Inspection Reports for
Riverwalk Post Acute

The facility failed to include fall prevention interventions in the baseline care plan for Resident 1, who was at high risk for falls and subsequently experienced a fall resulting in hospital transfer. The baseline care plan did not reflect the resident's history of falls or necessary interventions to prevent future falls.

The facility was found deficient in multiple areas including failure to maintain functioning call light systems, lack of written baseline care plans, incomplete care plans for Foley catheter use, medication administration errors, inadequate monitoring of fluid restrictions, failure to implement enhanced barrier precautions for Foley catheter residents, unsafe smoking material storage, improper infection control practices, and inaccurate facility assessment of staffing needs.

The complaint was substantiated based on the failure to provide medical records within the required timeframe. Resident 1's legal representative did not receive the requested records within two working days as required.

The facility failed to provide requested medical records for Resident 1 within the required two working day timeframe, resulting in the resident's legal representative not receiving the records on time. The Director of Medical Records sent the request to the legal department, which delayed the release beyond the 30-day policy timeframe.

The investigation was triggered by a complaint from the family of Resident 1 reporting missing belongings including a radio/CD player, jazz CD, pajama pants, and reading glasses. The complaint was substantiated as the facility admitted to losing the belongings.

The facility failed to keep one of five residents reviewed (Resident 1) belongings safe from theft or loss after the resident passed away, resulting in the belongings being lost and not available to the family. The facility did not update the resident's belongings inventory when new items were brought in by family.

The visit was complaint-related, triggered by allegations that the facility did not follow physician orders for medication administration and failed to accommodate a resident's gluten allergy. The deficiencies were substantiated with interviews and record reviews.

The facility failed to ensure that Resident 1's antihypertensive medication was held according to the physician's order and that the physician was notified. Additionally, the facility failed to provide food consistent with Resident 1's gluten allergy, serving her cornbread containing gluten despite dietary policies.

The visit was complaint-related, investigating a quality care concern about weight monitoring. The deficiency was substantiated as the facility did not weigh Resident 2 weekly after significant weight loss.

The facility failed to follow its weight management policy for Resident 2 by not weighing the resident weekly after severe weight loss was noted on January 8, 2025. This failure had the potential to lead to continued unmonitored weight loss negatively impacting the resident's health.

The facility failed to maintain residents' rooms in a clean and comfortable condition, with adhesive residue, chipped paint, black horizontal lines on walls, and stained floors observed in multiple rooms. Maintenance staff acknowledged the issues and stated renovations were ongoing but limited by residents' reluctance to move.

The complaint investigation focused on failure to notify Resident 1's POA about medication orders, failure to evaluate and monitor weight loss in residents, and failure to properly evaluate and monitor behavior prior to psychotropic medication use. The findings substantiated these issues with minimal harm or potential for actual harm to a few residents.

The facility failed to notify Resident 1's power of attorney about a physician's order for lorazepam, failed to evaluate and intervene appropriately for significant weight loss in Residents 1 and 2, and failed to evaluate and monitor anxiety behavior and side effects prior to administering PRN lorazepam for Resident 1. These failures had potential for minimal harm or potential for actual harm to a few residents.

The facility failed to properly assess and treat an unstageable pressure injury on Resident 1's right hip after a dressing was applied without further assessment or follow-up. Interviews and record reviews revealed gaps in wound identification, documentation, and treatment orders, contrary to facility policy.

The complaint investigation found that Resident 1's care conference was conducted but not documented, potentially impacting the resident's plan of care and communication among the care team and caregiver. The complaint was substantiated with findings of incomplete medical records.

The facility failed to ensure the medical record was complete for Resident 1 because a care conference meeting conducted on September 13, 2024, was not documented in the electronic health record system (PointClickCare). Interviews with staff confirmed the care conference occurred but was not documented, and the facility lacked a policy requiring documentation of care conferences.

The facility was found deficient in multiple areas including failure to keep call lights within reach for residents, inadequate monitoring and assessment of central dialysis catheters, failure to follow physician fluid restriction orders, insufficient skin condition assessments and treatments, and lapses in infection prevention and control practices.

The facility was found deficient in multiple areas including failure to keep call lights within reach for residents, inadequate monitoring and assessment of dialysis catheters, failure to follow physician fluid restrictions, insufficient skin condition assessments and treatments, and lapses in infection prevention practices such as improper handling of oxygen tubing and wound vacuum equipment.

The investigation was complaint-driven focusing on Resident 4's admission, transfer, and discharge rights, including failure to provide adequate discharge documentation, failure to notify the Ombudsman, failure to provide bed-hold notice, and failure to re-evaluate for readmission after hospitalization.

The facility failed to document that the discharge of Resident 4 was necessary, failed to provide updated discharge notices to the resident and Ombudsman after psychiatric hospitalization, failed to provide notice of bed-hold rights upon transfer to hospital, and failed to re-evaluate Resident 4's clinical and behavioral condition for readmission after psychiatric hold was discontinued. Resident 4 was ultimately not readmitted due to ongoing behavioral concerns despite being cleared by the hospital psychiatrist.

The complaint investigation was triggered by concerns that the facility was sending discharge notices to the Ombudsman on the day of discharge rather than at the time residents were notified, preventing the Ombudsman from contacting residents prior to discharge.

The facility failed to ensure that the notice of transfer or discharge was sent to the Ombudsman prior to the transfer or discharge of three sampled residents and did not maintain consistent documentation that the notice was sent. The Ombudsman received notices on the day of discharge rather than at the time residents were notified, limiting the Ombudsman's ability to advocate for residents.

The complaint was substantiated. The investigation confirmed that CNA 1 videotaped residents and staff without their knowledge and posted the video on social media, violating privacy and constituting abuse.

The facility failed to provide an environment free from abuse when CNA 1 videotaped residents and staff without consent and distributed the video outside the facility. Interviews with residents, staff, and review of medical records confirmed the incident and the violation of privacy and abuse policies. Additionally, the facility failed to follow a physician's fluid restriction order for one resident, potentially risking the resident's health.

The investigation was triggered by two linked complaints about delayed call light response times. Residents reported waiting up to one hour or longer for assistance. Staff interviews acknowledged the issue and the risks associated with delayed responses. The complaint was substantiated with findings of delayed call light responses.

The facility failed to ensure call lights were answered timely, as four residents reported waiting up to an hour or longer for assistance, which posed risks of delayed medical management and unmet care needs. Interviews with residents and staff confirmed inconsistent and delayed call light responses.

The complaint investigation focused on admission, transfer, and discharge processes. It was substantiated that Resident 1 did not have a physician discharge order documented in the medical record prior to discharge.

The facility failed to ensure a physician discharge order was transcribed into the resident's electronic medical record for one of three residents (Resident 1). This failure had the potential to affect Resident 1's overall health and well-being. Interviews with multiple staff confirmed the absence of a physician discharge order prior to discharge, and the facility did not follow its discharge policy requiring transcription of discharge orders within 72 hours.

The complaint was substantiated based on interviews and record reviews indicating the facility did not provide the requested assistance for Resident 1 to visit his significant other on May 28, 2023. The failure was attributed to miscommunication among staff and lack of timely response.

The facility failed to assist Resident 1 in arranging transportation to visit his significant other on May 28, 2023, resulting in the resident missing the opportunity to pay his last respects. Interviews revealed miscommunication among staff and that the resident should have been accommodated, especially since the other facility was nearby.

The visit was complaint-related, investigating two complaints regarding resident rights. The deficiency was substantiated based on observation, interview, and record review.

The facility failed to ensure one of seven residents (Resident 3) had the call light within reach, which had the potential for unmet needs and assistance for Resident 3.

The complaint investigation found that the facility failed to monitor anxiety behaviors and medication effectiveness for Resident 1 after lorazepam administration on May 18, 19, 21, 23, 25, 26, and 29, 2023. The licensed nurses did not document reasons for PRN medication administration, and non-pharmacological interventions were not documented as attempted prior to medication use.

The facility failed to ensure consistent monitoring of anxiety behaviors and evaluation of lorazepam effectiveness after administration on multiple dates in May 2023. There was no documented evidence that non-pharmacological interventions were attempted prior to medication administration, and licensed nurses did not document reasons for giving PRN lorazepam doses as required.

The visit was complaint-related, investigating an allegation of staffing shortage. The complaint was substantiated as interviews with Licensed Vocational Nurses and the Registered Nurse Supervisor confirmed insufficient staffing and concerns about compromised licenses.

The facility failed to allocate sufficient nursing staff to cover 54 residents in Station 1 Hallways A and B, resulting in nurses having limited time to attend to residents. Staff interviews and record reviews confirmed that nurses were often required to manage over 50 residents, which compromised resident care and jeopardized nurse licenses.

The visit was complaint-related, investigating quality care issues for Resident 1. The complaint was substantiated based on findings of missed weight monitoring and delayed care plan conference.

The facility failed to weigh Resident 1 for a month after admission, compromising accurate health monitoring for conditions such as congestive heart failure. Additionally, the facility did not conduct a care plan conference within the required timeframe, potentially impacting the resident's access to needed services and family communication.

Complaint investigation was conducted for two allegations related to unsafe transfer and discharge of Resident 1. The complaint was substantiated based on findings that the facility did not follow appropriate procedures to ensure Resident 1's safety after he left on pass and did not return within the allotted time.

The facility failed to ensure Resident 1's safety when he was discharged against medical advice (AMA) while out on pass and unable to return as arranged. The facility did not notify law enforcement to conduct a welfare check during the period Resident 1 was unaccounted for, which was identified as a failure to ensure a safe and orderly discharge.

The facility failed to prevent residents from possessing personal smoking materials, including cigarettes and lighters, contrary to its smoking policy. Three of four residents reviewed were found with smoking materials, posing a fire hazard due to the presence of flammable materials and oxygen use.

The complaint investigation was triggered by Resident 1's report on December 13, 2022, that CNA 1 took $200 for personal use. The allegation was not reported to the state agency within the required 2-hour timeframe, nor was a full investigation conducted. The Social Service Director and Director of Nursing acknowledged failures in reporting and investigation.

The facility failed to timely report and investigate the allegation of misappropriation of Resident 1's funds, resulting in a delay in notifying the appropriate state agency and police. The Social Service Director did not conduct a full investigation or report the incident properly, and the Director of Nursing was unaware of the incident until the investigation.

The facility was found deficient in multiple areas including failure to assess residents for safe self-administration of medications, failure to provide timely vision consults, unsafe possession of cigarettes by a resident, inadequate monitoring and documentation of self-catheterization, improper oxygen administration, lack of pain assessments before medication administration, improper medication storage including unlabeled insulin pens and medications of discharged residents, failure to complete ordered lab tests, improper food storage and thawing practices, and lapses in infection control such as reuse of catheters and unlabeled dirty urinals.