A list of the most recent deficiencies for Riverstreet Manor. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-08-16 | 2023-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-16 | 2023-09-15 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-08-16 | 2023-09-15 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-16 | 2023-09-15 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-16 | 2023-09-15 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-08-04 | 2023-09-12 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-08-04 | 2023-09-12 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-08-04 | 2023-09-12 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-08-04 | 2023-09-12 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-08-04 | 2023-09-12 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-04 | 2023-09-12 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-08-04 | 2023-09-12 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2023-05-10 | 2023-05-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-04-05 | 2023-05-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-23 | 2022-11-08 | N |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-09-23 | 2022-11-08 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-09-23 | 2022-11-08 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-23 | 2022-11-08 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2022-09-23 | 2022-11-08 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-09-23 | 2022-11-08 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-09-23 | 2022-11-08 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2022-09-14 | 2022-10-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-14 | 2022-10-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-14 | 2022-10-18 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-09-14 | 2022-10-18 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-11-19 | 2022-01-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-11-19 | 2022-01-04 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2021-11-19 | 2022-01-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-11-19 | 2022-01-04 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-19 | 2022-01-04 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-11-19 | 2022-01-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-19 | 2022-01-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2021-11-19 | 2022-01-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-02 | 2021-12-14 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2021-11-02 | 2021-12-14 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-11-02 | 2021-12-14 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2021-11-02 | 2021-12-14 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-11-02 | 2021-12-14 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2021-08-26 | 2021-10-19 | Y |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2021-08-26 | 2021-10-19 | Y |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2021-08-26 | 2021-10-19 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-06-20 | Not Fixed | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-06-20 | Not Fixed | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-06-20 | Not Fixed | Y |
| Ensure that residents are free from significant medication errors. | Health | 2023-06-20 | Not Fixed | Y |
