings
The facility failed to report complete information about COVID-19 infections, deaths, supplies, testing access, staffing shortages, vaccination status, and therapeutics to the NHSN during the seven-day period from 08/08/2022 to 08/14/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/08/2022 to 08/14/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's NHSN during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 8, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 08/01/2022 and 08/07/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Aug 8, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 08/01/2022 to 08/07/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period between 07/25/2022 and 07/31/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a seven-day required reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Aug 2, 2022
Visit Reason
The inspection was conducted to evaluate the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period from 07/25/2022 to 07/31/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Routine
Deficiencies: 1
Date: Jul 11, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 07/04/2022 to 07/10/2022 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jul 11, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 07/04/2022 to 07/10/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 5, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a required seven-day reporting period from 06/27/2022 to 07/03/2022, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a seven-day period as required by regulation.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jul 5, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 06/20/2022 and 06/26/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jun 27, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 06/20/2022 and 06/26/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Jun 21, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 06/13/2022 and 06/19/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Jun 21, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 06/13/2022 and 06/19/2022 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 0
Date: May 25, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for River Towne Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details on deficiencies or findings.
Inspection Report
Re-Inspection
Census: 147
Deficiencies: 0
Date: May 25, 2022
Visit Reason
A Revisit Survey was conducted from May 24 through May 25, 2022 to verify correction of deficiencies cited during the Recertification with Complaints Survey on March 17, 2022.
Findings
All deficiencies cited as a result of the Recertification with Complaints Survey on March 17, 2022 were found to be corrected during this revisit survey.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 2, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Date range: Between 2022-04-25 and 2022-05-01, the facility did not report complete information
Inspection Report
Deficiencies: 1
Date: May 2, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 04/25/2022 and 05/01/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Apr 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 04/11/2022 and 04/17/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Apr 18, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Apr 11, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 04/04/2022 and 04/10/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Apr 11, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period from 04/04/2022 to 04/10/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Report Facts
Reporting period: 7
Inspection Report
Deficiencies: 1
Date: Mar 28, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 03/21/2022 and 03/27/2022 as required by regulation, which has the potential to cause more than minimal harm to all residents.
Deficiencies (1)
Failure to report complete information about COVID-19 to the CDC's National Healthcare Safety Network during a required seven-day reporting period.
Report Facts
Reporting period: 7
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Mar 28, 2022
Visit Reason
The inspection was conducted to assess the facility's compliance with COVID-19 reporting requirements to the Centers for Disease Control and Prevention's National Healthcare Safety Network (NHSN).
Findings
The facility failed to report complete information about COVID-19 to the NHSN during a seven-day period between 03/21/2022 and 03/27/2022 as required by regulation, which has the potential to cause more than minimal harm to residents.
Deficiencies (1)
Failure to report complete COVID-19 information to the CDC's National Healthcare Safety Network during a required seven-day period.
Report Facts
Reporting period: 7
Inspection Report
Annual Inspection
Census: 146
Deficiencies: 4
Date: Mar 17, 2022
Visit Reason
A licensure survey was conducted from 03/14/2022 through 03/17/2022, including investigation of multiple complaint intake numbers, to assess the facility's compliance with state regulations.
Complaint Details
Multiple complaint intake numbers were investigated in conjunction with the standard survey. No deficiencies were cited for most complaints except for complaint intake number GA00216744, which resulted in citation F677 related to failure to provide required transfer notices.
Findings
The facility was found not in substantial compliance due to deficiencies including failure to provide required written transfer notices to residents and the Ombudsman, unsecured medication carts accessible to unauthorized persons, inadequate oral care for a dependent resident, and incomplete and inaccurate clinical documentation of medication and treatment administration.
Deficiencies (4)
Failure to provide required written transfer notices to residents and the Ombudsman for hospital transfers.
Failure to ensure medication and treatment carts were locked, attended by licensed staff, and inaccessible to others.
Failure to provide good oral care/hygiene as needed for a dependent resident, placing the resident at risk for discomfort and decline in teeth and gum condition.
Failure to maintain complete and accurate clinical records, including documentation of medication and treatment administration for one resident.
Report Facts
Residents reviewed for hospitalization: 3
Residents reviewed for ADL care: 6
Residents sampled: 29
Medication carts unlocked: 4
Treatment carts unlocked: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse 3 | LPN | Identified unlocked medication cart and locked it upon survey team inquiry |
| Licensed Practical Nurse 8 | LPN | Left medication cart unlocked after unsuccessful locking attempt |
| Director of Nursing | DON | Acknowledged expectations for medication cart security and confirmed incomplete documentation of medication administration |
| Business Office Manager | BOM | Reported lack of notification to Ombudsman for resident hospital transfers |
| Certified Nursing Assistant 6 | CNA | Confirmed resident had visible white particles on teeth and that respiratory staff had provided suction care |
| Respiratory Therapist Lead | RT | Described oral care procedures and confirmed filter changes were not documented |
| Licensed Practical Nurse 6 | LPN | Confirmed medications and treatments should be signed off immediately after administration |
| Administrator | Unaware of regulatory requirement to notify Ombudsman of resident transfers | |
| Medical Director | Stated expectation for mouth care frequency for ventilator-dependent residents |
Inspection Report
Annual Inspection
Census: 146
Deficiencies: 9
Date: Mar 17, 2022
Visit Reason
A Recertification and Complaint survey was conducted from 03/14/2022 through 03/17/2022, including investigation of multiple complaint intake numbers.
Complaint Details
Complaint Intake number GA00216744 was investigated and deficiency F677 was cited.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies related to resident self-administration of medications, advance directives, transfer notices, bed hold notices, care plan revisions, ADL care, respiratory care, medication storage, and medical record documentation.
Deficiencies (9)
Failed to ensure two residents self-administered medications only when clinically appropriate and supervised.
Failed to assist four residents with advance directives and document code status.
Failed to provide required written transfer notices to residents and Ombudsman for two residents transferred to hospital.
Failed to provide written bed hold notices to two residents transferred to hospital.
Failed to revise care plan for one resident after Foley catheter removal.
Failed to provide good oral care for one dependent resident on ventilator.
Failed to provide respiratory care consistent with orders for six residents, including oxygen therapy at correct flow rates, monitoring oxygen saturation, and cleaning/changing oxygen equipment.
Failed to ensure medication and treatment carts were locked and attended, allowing potential unauthorized access.
Failed to maintain complete and accurate medical records for one resident, including documentation of medication administration and treatment.
Report Facts
Resident census: 146
Residents receiving respiratory treatment: 31
Number of complaint intake numbers investigated: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| West Hall | Unit Manager | Confirmed lack of code status documentation for resident R77 |
| Assistant Director of Nursing | ADON | Confirmed lack of physician orders and assessments for self-administration and code status |
| Medical Director | Stated importance of advance directives and code status documentation | |
| Director of Nursing | DON | Confirmed removal of unauthorized medications at bedside and lack of transfer notices |
| Licensed Practical Nurse 3 | LPN | Found medication cart unlocked and locked it |
| Licensed Practical Nurse 8 | LPN | Left medication cart unlocked and confirmed it did not lock |
| Respiratory Therapist Lead | RT | Confirmed responsibility for oxygen concentrator filters and lack of cleaning |
| Licensed Practical Nurse 6 | LPN | Confirmed medication documentation expectations |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 15, 2022
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to medication self-administration, advance directives, transfer notifications, care planning, respiratory care, medication storage, and clinical record documentation.
Findings
The facility failed to ensure proper assessment and physician orders for residents self-administering medications, lacked documentation and assistance for advance directives, did not provide timely transfer and bed hold notices, failed to update care plans after clinical changes, did not provide adequate oral care for dependent residents, failed to provide respiratory care as ordered including oxygen therapy and equipment maintenance, left medication carts unlocked and unattended, and had incomplete clinical documentation for medications and treatments.
Deficiencies (9)
Failed to ensure residents self-administered medications only when clinically appropriate with physician orders and staff supervision.
Failed to ensure residents had assistance with advance directives and documentation of code status.
Failed to provide timely written transfer notices and notification to Ombudsman for residents transferred to hospital.
Failed to provide written bed hold notices to residents or representatives after hospital transfers.
Failed to update care plan after removal of indwelling catheter for a resident.
Failed to provide adequate oral care for a ventilator-dependent resident, resulting in visible debris on teeth.
Failed to provide respiratory care as ordered including oxygen therapy at prescribed flow rates, monitoring oxygen saturation, cleaning and changing oxygen tubing, filters, and water bottles, and proper storage of oxygen equipment.
Failed to ensure medication carts and treatment carts were locked, attended, and inaccessible to unauthorized persons.
Failed to maintain complete and accurate clinical records including documentation of medication administration and respiratory filter changes.
Report Facts
Residents receiving respiratory treatment: 31
Oxygen flow rate: 3
Oxygen flow rate: 5
Bed hold days: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Unit Manager | Confirmed resident R42 was self-administering nebulizer treatment without staff supervision and oxygen concentrator was set incorrectly | |
| Assistant Director of Nursing | ADON | Confirmed lack of physician orders and assessments for self-administration of medications for residents R42 and R86 |
| Director of Nursing | DON | Confirmed lack of advance directive policies, transfer notices, bed hold notices, and expectations for medication cart security |
| Medical Director | MD | Stated all medications need orders and self-administration evaluations; confirmed lack of advance directive assistance |
| Certified Nursing Assistant | CNA 4 | Confirmed resident R95 did not have Foley catheter and care plan was not updated |
| Licensed Practical Nurse | LPN 6 | Confirmed resident R95 did not have Foley catheter and medications should be signed off immediately after administration |
| Respiratory Therapist Lead | RT | Confirmed responsibility for oxygen concentrator filter changes and lack of documentation |
| Licensed Practical Nurse | LPN 3 | Found medication cart unlocked with keys on top and locked it |
| Licensed Practical Nurse | LPN 8 | Left medication cart unlocked due to malfunctioning lock |
Inspection Report
Life Safety
Census: 146
Capacity: 210
Deficiencies: 0
Date: Mar 15, 2022
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and emergency preparedness requirements.
Findings
The facility was found to be in substantial compliance with the requirements for participation in Medicare/Medicaid under 42 CFR Subpart 483.90(a) and the NFPA 101 Life Safety Code 2012 edition. The Emergency Preparedness Program was also reviewed and found to be in substantial compliance with 42 CFR 483.73.
Report Facts
Census: 146
Total Capacity: 210
Inspection Report
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for River Towne Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific findings or deficiencies in the provided page.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 29, 2021
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the complaint survey of 5/24/2021.
Complaint Details
The revisit survey was conducted following a complaint survey on 5/24/2021; all deficiencies from that complaint survey were corrected.
Findings
The revisit survey found that all deficiencies cited during the complaint survey were corrected.
Inspection Report
Abbreviated Survey
Census: 135
Deficiencies: 3
Date: May 24, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted from 4/13/2021 to 5/24/2021 to investigate multiple complaints, including GA00211820, GA00212582, GA00212694, GA00213426, GA00214236, GA00214360, and GA00214500.
Complaint Details
Complaint GA00212694 was substantiated with deficiencies related to criminal background checks, care plan implementation, and abuse reporting. Other complaints investigated were unsubstantiated.
Findings
The survey substantiated one complaint (GA00212694) with deficiencies including failure to perform a timely criminal background check for the Administrator, failure to implement care plan interventions for a resident's wound treatment, and failure to report an allegation of abuse in a timely manner involving a resident and a staff member.
Deficiencies (3)
Facility failed to perform a thorough criminal background check for the Administrator prior to hire.
Facility failed to implement care plan interventions for one resident (R#16) regarding wound treatment as ordered.
Facility failed to ensure timely reporting of an allegation of abuse involving resident R#23 and Licensed Practical Nurse (LPN) BB.
Report Facts
Resident census: 135
Sampled residents: 28
Incident report date: Apr 6, 2021
Incident date and time: Apr 2, 2021
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in substantiated abuse allegation and subsequent termination |
| RT DD | Respiratory Therapist | Witness to abuse incident and delayed reporting |
| RT CC | Respiratory Therapist | Witness to abuse incident and delayed reporting |
| Administrator | Interviewed regarding background check, care plan implementation, and abuse reporting |
Inspection Report
Abbreviated Survey
Census: 135
Deficiencies: 5
Date: May 24, 2021
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints against the facility, including GA00211820, GA00212582, GA00212694, GA00213426, GA00214236, GA00214360, and GA00214500.
Complaint Details
The survey investigated multiple complaints, with one substantiated complaint (GA00212694) involving abuse of resident R#23 by LPN BB. The abuse was confirmed through staff witness statements and investigation, resulting in termination of LPN BB.
Findings
The survey substantiated one complaint involving abuse of a resident by a Licensed Practical Nurse (LPN BB) and identified failures in abuse prevention policies, timely reporting of abuse allegations, criminal background checks for staff, and implementation of care plans and treatments for residents.
Deficiencies (5)
Failure to ensure one resident (R#23) was free from verbal and physical abuse by staff.
Failure to perform thorough criminal background checks for the Administrator and one Licensed Practical Nurse (LPN AA).
Failure to report an allegation of abuse in a timely manner for one resident (R#23).
Failure to implement care plan interventions for one resident (R#16) with wounds.
Failure to ensure wound treatment was completed as ordered for one resident (R#16).
Report Facts
Resident census: 135
Date of incident: Apr 2, 2021
Date of report: Apr 6, 2021
Number of sampled residents: 28
Wound size: 1
Wound depth: 0.4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN BB | Licensed Practical Nurse | Named in abuse finding involving resident R#23; terminated after substantiated abuse |
| LPN AA | Licensed Practical Nurse | Named in deficiency for lack of criminal background check |
| RT CC | Respiratory Therapist | Witnessed abuse incident involving resident R#23 and LPN BB |
| RT DD | Respiratory Therapist | Witnessed abuse incident involving resident R#23 and LPN BB; delayed reporting abuse |
| Administrator | Interviewed regarding background checks and abuse reporting delays |
Inspection Report
Complaint Investigation
Census: 104
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted in conjunction with a Complaint survey to investigate Complaint Intake number GA00211427, and a Revisit survey was also conducted.
Complaint Details
Complaint Intake number GA00211427 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with infection control regulations and COVID-19 preparedness practices. The complaint was found to be unsubstantiated, and all previously cited deficiencies had been corrected.
Report Facts
Facility census: 104
Inspection Report
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
The document is a statement of deficiencies and plan of correction for River Towne Center, indicating a regulatory inspection was conducted.
Findings
The report contains initial comments but does not provide specific details about deficiencies or findings.
Inspection Report
Re-Inspection
Census: 104
Deficiencies: 0
Date: Jan 29, 2021
Visit Reason
A revisit survey was conducted in conjunction with a Focused Infection Control survey and a Complaint survey investigating complaint intake number GA00211427.
Complaint Details
Complaint intake GA00211427 was investigated and found to be unsubstantiated.
Findings
The revisit survey revealed that all previously cited deficiencies from the November 6, 2020 complaint survey had been corrected. The facility was found to be in compliance with infection control regulations and COVID-19 recommended practices. The complaint intake was found to be unsubstantiated.
Report Facts
Census: 104
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 14, 2021
Visit Reason
An abbreviated/partial extended survey was conducted to investigate multiple complaints numbered GA00209450, GA00209521, GA00209538, GA00209554, and GA00210480.
Complaint Details
The survey investigated complaints GA00209450, GA00209521, GA00209538, GA00209554, and GA00210480, all of which were unsubstantiated with no deficiencies.
Findings
The complaints investigated during the survey were found to be unsubstantiated, and no deficiencies were identified.
Report Facts
Complaint numbers investigated: 5
Inspection Report
Complaint Investigation
Census: 131
Deficiencies: 2
Date: Nov 6, 2020
Visit Reason
An Abbreviated/Partial Extended survey and a COVID-19 Focused Infection Control survey were conducted, investigating twenty-five complaint intakes related to the facility's compliance with Medicare/Medicaid regulations.
Complaint Details
Twenty-five complaint intakes were investigated; several were unsubstantiated, some partially substantiated without deficiencies, some substantiated without deficiencies, and two substantiated with deficiencies resulting in Immediate Jeopardy. The Immediate Jeopardy related to failure in monitoring and care planning for residents at risk of falls and on anticoagulant therapy, leading to serious injury and death.
Findings
The facility was found not in substantial compliance with regulations, with Immediate Jeopardy identified related to failure to monitor and assess residents after falls, failure to notify physicians and responsible parties timely, and failure to develop comprehensive person-centered care plans addressing falls and anticoagulant use. Immediate Jeopardy was removed after corrective actions including staff education, audits, and care plan reviews.
Deficiencies (2)
Failure to notify the Attending Physician and Responsible Party promptly after a resident's fall resulting in a fractured elbow.
Failure to implement interventions for monitoring and assessing residents after falls and failure to develop comprehensive person-centered care plans for anticoagulant use and other care needs.
Report Facts
Resident census: 131
Complaint intakes investigated: 25
Residents with falls care plans reviewed: 14
Residents on anticoagulation therapy care plans reviewed: 32
Licensed nursing staff educated: 29
Licensed nursing staff total: 32
Education completion rate: 85
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Nurse assigned to Resident #10 at time of fall who failed to notify MD and Responsible Party timely |
| RN GG | Registered Nurse | Agency nurse interviewed regarding care plan responsibilities |
| Assistant Administrator | Interviewed regarding care plan deficiencies and corrective actions | |
| Director of Nursing | Interviewed regarding care plan deficiencies and corrective actions | |
| Medical Director | Interviewed regarding expectations for fall notifications | |
| Unit Manager | Investigated Resident #10's fall and reported late notification | |
| RN Nurse Educator | Nurse Educator | Provided in-service education on care plans and interventions |
Inspection Report
Abbreviated Survey
Census: 131
Deficiencies: 6
Date: Nov 6, 2020
Visit Reason
An Abbreviated/Partial Extended survey and a COVID-19 Focused Infection Control survey were conducted, including investigation of twenty-five complaint intakes related to the COVID-19 survey.
Complaint Details
Twenty-five complaint intakes were investigated; several were unsubstantiated, some partially substantiated without deficiencies, some substantiated without deficiencies, and two were substantiated with deficiencies and Immediate Jeopardy.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with Immediate Jeopardy related to failure to monitor a resident on anticoagulant therapy after a fall, failure to notify physician and responsible party timely after a fall resulting in fracture, and failure to develop comprehensive care plans. The Immediate Jeopardy was removed after corrective actions including staff education, audits, and policy reviews.
Deficiencies (6)
Failure to monitor a resident on anticoagulant therapy after an unwitnessed fall, resulting in death.
Failure to notify physician and responsible party timely after a resident's fall resulting in a left distal humerus fracture.
Failure to maintain a homelike environment due to missing window screens in eight resident rooms.
Failure to develop and implement comprehensive person-centered care plans for anticoagulant use and other care needs for residents.
Failure to identify change in condition and failure to follow physician orders for monitoring and timely medical care after a fall.
Failure of administration to ensure effective oversight, timely medical care, and implementation of care plans related to falls and anticoagulant use.
Report Facts
Complaint intakes investigated: 25
Resident census: 131
Nurses educated: 29
CNAs educated: 36
Falls care plans reviewed: 14
Anticoagulation care plans reviewed: 32
Fall risk score: 75
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN HH | Licensed Practical Nurse | Named in failure to monitor resident after fall and failure to notify physician and responsible party |
| RN AA | Registered Nurse | Agency nurse, described standard of care for unwitnessed falls |
| Assistant Administrator | Involved in investigation and corrective action planning | |
| Director of Nursing | Involved in investigation and corrective action planning | |
| Medical Director | Involved in investigation and corrective action planning | |
| MDS Coordinator | Responsible for care plan development |
Inspection Report
Routine
Census: 122
Deficiencies: 0
Date: Jul 29, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and 42 CFR §483.80 infection control regulations and had implemented the recommended practices to prepare for COVID-19.
Inspection Report
Routine
Census: 120
Deficiencies: 0
Date: Jun 17, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented the recommended practices to prepare for COVID-19.
Inspection Report
Original Licensing
Capacity: 40
Deficiencies: 0
Date: Jun 15, 2020
Visit Reason
A walkthrough licensure survey was conducted for the expansion of 15 additional beds to the ventilation unit.
Findings
The 15 additional beds for the ventilation unit were found to be in compliance with State requirements. River Towne Center is approved for a 40 bed Mechanical Ventilation Unit.
Report Facts
Additional beds approved: 15
Total licensed capacity: 40
Inspection Report
Re-Inspection
Census: 127
Deficiencies: 0
Date: Dec 3, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited during the 10/10/19 Complaint Survey.
Complaint Details
The visit was a follow-up to a complaint survey conducted on 10/10/19; all cited deficiencies were corrected.
Findings
All deficiencies cited as a result of the 10/10/19 Complaint Survey were found to be corrected.
Report Facts
Census: 127
Inspection Report
Abbreviated Survey
Deficiencies: 4
Date: Oct 10, 2019
Visit Reason
An Abbreviated/Partial Extended Survey was conducted to investigate multiple complaints regarding the facility.
Complaint Details
The survey investigated complaints GA00198118, GA00198618, GA00199727, GA00199837 and GA00199916. Complaints GA00199727 and GA00199837 were unsubstantiated. Complaints GA00198118, GA00198618 and GA00199916 were partially substantiated with deficiencies.
Findings
The facility was found deficient in multiple areas including failure to consistently provide and document pressure ulcer treatments and assessments for several residents, failure to provide thorough ADL assistance for one resident, failure to accommodate a resident's food allergy, and failure to maintain effective pest control resulting in insect infestations in resident areas.
Deficiencies (4)
Failure to ensure pressure ulcer treatments and/or assessments were provided and documented consistently for multiple residents.
Failure to ensure Activities of Daily Living (ADL) assistance was provided in a thorough manner for one resident.
Failure to ensure food served accommodated the food allergies of one resident.
Failure to maintain an effective pest control program resulting in insect infestations in resident hall 300.
Report Facts
Pressure ulcer measurements: 13.8
Pressure ulcer measurements: 5.2
Pressure ulcer measurements: 2.8
Missing treatment documentation days: 38
Missing treatment documentation days: 15
Missing treatment documentation days: 10
Missing treatment documentation days: 11
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Treatment Nurse | Reported problems with wound treatment documentation and provided wound care |
| LPN JJ | Licensed Practical Nurse | Reported changing dressings on resident #10 on 9/28/19 |
| CNA KK | Certified Nursing Assistant | Assisted with dressing changes on resident #10 on 9/28/19 |
| LPN DD | Licensed Practical Nurse | Assisted with removal of insects from resident #11 and notified physician and DON |
| RT Director | Respiratory Therapy Director | Observed insects on resident #11 and reported pest issues on hall 300 |
| LPN Unit Manager CC | Licensed Practical Nurse Unit Manager | Responsible for showering resident #11 and confirmed food allergy documentation for resident #1 |
| Dietary Manager | Reviewed dietary forms and acknowledged delay in allergy documentation for resident #1 | |
| Maintenance Director | Reported pest control actions and delays in installing fly lights | |
| Physician HH | Primary Physician | Expected nursing staff to carry out wound care orders for resident #10 |
| Wound Physician | Provided wound care orders and assessments for multiple residents and commented on wound care documentation issues | |
| LPN GG | Licensed Practical Nurse | Reported frustration with incomplete wound dressing changes |
| Corporate Vice President of Operations | Investigated pest incident and oversaw installation of bug lights | |
| Former DON AA | Director of Nursing | Signed statements confirming wound assessments |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 10, 2019
Visit Reason
The inspection was conducted due to complaints regarding inconsistent pressure ulcer treatments and assessments, and inadequate assistance with Activities of Daily Living (ADL) for residents.
Complaint Details
The visit was complaint-related, focusing on pressure ulcer care and ADL assistance. Substantiation status is not explicitly stated.
Findings
The facility failed to consistently provide and document pressure ulcer treatments and assessments for four residents and failed to ensure thorough ADL assistance for one resident. Specific deficiencies included delayed or missing treatments, inadequate documentation, and failure to meet care plan interventions.
Deficiencies (2)
Failure to ensure consistent pressure ulcer treatments and assessments for residents #10, #9, #2, and #14 as per care plans.
Failure to provide thorough Activities of Daily Living (ADL) assistance for resident #11 as care planned.
Report Facts
Pressure ulcer measurements: 13.8
Pressure ulcer measurements: 8
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 2.8
Pressure ulcer measurements: 2
Pressure ulcer measurements: 0.1
Pressure ulcer measurements: 2.4
Pressure ulcer measurements: 1.3
Pressure ulcer measurements: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN FF | Treatment Nurse, Licensed Practical Nurse | Interviewed regarding wound treatments and documentation issues |
| BB | Acting Director of Nursing | Interviewed about pressure ulcer dressing changes on 9/28/19 |
| LPN JJ | Licensed Practical Nurse | Reported changing resident dressings on 9/28/19 |
| CNA KK | Certified Nursing Assistant | Assisted LPN JJ with dressing changes on 9/28/19 but did not assist with foot dressings |
| LPN Unit Manager CC | Licensed Practical Nurse Unit Manager | Interviewed regarding ADL assistance responsibilities |
| LPN Treatment Nurse FF | Licensed Practical Nurse | Clarified necrotic tissue description on resident #9's pressure ulcer |
| Wound Physician | Assessed and ordered treatments for multiple pressure ulcers |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 3, 2019
Visit Reason
A revisit survey was conducted from 7/1/19 through 7/3/19 to verify correction of deficiencies cited during the Complaint survey conducted on 4/25/19. Additionally, an abbreviated/partial extended survey was conducted to investigate complaints GA00196553 and GA00196992.
Complaint Details
Complaints GA00196553 and GA00196992 were investigated and found to be unsubstantiated with no deficiencies cited.
Findings
All deficiencies cited in the prior Complaint survey were found to be corrected. The complaints investigated during the abbreviated/partial extended survey were found to be unsubstantiated with no deficiencies cited.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jul 3, 2019
Visit Reason
An abbreviated / Partial Extended Survey was conducted investigating complaints GA00196553 and GA00196992 as well as a revisit survey.
Complaint Details
The complaint was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated with no deficiencies identified during the survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Feb 18, 2019
Visit Reason
The inspection was conducted to investigate complaint #GA00194750 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00194750 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Re-Inspection
Census: 123
Deficiencies: 0
Date: Jan 30, 2019
Visit Reason
A revisit survey was conducted to verify correction of deficiencies found during the annual survey conducted December 3-6, 2018.
Findings
All deficiencies resulting from the prior annual survey were found to be corrected during this revisit survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jan 25, 2019
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The survey noted that all previously cited survey tags have been corrected.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 15, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaints GA00194023 and GA00193965.
Complaint Details
Complaint GA00194023 was partially substantiated with no deficiencies; complaint GA00193965 was unsubstantiated.
Findings
Complaint GA00194023 was partially substantiated but with no deficiencies, and complaint GA00193965 was unsubstantiated.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jan 7, 2019
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00193697.
Complaint Details
Complaint GA00193697 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were found during the survey.
Inspection Report
Annual Inspection
Census: 121
Deficiencies: 6
Date: Dec 6, 2018
Visit Reason
A standard annual survey was conducted from December 3 through December 6, 2018, including investigation of Complaint Intake Number GA00193934.
Complaint Details
Complaint Intake Number GA00193934 was investigated in conjunction with the standard survey.
Findings
The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to promote dignity and privacy for residents, inadequate privacy during showers, failure to provide appropriate treatment to prevent contractures and maintain mobility, unsafe use and condition of mechanical lifts, failure to date and time enteral feedings, and lapses in infection control practices.
Deficiencies (6)
Failure to promote dignity and provide privacy related to an uncovered urinary catheter bag for one resident.
Failure to ensure privacy for one resident during showers due to shared shower room layout and lack of privacy curtains.
Failure to provide appropriate treatment and services to increase or prevent further decrease in range of motion for three residents with contractures and limited mobility.
Failure to ensure accident risk was minimized due to unsafe use of mechanical lifts and torn lift slings for three residents.
Failure to date and time nutritional enteral feedings for two residents receiving tube feeding.
Failure to remove gloves and wash hands after providing care for a resident on contact precautions and failure to wash hands during meal tray delivery to residents on contact precautions.
Report Facts
Resident census: 121
Tube feeding rate: 50
Tube feeding volume: 1100
Tube feeding volume infused: 618
Tube feeding volume infused: 700
BIMS score: 12
BIMS score: 1
BIMS score: 5
BIMS score: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN NN | Registered Nurse | Provided care to Resident #84 and did not remove gloves or wash hands after care |
| CNA GG | Certified Nurse Assistant | Delivered meal trays without washing hands between rooms, transferred Resident #61 using mechanical lift |
| CNA OO | Certified Nurse Assistant | Provided care to Resident #84 and did not remove gloves or wash hands after care |
| CNA PP | Certified Nurse Assistant | Assisted with mechanical lift transfers and provided observations on restorative care |
| LPN RR | Licensed Practical Nurse | Provided observations on restorative care and mechanical lift use |
| Director of Nursing | Director of Nursing | Interviewed regarding restorative nursing program, mechanical lift use, and infection control |
| Therapy Director | Therapy Director | Interviewed regarding restorative nursing services and therapy assessments |
| Administrator | Administrator | Interviewed regarding restorative nursing program and facility improvements |
| Laundry Aide MM | Laundry Aide | Described washing and inspecting mechanical lift slings |
| Housekeeping Supervisor | Housekeeping Supervisor | Described sling inspection and replacement process |
Inspection Report
Routine
Census: 41
Deficiencies: 2
Date: Dec 6, 2018
Visit Reason
The inspection was conducted to assess compliance with nursing care and infection control regulations, focusing on treatment and services to prevent further decrease in range of motion for sampled residents and adherence to infection control protocols.
Findings
The facility failed to provide appropriate restorative nursing care to prevent contractures in three sampled residents, including lack of range of motion exercises and splint application. Additionally, staff failed to follow infection control protocols by not removing gloves and washing hands after care and during meal service for residents on contact precautions.
Deficiencies (2)
Failure to ensure appropriate treatment and services to increase and/or prevent further decrease in range of motion for three sampled residents (R#57, R#84, R#116).
Failure to remove gloves and wash hands after providing care to a resident on contact precautions and failure to wash hands during meal service delivery to residents on contact precautions.
Report Facts
Sample size: 41
BIMS score: 5
Restorative nursing participation records: 113
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN NN | Registered Nurse | Observed providing care to R#84 and acknowledged gloves should have been removed and hands washed |
| CNA GG | Certified Nursing Assistant | Observed providing care to R#84 and delivering meal trays without proper hand hygiene |
| CNA OO | Certified Nursing Assistant | Observed providing care to R#84 and acknowledged gloves should have been removed and hands washed |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding restorative nursing program and infection control practices |
| Rehabilitation Manager | Rehabilitation Manager (RM) | Interviewed about therapy services for R#84 |
| Speech Language Pathologist | Speech Language Pathologist (SLP) | Interviewed about therapy services for R#84 |
| Therapy Director | Therapy Director | Interviewed about restorative nursing services and therapy screenings |
| CNA QQ | Certified Nursing Assistant | Interviewed about splint application for R#116 and R#57 |
| LPN RR | Licensed Practical Nurse | Interviewed about observations of splint use for R#116 and R#57 |
| CNA PP | Certified Nursing Assistant | Interviewed about range of motion exercises and splint application for R#57 |
Inspection Report
Life Safety
Census: 121
Capacity: 210
Deficiencies: 4
Date: Dec 4, 2018
Visit Reason
A Life Safety Code Survey was conducted to assess compliance with fire safety regulations and the National Fire Protection Association (NFPA) 101 Life Safety Code 2012 edition.
Findings
The facility was found not in substantial compliance with life safety requirements, including failure to maintain smoke barrier walls with proper fire resistance, lack of documentation for annual fire door inspections, failure to maintain electrical cover plates, and inadequate maintenance and testing of the emergency generator.
Deficiencies (4)
Failed to maintain smoke barrier walls with construction having a fire resistance rating of at least one-half hour; unsealed penetrations where new camera system wiring was installed.
Failed to document the annual inspection and testing of fire, corridor, and smoke barrier doors.
Failed to maintain electrical cover plates; open junction box in ceiling outside room 816 and missing switch cover in main electrical room.
Failed to properly conduct monthly load testing of the emergency generator and maintain a clean fuel supply; generator exercised under load only twice in 2018 and fuel test failed due to high particle counts.
Report Facts
Residents at risk: 121
Certified beds: 210
Emergency generator load tests: 2
Required emergency generator load tests: 12
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G confirmed findings during observations and record reviews. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 14, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00192700 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00192700 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Nov 7, 2018
Visit Reason
The inspection was conducted to investigate complaint #GA00192394 and determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00192394 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 22, 2018
Visit Reason
A complaint survey was conducted on 10/22/18 to investigate complaint GA00192025 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.
Complaint Details
Complaint GA00192025 was investigated and no deficiency was cited.
Findings
No deficiency was cited during the complaint investigation survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 23, 2018
Visit Reason
A revisit survey was conducted on 8/23/18 to verify correction of deficiencies cited in the 7/3/18 Abbreviated/Partial Extended Survey. Additionally, complaint investigations for Intake Numbers GA00190645, GA00190891, and GA00190905 were conducted in conjunction with this revisit survey.
Complaint Details
Complaint Intake Numbers GA00190645, GA00190891, and GA00190905 were investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the prior 7/3/18 survey were found to be corrected. The complaint investigations were unsubstantiated with no deficiencies identified.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Aug 22, 2018
Visit Reason
A revisit survey was conducted on 8/23/18 to verify correction of deficiencies from the 7/3/18 Abbreviated/Partial Extended Survey and to investigate complaint intake numbers GA00190645, GA00190891, and GA00190905.
Complaint Details
Complaint Intake Numbers GA00190645, GA00190891, and GA00190905 were investigated and found to be unsubstantiated with no deficiencies.
Findings
All deficiencies cited in the prior 7/3/18 survey were found to be corrected. The complaint investigations were unsubstantiated with no deficiencies identified.
Inspection Report
Re-Inspection
Census: 122
Deficiencies: 0
Date: Jun 14, 2018
Visit Reason
A revisit survey was conducted to verify correction of deficiencies cited in the April 19, 2018 Abbreviated/Partial Extended Survey.
Findings
All deficiencies cited in the prior abbreviated/partial extended survey were found to be corrected during this revisit survey.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jun 12, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint #GA00188976.
Complaint Details
Complaint #GA00188976 was investigated and found to be unsubstantiated with no deficiencies.
Findings
The complaint was unsubstantiated and no deficiencies were identified during the investigation.
Inspection Report
Original Licensing
Deficiencies: 0
Date: May 30, 2018
Visit Reason
An initial walk-through survey of the Mechanical Ventilation Unit at River Towne Center was conducted on 5/29/18 - 5/30/18 by two Certified Respiratory Therapists.
Findings
The facility was found to be in compliance with the policies and procedures for mechanical ventilation services.
Inspection Report
Abbreviated Survey
Census: 122
Deficiencies: 3
Date: Apr 19, 2018
Visit Reason
An abbreviated/partial extended survey was conducted investigating a complaint related to unsafe hot water temperatures causing burns to a resident.
Complaint Details
Complaint GA#00187484 was substantiated with deficiencies related to unsafe hot water temperatures causing burns to a resident.
Findings
The facility was found not in substantial compliance due to failure to monitor and maintain safe hot water temperatures, resulting in a resident sustaining first and second degree burns. The facility failed to routinely monitor water temperatures and lacked a system to monitor mixing valve temperatures. Immediate Jeopardy was identified and removed after corrective actions including hourly water temperature checks, staff in-service, and plumbing repairs. The facility also failed to ensure competency of newly hired nursing staff and did not adequately report water temperature monitoring issues in QAPI meetings.
Deficiencies (3)
Failure to routinely monitor and maintain safe hot water temperatures, resulting in resident burns.
Failure to ensure competency of newly hired Certified Nursing Assistant prior to independent resident care.
Failure to report inconsistent water temperature monitoring and documentation in QAPI meetings.
Report Facts
Resident census: 122
Water temperature: 120.5
Water temperature: 126.5
Residents affected: 14
Rooms with unsafe water temperatures: 9
Skin assessment audits: 5
Skin assessments per shift: 2
In-service completion: 87
In-service completion: 95
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA AA | Certified Nursing Assistant | Provided shower to resident #1 on 4/9/18; competency validation forms incomplete |
| Maintenance Director | Responsible for water temperature monitoring and reporting; participated in QAPI and in-service trainings | |
| Director of Nursing | DON | Oversaw staff competency, in-service trainings, QAPI committee participation, and incident audits |
| Medical Director | Examined resident #1 on 4/10/18 and ordered hospital transfer | |
| Wound Treatment Nurse | Responsible for skin assessment audits and staff education on burns | |
| Administrator | Involved in investigation, QAPI oversight, and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 19, 2018
Visit Reason
The inspection was conducted following a complaint and investigation of unsafe hot water temperatures in resident rooms and common shower rooms, which caused a resident to suffer first and second degree burns.
Complaint Details
The complaint investigation was substantiated. Immediate Jeopardy was identified due to unsafe hot water temperatures causing serious injury (burns) to Resident #1. Immediate Jeopardy was removed after corrective actions were implemented and validated.
Findings
The facility failed to routinely monitor and maintain safe hot water temperatures below 110 degrees Fahrenheit, resulting in unsafe water temperatures ranging from 120.5 to 126.5 degrees Fahrenheit in five bathrooms shared by nine resident rooms housing 14 residents. One resident suffered burns requiring hospitalization. The facility implemented corrective actions including hourly water temperature checks, staff in-service training, and policy revisions. Immediate Jeopardy was removed on 4/19/2018 after corrective measures were validated.
Deficiencies (2)
Failure to routinely monitor and maintain safe hot water temperatures below 110 degrees Fahrenheit in resident rooms and common shower rooms.
Substandard Quality of Care identified related to unsafe hot water temperatures causing resident burns.
Report Facts
Water temperature: 126.5
Water temperature: 120.5
Residents affected: 14
Rooms affected: 9
Skin assessment audits: 5
Licensed staff in-service completion: 23
Certified Nursing Assistants in-service completion: 44
Employees mentioned
| Name | Title | Context |
|---|---|---|
| AA | Certified Nursing Assistant | Gave Resident #1 a shower on 4/9/18 when burns occurred. |
| Maintenance Director | Interviewed multiple times regarding water temperature monitoring and corrective actions. | |
| DD | Maintenance Staff | Responsible for weekly water temperature checks and recording. |
| DON | Director of Nursing | Reviewed and accepted policies, conducted audits, participated in staff in-service training, and monitored incident reports. |
| Medical Director | Examined Resident #1 and confirmed burn injuries. | |
| Wound Treatment Nurse | Responsible for skin assessment chart audits and monitoring. | |
| Administrator | Involved in investigation, development and implementation of corrective plans, and staff in-service. |
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Feb 14, 2018
Visit Reason
An abbreviated/partial extended survey was conducted to investigate complaint GA00185182.
Complaint Details
Complaint GA00185182 was investigated and found to be unsubstantiated.
Findings
The facility was found to be in compliance with Federal and State Long Term Care regulations. The complaint was unsubstantiated and no deficiencies were cited.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Feb 12, 2018
Visit Reason
A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.
Findings
The surveyor noted that all previously cited survey tags have been corrected during the follow-up survey.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 8, 2018
Visit Reason
A Revisit Survey was conducted at River Towne Center on 2/5/18 and 2/5/18 in conjunction with complaint investigations GA00184677 and GA00184864.
Complaint Details
Complaint Intake Numbers GA00184677 and GA00184864 were investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited during the standard survey on 12/22/17 were found to be corrected. The complaint investigations were unsubstantiated with no deficiencies identified.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Feb 8, 2018
Visit Reason
A Revisit Survey was conducted at River Towne Center on 2/8/18 to investigate Complaint Intake Numbers GA00184677 and GA00184864 in conjunction with this revisit survey.
Complaint Details
Complaint Intake Numbers GA00184677 and GA00184864 were investigated and found unsubstantiated with no deficiencies.
Findings
All deficiencies cited as a result of the standard survey on 12/22/17 were found to be corrected. The complaint investigation found GA00184677 and GA00184864 unsubstantiated with no deficiencies.
Inspection Report
Life Safety
Census: 127
Capacity: 210
Deficiencies: 13
Date: Dec 19, 2017
Visit Reason
The inspection was conducted as a Life Safety Code Survey to assess compliance with fire safety and emergency preparedness regulations.
Findings
The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness plan deficiencies, exit discharge issues, inadequate illumination and signage, improper hazardous area enclosures, fire alarm system malfunction, improper fire extinguisher signage, corridor door smoke resistance failures, unmaintained smoke barriers, smoking area safety violations, emergency generator testing documentation deficiencies, improperly mounted power strips, and missing oxygen storage signage.
Deficiencies (13)
Emergency Preparedness Plan was in draft form, not approved by administrator, and staff training had not been conducted.
Exit discharge from the west 400 hall exit had standing water at the bottom of the ramp.
No lighting of the means of egress from the east doors of the 400 hallway; all light bulbs missing.
Facility failed to maintain exit signage; exit sign outside Doctor's office not illuminated on AC or battery power; monthly and annual battery testing not conducted.
Medical records room door did not have a door closer installed.
Magnetic door holder on smoke barrier door next to vending machines failed to release, preventing door closure.
Facility failed to display proper signage for kitchen type K fire extinguisher.
Corridor doors 203 and 205 had gaps greater than 0.5 inch between door face and door stop, failing to resist passage of smoke.
Smoke barriers on hallways 100, 300, 400, 700, and 800 had unsealed penetrations, failing to maintain required fire resistance rating.
Metal container with self-closing lid in smoking area was broken; ashes and butts observed in trash receptacle.
Facility failed to properly document weekly and monthly testing of emergency generator.
Power strips in Staff Development and Rehab Clinical Care Manager offices were not properly secured off the floor.
Oxygen storage areas lacked required precautionary signage stating 'CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING'.
Report Facts
Residents at risk: 127
Residents at risk: 15
Residents at risk: 5
Residents at risk: 40
Residents at risk: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff G | Confirmed multiple findings including exit discharge, lighting, exit signage, hazardous area enclosure, fire alarm system, fire extinguisher signage, corridor doors, smoke barriers, smoking area container, emergency generator documentation, power strips, and oxygen storage signage. | |
| Staff M | Confirmed Emergency Preparedness Plan deficiencies. | |
| Staff H | Confirmed medical records room door lacked door closer. |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: May 24, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00175327 to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00175327 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey.
Inspection Report
Follow-Up
Deficiencies: 0
Date: Apr 17, 2017
Visit Reason
A follow-up visit was conducted on 4/17/17 to verify correction of deficiencies identified during the complaint survey conducted on 2/24/17.
Complaint Details
The follow-up was related to a complaint survey conducted on 2/24/17; deficiencies were corrected.
Findings
The deficiencies identified in the prior complaint survey were corrected as of the follow-up visit.
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 4, 2017
Visit Reason
The inspection was conducted to investigate complaint #GA00167641 and to determine compliance with Federal and State Long Term Care regulations.
Complaint Details
Complaint #GA00167641 was investigated and found to have no deficiencies.
Findings
No deficiencies were cited during the complaint survey conducted from 01/03/17 through 01/04/17.
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