RIVER BLUFFS MEMORY CARE COMMUNITY

Official classification

Type B

Official code

87608(a)(3)

Regulation authority

CCR

What the official deficiency says

87608 Postural Supports (a) Based on… Postural supports may be used under the following conditions.(3) A written order from a physician indicating the need for the postural support shall be maintained... This requirement was not met as evidenced by: Licensee did not ensure there was a written physician's order indicating the resident's need for a postural support (1/2 side rails) for R1's hospital bed. There were 3 1/2 side rails attached to the bed, there should only be 1 per side This poses a potential health and safety risk to persons in care.

Official plan of correction

AD obtained a complete written physician's order for R1's 1/2 siderails during the visit. The extra (3rd) side rail was removed to ensure the postural support was used safely and properly. DEFICIENCY CLEARED DURING VISIT

Deadline recorded: Aug 29, 2025. A deadline is not proof that correction was completed.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents are in locked storage and are not left unattended if outside the locked storage. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and interview, the licensee did not comply with the section cited above which poses an immediate health, safety or personal rights risk to persons in care. LPA observed sharp knives used for cooking in a drawer in the kitchen. During interview, the Cook confirmed that the lock on the drawer was not in working order. Thhis leaves the knives in an unlocked, accessable drawer when the kitchen is unattended.

Official plan of correction

POC Due Date: 06/04/2025 Plan of Correction During the inspection, AD provided a locking tool box. Knives and sharps will be kept in the locking tool box at all times that the kitchen in unattended. DEFICIENCY CLEARED DURING INSPECTION.

Official classification

Type B

Official code

87309(b)

Regulation authority

CCR

What the official deficiency says

(b) Residents may have access to items specified in subsection (a) for personal use unless there is documentation, as specified in Section 87457, Pre-Admission Appraisal or Section 87463, Reappraisals, that indicates the resident's or other residents’ safety would be at risk if allowed access. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above inwhich poses/posed a potential health, safety or personal rights risk to persons in care. During the facility tour, LPA observed the Beauth Shop door unlocked which contained scissors and haircare supplies. Additionally room 13 had accessible hygiene supplies under the bathroom sink. R4's Physician Report states at risk if allowed access to Hygiene supplies. As does R1 and R2's.

Official plan of correction

POC Due Date: 06/11/2025 Plan of Correction AD has agreed to provide all care providers in-service on required storage requirements. A complete inservice sign in sheet along with training materials will be submitted to CCLD by poc date.

Official classification

Type A

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

87309 Storage Space and Access (a) Except as specified in subsection (b), the licensee shall ensure that disinfectants, cleaning solutions, poisonous substances, knives..., are in locked storage and are not left unattended if outside the locked storage.This requirement was not met as evidenced by: Licensee did not ensure a sharp cooking knife in the kitchen, bottle of bleach in a laundry room and an open housekeeping cart were locked and inaccessible to residents in care. This poses an immediate health and safety risk to residents in care.

Official plan of correction

During the visit, the knife was removed and locked, bleach and housekeeping cart containing cleaning supplies were locked and secused. DEFICIENCY CLEARED DURING VISIT

Deadline recorded: Mar 6, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87303(a)(1)

Regulation authority

CCR

What the official deficiency says

87303 Maintenance and Operation (a) The facility shall be clean, safe, sanitary and in good repair at all times..... (1) Floor surfaces in bath, laundry and kitchen areas shall be maintained in a clean, sanitary, and odorless condition. This requirement was not met as evidenced by: Licensee did not ensure that resident bathrooms are clean, safe, sanitary and in good repair. LPA observed multiple resident toilets that were unsanitary and unclean. 2 toilet seats are broken requiring replacement and a soiled resident brief was found on the floor in a resident bathroom.

Official plan of correction

Administrator has agreed to provide inservice to all staff on the maintenance of resident bathroom requirements. A sign in sheet will be provided containing the name and signature of all appropriate staff attending the inservice. LVN ordered new toilet seats during the visit. A receipt and written statement that the repairs have been made as well as a receipt copy will be provided. The poc will be submitted to CCL via email by poc date.

Deadline recorded: Mar 19, 2025. A deadline is not proof that correction was completed.

Official classification

Type B

Official code

87632(a)(1)

Regulation authority

CCR

What the official deficiency says

87632 Hospice Care Waiver (a) In order accept or retain terminally ill residents and permit them to receive care from a hospice agency, the licensee shall have obtained a facility hospice care waiver from the Department…. The request shall include, but not be limited to the following: (1) Specification of the maximum number of terminally ill residents which the facility wants to have at any one time. This requirement is not met as evidenced by: Deficient Practice Statement Based on Record review and interview, the licensee did not comply with the section cited above, which poses/posed a potential health, safety or personal rights risk to persons in care. The facility has a Hospice Waiver for 8. There are currently 9 residents admitted to and receiving Hospice care.

Official plan of correction

POC Due Date: 05/22/2024 Plan of Correction AD has agreed to submit a request to increase hospice capasity from 8 to 9 residents. The written request will be submitted via fax to CCLD by POC date.

Official classification

Type B

Official code

87465(h)(6)

Regulation authority

CCR

What the official deficiency says

87465 Incidental Medical and Dental Care (h) The following requirements shall apply to medications which are centrally stored: (6) The licensee shall be responsible for assuring that a record of centrally stored prescription medications for each resident is maintained for at least one year and includes: This requirement is not met as evidenced by: Deficient Practice Statement Based on observation and record review, the licensee did not comply with the section cited above in 2 out of 3 medication count audits medication start dates were not accurately recorded which poses/posed a potential health, safety or personal rights risk to persons in care. R1 Pantoprazole start date 4/17/24 and R2 Aspirin start date is not recorded on the centrally stored log.

Official plan of correction

POC Due Date: 05/22/2024 Plan of Correction AD has agreed to provide an in person in-service to review facility medication documentation requirements and procedure with all Med Techs. Sign in sheet with names and signature will be provided along with training materials. This will be submitted to CCLD by POC date.

Official classification

Type B

Official code

87309(a)

Regulation authority

CCR

What the official deficiency says

(a) Disinfectants, cleaning solutions, poisons, firearms and other items which could pose a danger if readily available to clients shall be stored where inaccessible to clients. This requirement is not met as evidenced by: Deficient Practice Statement Based on observation, the licensee did not comply with the section cited above. LPAs observed a razor in the shower of room 2 and Shout laundry spray in the bathroom of room 16. This poses a potential health, safety or personal rights risk to persons in care.

Official plan of correction

POC Due Date: 06/14/2023 Plan of Correction Administrator has agreed to provide in-service to staff on proper storage of items that may risk resident safety. A sign in sheet which will include the date, trainer, staff names and signatures will be provided via fax to CCLD by the POC date.

Official classification

Type B

Official code

Not listed

Regulation authority

CCR

What the official deficiency says

Deficiency narrative not available.